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Kara Fletcher, PhD, MSW, RSW - Guest
Kara Fletcher, PhD, MSW, RSW is the Director of the Social Work Research Centre at the University of Regina and an Associate Professor at the University of Regina Faculty of Social Work, Saskatoon Campus. She is also a trained AAMFT couple and family therapist. Her program of research seeks to better understand the impact of mental wellness, substance use and trauma on couple, family, and community well-being. Her current research is considering the impact of conspiracy theories, misinformation, and political polarization on intimate relationships. Kara recently published Integrative Approaches to Couple and Family Therapy in Canada: A Beginner’s Guide. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D. (00:25):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in - person and online trainings, on- demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach with our lifespan centers, Center for Children, and Center for Adolescents, where all the therapists are working systemically, our Center for Couples, where all the therapists are using emotionally focused couples therapy, and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma, and our Center for ADHD and Oppositional and Conduct Disorder Clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:32):
In the Institute, we have our licensed experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com, and to support our nonprofit, you can go to SF-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501 nonprofit, so all donations are tax deductible. Today, I'll be speaking with Kara Fletcher, PhD MSW RSW, who is the director of the Social Work Research Center at the University of Regina and an associate professor at the University of Regina Faculty of Social Work, Saskatoon Campus.
Keith Sutton, Psy.D. (02:36):
She is also a trained American Association of Marriage and Family Therapist, Couple and Family Therapist. Her program of research seeks to better understand the impacts of mental wellness, substance use, and trauma on couple family and community wellbeing. Her current research is considering the impact of conspiracy theories, misinformation, and political polarization on intimate relationships. Kara recently published Integrative Approaches to Couple and Family Therapy in Canada: A Beginner's Guide. Let's listen to the interview. Well, hi, Kara. Welcome. Thanks for joining us.
Kara Fletcher, Ph.D., MSW, RSW (03:09):
Thank you for having me.
Keith Sutton, Psy.D. (03:11):
Well, I'm so interested to hear about your work. So I was doing some research and looking at research papers on working with couples with addiction and also looking emotionally focused couples therapy. And then I happened upon, I think it might have been your dissertation research and there was another paper that you had done with a previous guest of mine, Heather McIntosh, who does work with complex trauma and couples. So I reached out and was wanting to learn more. And so before we even get into the work that you're doing or the, that you've written about, I always love to hear about kind of people's evolution of their thinking and how you got to doing what you're doing.
Kara Fletcher, Ph.D., MSW, RSW (03:51):
Sure, so I did... When I was doing my master's training, I was training in Montreal in a couple and family therapy clinic. So I was really had a systems training at that point. And I then moved to Vancouver, BC, and I was working out of my master's in an outpatient, addiction and mental health clinic. And I was struck there by how many of my clients wanted to bring in their, either their romantic partner or their family member, into the session with them to talk about their substance use challenges. And when I went to kind of see what was best practice in terms of doing that work, there was very little out there, at the time. This was back in 2009, 2010. And there was a lot of behavioral couples therapy, but nothing really that spoke to how I liked to work with, with couples or with families.
Kara Fletcher, Ph.D., MSW, RSW (04:52):
So at that point that I just started doing couples work and kind of doing what worked at the time and I was using a lot of emotionally focused therapy., and I discovered there was a theoretical extension that someone had proposed using EFT. So that was when I decided to go back to school, do my PhD at McGill University and look at how possible or plausible is this, is the use of EFT in the context of substance use and addictions? And so that's kind of how I got there was knowing I already liked working systemically with couples and families and then really seeing the desire from clients to do that kind of work.
Keith Sutton, Psy.D. (05:35):
Great. Wonderful. I think that when I did my EFT training many years ago, kind of the party line was, it's contraindicated when there's addiction, and so on. And so, that's, I'm really interested. So tell me about what you found and your experience over time in working with couples with addiction.
Kara Fletcher, Ph.D., MSW, RSW (05:56):
I had the same experience that it was contraindicated and I did even at that, at the time when I was bringing in family members have some supervisors being like, "Is this ethical? Like, what are you doing?", and I think one of the things is that I think that comes from the history of how we've worked with addictions. Like we've really come from this kind of fear-based and then behavioral model of understanding addiction. And for me, the evolution was really looking at addiction through the lens of attachment and thinking about all the ways in which people don't set out to get an addict to become addicted to something, right? Really it's, usually initially quite an adaptive choice at managing suffering or pain or whatever's happening for them. And then that, you know, slowly gets out of control for them.
Kara Fletcher, Ph.D., MSW, RSW (06:46):
So if we... I thought if we were conceptualizing it more as an issue of attachment or using that lens, then actually strengthening the couple relationship is a possibility for removing the dependence or lessening the dependence on the substance. So I would say that my research, when I did my doctoral research, I was doing a multiple baseline case study with four different couples. And it was actually quite amazing. First of all, when I went to advertise people, I had a wait list. People wanted to be part of the study. They wanted to participate in this. And then, certainly there were challenges. So I think what I learned was there has to be some level of stability around the substance use for couples' work to make sense. So if someone's just not functioning very well because they're using all of time, they can't really engage fully in couples therapy.
Kara Fletcher, Ph.D., MSW, RSW (07:44):
But, if there is stability and if there is like a core connection in the relationship with it. Which they think is worth working on or addressing, then it's quite hopeful work. People are really into it and wanting to make their relationship stronger and lessen all of this anxiety and I would say it's sometimes hyper-focused on the addictive element.
Keith Sutton, Psy.D. (08:10):
Okay. And were most of the couples in recovery that were coming to you? Were they in active addiction? Were they in early recovery?
Kara Fletcher, Ph.D., MSW, RSW (08:21):
So I think they were all in early recovery, when I met with them. One, two... now I'm just trying to remember now. Two of them relapsed during the course of therapy, but very briefly. And so we were able to kind of get back on track and actually have a productive conversation around relapse and how we think about relapse and what it means. And, again, I think some of the kind of early literature around addiction and, and that idea of, like, codependence created some, challenges in those spaces because, what a lot of the, the person who wasn't using or addicted to substances would say is, like, "I've been told to detach from this person. I've been told not to enable them. I've been told all of these things. And so I'm in this inner conflict where I love them.
Kara Fletcher, Ph.D., MSW, RSW (09:12):
I think they're more than their addiction, there's lots of great things about a relationship, but it's still hard when they, when they relapse or when I can tell that they're craving" or when these things, these dynamics are playing out in the relationship. So it was a mix, but I think certainly we had, two of the couples had, had sustained recovery, throughout the study. And, you saw, like, just the benefit in terms of their relationship. They started kind of sharing feelings and emotions with each other, which had felt too frightening, in the past, which was pretty powerful.
Keith Sutton, Psy.D. (09:52):
Great. And can you talk about that codependent aspect and kind of how you worked with that? And, I don't know if this is a part of your practice now since you've gotten your doctorate and so on. Or working with more couples around this, but, what's your thinking around that aspect of that dirty word of, codependency and enabling and so on, but also, right, an attachment relationship?
Kara Fletcher, Ph.D., MSW, RSW (10:21):
I guess I really, still draw from how Sue Johnson conceptualized dependency and saying that we need to have effective dependence. On each other as humans, right, and in relationships. So I think we have kind of wrongly pathologized dependence, but we're interactional human beings. Everything is relational. And so I think just if someone wants to identify themselves as codependent, that's their call. But, I will often gently suggest that actually dependence itself is adaptive and healthy. It's how we do it that matters, right? And how we are dependent on each other in a ways that are functional and healthy for us, as opposed to, you know, really having someone else take over for you, then that's maybe not the healthiest type of dependence.
Kara Fletcher, Ph.D., MSW, RSW (11:18):
So I try to work with couples towards: can we create effective dependency in this relationship? What does that look like? And then we can compare it to substance use, right? Substance use is not usually an effective dependency, right? It becomes ineffective very quickly. So how can we actually think about that relationship and then the types of relationships we want to have with the people we love in our lives, and to challenge that and what that looks like? And for most of my clients, you know, even now as I'm working, when they really look at it, it really always comes back to attachment and insecurity and feeling like they just want someone who's consistent, responsive, caring, reassuring, et cetera.
Keith Sutton, Psy.D. (12:05):
I guess they conceptualize our thought as, like, the healthy interdependence that there's dependence, but they're also able to be, have boundaries and have independence. And I remember talking to Sue during my externship and talking about models that maybe were like, oh, each person has to go off and get their own therapist and become whole. She's like, that's a way to just flare up the insecure, relationship or the dynamic. But when we have that secure relationship, we can be independent because we have that healthy dependence that's going on.
Kara Fletcher, Ph.D., MSW, RSW (12:37):
Yes. And sometimes starting with the relationship increases that ability, right, to go because of that feels so solid, they feel more like they can go off and get their own therapy or they can go and make a big move in their own kind of independent life. .
Keith Sutton, Psy.D. (12:53):
Can you maybe talk about, or give some examples about, like, you know, what that looks like, that healthy dependence/ you know, kind of codependence kind of in a situation where you've got somebody who... I don't know, we've got maybe one partner who's in recovery, the other one who's maybe not in addiction. Maybe the one who's not in addiction is anxious about the other relapsing or whether there's been lying or so on, and the other one...Or I don't know what a common dynamic is that you experience or notice in couples. I know there's a, of course, a pursuer withdrawer dynamic in EFT.
Kara Fletcher, Ph.D., MSW, RSW (13:33):
I think quite often in these couples, it varies, but I would say there's often a pattern of, the person who's in early recovery is the more withdrawn withdrawer position and then their partner, the more the pursuer. And for good reason, right? There's anxiety that's built up around maybe lack of trust or some sort of injury in their relationship throughout the, you know, course of an addiction. And so, where the changes and I think where EFT works beautifully is recognizing that cycle, recognizing the role that addiction plays in the couple's cycle. And then once they kind of understand those positions, encouraging, especially that more withdrawn partner to take a new position where maybe instead of reaching for a drink or reaching for, I don't know, whatever it was that they were doing, some sort of maladaptive coping strategy.
Kara Fletcher, Ph.D., MSW, RSW (14:35):
What would happen if they just tried reaching for their partner and then working with the partner, how could you be there for them in this consist of responsible, or responsive, sorry, gentle way where you say, "I see you, I hear you. It's hard for you, but I'm not afraid of you struggling," right? So to lessen that fear in the... Because I think that anxiety gets activated so quickly, that the withdrawn partners afraid to say I'm struggling because they don't want to cause their partner to, you know, freak out or become hypervigilant or whatever, right? So that, that I've seen and I, and why I like, you know, EFT specifically and I'm not like a theoretical purist in any way. I integrate a bunch of different pieces in my work, but that I think EFT works so beautifully.
Kara Fletcher, Ph.D., MSW, RSW (15:28):
Like it just makes sense to couples. And then once they are able to do that, then you can do some really powerful enactments in session and have them really both kind of soft and responsive, which is in some cases, the first time that's ever happened in their relationship.
Keith Sutton, Psy.D. (15:51):
Sure. I imagine I'm thinking of someone now who maybe is steeped in working with addiction and they're like, "Oh, no, but you're just trading the addiction because now the person is just going to their partner to manage all their urges or their overwhelm or so on." Do you have any thoughts on that or, or kind of how it's different in a EFT kind of way?
Kara Fletcher, Ph.D., MSW, RSW (16:15):
I think it is different. I mean, I think, I don't think that their partners should be their only resource. Sure. Right? Like I think they should have hopefully lots of good supports in place and I certainly will work with my clients on that. Like what else? Like where can you go? Who can you go to? But if we're thinking again with that attachment lens, and can we be safe havens for one another in this relational way. I don't think we need to pathologize someone going to their partner to say, "I'm struggling." I think it would be very different if they were going to their partner and saying, "You're the only thing that keeps me sober. I can't live without you, " you know? That's not healthy, right? But if it's more like I have never made it a habit to reach out and to say I'm struggling and now I'm practicing this and I'm actually getting a gentle and affirmative response, that makes them want to do it more, right?
Kara Fletcher, Ph.D., MSW, RSW (17:12):
Because it feels good and you feel close and connected and all of those good feelings--You're not alone. Yeah, you're not alone. And so I think that the part. So it's not all or nothing. And in the addiction world, I think, you know, a lot of people who develop substance use disorders have all or nothing thinking so it is about challenging that. But, I think there's lots of benefit to strengthening that love relationship that already exists, right? And building on it.
Keith Sutton, Psy.D. (17:43):
Well, and, you know, and it's such a big part of addiction also is the shame and sometimes the hiding or the secrecy in all those. And, you know, one part of the 12-step programs is having people kind of speak and share and all these things that maybe they kind of were keeping secret and talking to sponsors and so on. And so it's nice to be able to then take those risks to be vulnerable with one's partner to be able to talk about those struggles and actually have them showing up. had somebody on the podcast, Bob Navarro, who does work with addiction couples and Gottman work. And he talked a lot about the trauma that the non-addicted partner, if there's a non-addicted partner, is often I'm struggling with, from the numerous betrayals or relapses or the scary things that might have happened and the overdoses or so on.
Keith Sutton, Psy.D. (18:44):
Can you talk a little bit about that? Because I imagine, like, you're saying the anxiety that they might feel hearing their partner saying they are feeling that urge or going to go relapse or, you know whatever it might be. Can you share any thoughts on that?
Kara Fletcher, Ph.D., MSW, RSW (19:01):
I think that's very true. There's that whole experience, especially if it's gone on for a long time, I think is, there's, there's a lot of trauma that's experienced there. So I think in the same way that the non, you know, substance using or non-addicted partner can support their partner coming to them saying they're struggling, that has to happen the other way around, right? So I'm struggling to trust, I'm fearful, all of those feelings. The other partner has to be able to hold that with them, right? And so we work on that. So to say things like, "I hear you. I understand. It's hard to trust me. I get it. And it's going to take time." As opposed to, like, activating that defensive cycle, right, where you're never going to trust me.
Kara Fletcher, Ph.D., MSW, RSW (19:59):
You're always going to think of me as an addict, or whatever that kind of that defensive action is there. And instead to hear and to have empathy for, the pain that, that still exists, the hurt that still exists, and, like, the need for reassurance that, like, we all need reassurance and we all need consistent, you know, reliable connection. So, they have to be able to provide that for it to work.
Keith Sutton, Psy.D. (20:30):
Well, that validation, that acceptance.
Kara Fletcher, Ph.D., MSW, RSW (20:34):
And so that once... And it's funny because I work a lot with couples where there's infidelity as well, right?
Keith Sutton, Psy.D. (20:41):
Infidelity doubt.
Kara Fletcher, Ph.D., MSW, RSW (20:42):
It's the same thing. It's like, at a certain point, you have to stop the defensive cycle and say, "I get it, and it's going to take time, and I'm sorry, and I'm here.""I'm not going anywhere," you know?
Keith Sutton, Psy.D. (20:55):
And those feelings may come up even months, years later. Of that, you know, kinda being reminded of that betrayal or whatever might happen and--
Kara Fletcher, Ph.D., MSW, RSW (21:06):
And actually I just--
Keith Sutton, Psy.D. (21:07):
Or not being able to turn to them and, be able to say, "I'm scared," or, "It makes me think about this, " like, and getting that reassurance or being seen or held in that.
Kara Fletcher, Ph.D., MSW, RSW (21:16):
And I'm just thinking of a couple I'm working with and recently one of them said, "Hey, I just have to ask you, like, you did this thing last night that reminded me of when you were using. Are you using?" And instead of getting defensive, their partner was like, "No, I'm not using, but I can see how you made that association. And I, you know, I'll try not to... " I can't remember exactly what it was that he had done, but it's like, "I'll try not to do that anymore because I can see that you're connecting that to the... " So he wasn't... It didn't start a defensive cycle. She was able to ask with clarity and he was... He... I didn't have to do anything. He other than, you know, punctuate what had happened. But he--
Keith Sutton, Psy.D. (21:59):
That's great.
Kara Fletcher, Ph.D., MSW, RSW (22:00):
He was able to get in there and respond that way, which was very relieving for her, right?
Keith Sutton, Psy.D. (22:04):
Definitely. And oftentimes when you have that more secure attachment, you feel like even if the person's having this feeling about you, you know, you're still have that connection, so being able to kind of tolerate that. And talk about it rather than going into a panic of needing to defend and explain how you're not this person they're seeing you as.
Kara Fletcher, Ph.D., MSW, RSW (22:24):
Totally.
Keith Sutton, Psy.D. (22:26):
So, and one of the things you were saying is the, you know, that there is the addiction's not inactive addiction. And I'm curious about your thoughts or conceptualizations on when there is a couple where there is addiction, either one or, or more than one, and how you think about that, what you have suggestions or even how you work with that.
Kara Fletcher, Ph.D., MSW, RSW (22:54):
So where, when they're still, like, using pretty frequently? Is that what--
Keith Sutton, Psy.D. (22:58):
When there's, when a couple comes in, maybe they're not even necessarily coming in because of the addiction, but as you're working together, you find out that, you know, this is, this is a big issue in their relationship. .
Kara Fletcher, Ph.D., MSW, RSW (23:09):
I wouldn't... I'm still not,... It would be very unlikely that I would send them away. I really, truly, because I think if they're there, there's pieces that you can still kind of address together. And I think people so often get sent away in these situations where they're like, "We just want someone to talk to about this." So I would say there's a few different things that I think about. One is, if someone's in active addiction, I wouldn't use something like EFT. I think it's too heightening, and it can, you know, if you're not clear in your mind and someone's using EFT with you, I think it can go sideways very quickly and become overactivating and not useful for either partner. So I might get more behavioral in approach with them.
Kara Fletcher, Ph.D., MSW, RSW (24:01):
I might also be really, like, honest. "Okay, you're still... This is what this looks like until this changes, and I'm not telling you to change anything, but until we have a slightly different situation, we're limited in what we can do together. So here's some things we can do. So maybe it's, like, basic communication stuff or, you know, maybe there's a specific thing that they want to kind of target together. Great, we can do that. But, in terms of really looking at relating and their cycle together and their, getting them kind of processing on an emotional level, it might not be the right time for that and I'll be honest about that. So, I'm not there to tell anyone that they have to stop using, right? And it is, I would say, and maybe you've experienced this in your work, but quite often you'll get people in and they're not there for substance use at all, but then you get to talking.
Kara Fletcher, Ph.D., MSW, RSW (25:01):
And you're like, "Okay, so every night you're doing this," how on earth are you clear enough to address some of the other challenges you're having, right? So, I think we have a bigger reaction when it's, you know, more illicit substances than if someone says they're struggling with alcohol or cannabis use. I think that's all embedded in class and race and all of that stuff, right? So I try not to have a big reaction to any of that, but I will be honest in terms of what's possible for our work together.
Keith Sutton, Psy.D. (25:38):
Definitely. I've had situations where I have worked with couples and I've almost thought about the EFT as, like, almost motivational interviewing for change sometimes as they're hearing their partner's experience and the feeling alone, this fear, the longing, and so on of the non-addicted partner, oftentimes that as the other person hears that vulnerability, they feel empathy and then it kinda this dissonance between, "I don't want to be hurting this person I love, but at the same time, I can't, you know, I don't know if I want to not have this use and sometimes even moving someone into treatment, you know, kinda through that process, versus, like, maybe if it was just kinda nagging or annoying or avoidance or someone kinda processes.
Kara Fletcher, Ph.D., MSW, RSW (26:35):
Yes. And you saying that makes me think, too, of, even just the hearing of that, like, hearing their partners say that, like, " I want to be different. I don't know how to get there." That can be powerful enough. That can be therapeutic, or maybe therapeutic frame is then really about supporting that person and having their other partner be a witness to that support, right? Like, that can happen too. But just being clear about what is it we're doing here? Are we all okay with this? Does this make sense?
Keith Sutton, Psy.D. (27:11):
Definitely. In a situation, where maybe there's active use or even two partners actively using, which I think is extremely hard because, you know, oftentimes, even if one is trying to make a change, the other one is, like, it's like if two people are trying to work on their eating or health. Like, one's like, "Oh, I'm going to have ice cream tonight." The other one's like, "Okay, I'll have ice cream too." And they just kinda ping pong off of each other until one of them finally decides, like, okay, I'm making this change regardless of what the other one is doing. But I think that's very hard oftentimes for couples where there's an addiction piece where both are struggling with addiction, smoking, or drinking, or opioids, or whatever is kinda going on.
Kara Fletcher, Ph.D., MSW, RSW (27:54):
Totally. And I have seen couples where that's the case and they joke about, like they met in the AA and it was the 13th step, right? Like getting together or whatever. But if they're both well, they're an ideal couple to work with because they, you know, they've really worked on things already, done a lot of individual growth. But if they're both still in, in active addiction, then it's, that'd be really tricky.
Keith Sutton, Psy.D. (28:19):
Definitely. And so, what are the different ways that you kinda notice in working with couples with addiction about how things show up, how things progress in treatment? Things for therapists to kinda be thinking about in, in their work, if they do work with a couple that's dealing with--
Kara Fletcher, Ph.D., MSW, RSW (28:43):
I think when they come in and they're transparent about the substance use issue, it's almost easier. Because I find that I get a probably fifty fifty, right? And then the others, like, it's like the hidden agenda, like- "He's got an alcohol issue, I need you to help me with that." You know, that kind of, that's actually harder because there's usually a much more shame. Maybe a hyper-focus, so there's some things there. But so I guess that would be the one thing to be aware of is, is there a hidden agenda there? And then, you know, what is the capacity or willingness for change in that area? But if they're both coming in and one partner's, you know, in early recovery or what have you, I'm always just really interested initially in terms of, what's the cycle?
Kara Fletcher, Ph.D., MSW, RSW (29:34):
So how did the addiction show up in the cycle? How does it now? So where are they at in terms of trust with each other? That's usually the big one. And so trust is usually low. And then also there's often the kind of the, like, imbalance in the power dynamic in the couple, the well one and the sick one. And, you know, the functional one and the dysfunctional one and the shame around that. So those are the things that I'm thinking about right away and so making sure that I'm creating good relationship with the person who's likely to feel more shamed. More ganged up upon, you know, more like the dysfunctional identified patient person in the space. Because if you don't have them, you're not going to do anything, right?
Kara Fletcher, Ph.D., MSW, RSW (30:31):
And also, I guess the other big one is anger, right? Sometimes these couples come in and they're angry. They're so angry. So getting them as smoothly as possible to kind of move into their feelings and the other feelings that are there and then getting them talking to each other as soon as possible.
Keith Sutton, Psy.D. (30:53):
And, anger meaning both kind of being angry or more the one that's the pursuer that's kind of--
Kara Fletcher, Ph.D., MSW, RSW (31:00):
More the pursuer usually, but the other one is sometimes angry because they feel like undervalued or like all you see is my addiction or like I'm the failure and you're the, you know, the functioner, functional one and tired of like angry about being in that position all the time, even if there's been a period of like general wellness, right?
Keith Sutton, Psy.D. (31:23):
Well, and, I imagine too, just like other pursuers in other situations oftentimes they're trying to influence their partner in ways that aren't so vulnerable, so maybe criticism or pushing or things like that or you know, kind of, another person might feel nitpicked or so on. So kind of helping them be able to come at that more vulnerability. But I imagine, there's gotta be such a sense of helplessness and powerlessness on the partner without the addiction, trying to get the partner with the addiction to make changes that it might come out much more forcefully, aggressively or so on.
Kara Fletcher, Ph.D., MSW, RSW (32:01):
Absolutely. And I was just also thinking of another dynamic that can come up is, the pursuing partner, you know, it's quit blaming, shaming, you have the addiction, you have the problem. And then over time the, you know, partner with the addiction says, "But you know, you drink wine every night in front of me or like you do this thing that is its own, you know, and then the real fireworks come out, right? So like there's some, there's a real commitment to having one person be the problem, but when you, talking, it's like, okay, this is very interactional there's lots of things that can be done here to kind of help them get talking to each other about the things that are harmful or helpful.
Keith Sutton, Psy.D. (32:50):
Sure, definitely. Or it sounds like it's very one-sided in that case where the person is making changes to kind of help along with the process of the recovery. Not that it's their responsibility completely, but that they're in it together rather than just kind of, you know, they're not going to change. The other person has to make all the changes.
Kara Fletcher, Ph.D., MSW, RSW (33:12):
Exactly.
Keith Sutton, Psy.D. (33:15):
I'm curious about too, with the addiction and, I don't know if you've had different experiences or if you mostly work with folks where there's alcoholism or if there's other substances or so on, just kinda any differences or nuances that you've kind of noticed with folks, in these different processes.
Kara Fletcher, Ph.D., MSW, RSW (33:43):
I think so when I worked in public systems, it was a real wide range of substance use, usually polysubstance use and anything you could think of. Now that I'm mostly doing therapy in the private sector, it tends to be more, alcohol and I would say alcohol and cannabis and cocaine seem to be the top three that people are using or struggling with. In terms of differences, you know, how that plays out in therapy, I don't actually see much of a difference other than the shame around the substance. So we have socially acceptable substances and we have ones that are not socially acceptable. So, I think that shame is very apparent, when we start talking about that. Or, and I'm also thinking too, addiction to prescription medicine is something else I see quite frequently.
Kara Fletcher, Ph.D., MSW, RSW (34:42):
And there's a lot of shame when their use involves illegal activity.
Keith Sutton, Psy.D. (34:53):
And I was thinking too, I don't know if you, how do you or would you or have you dealt with the situation if you've had a client under the influence, coming to a session?
Kara Fletcher, Ph.D., MSW, RSW (35:06):
Actually, I think one of my very first, it was individual therapy. One of my very first clients when I was working in the public sector out in Vancouver came in high on heroin. And I was very green. I was like fresh out of my master's. And first of all, I didn't really know what was going on, and then they shared with me what they had taken. And so we just had, like, a containing conversation in the room. And then, I got them set up in kind of a spare room until with some water and some snacks until they kind of came down. And then they were within walking distance, thankfully. They weren't driving. But basically, they stayed in the building until they were sober enough to safely go home.
Kara Fletcher, Ph.D., MSW, RSW (36:02):
So I think it's funny, because I think that's the only time that happened to me, and it was probably my first or second day of work. So it was very jarring. I was like, "Why, why are they lying on the floor? What's happening here? But oh yeah. So it's like, is this "what my job's going to be like?".
Keith Sutton, Psy.D. (36:25):
And I have very, you know, kinda mixed feelings about, like, of course, if, I don't know, if somebody's drunk or something, like, you know, it's especially depending if you're in a couple session or something, it may not be safe or so on. But, like, sometimes there are people that are, you know, opioid or heroin users that are just maintenance and if they are not using, then they're going through, like, withdrawals.
Kara Fletcher, Ph.D., MSW, RSW (36:46):
Exactly.
Keith Sutton, Psy.D. (36:47):
And or cannabis users that are kind of just, you know, daily every day, you know, kind of using cannabis or so on. And then that question about, like, how do you, you know, addressing and how do you, do you not work with them or, or tell them, you know, to ideally not be using, but sometimes there is that kind of aspect of how you decide what to do. So, I think it's really complex or even, you know, realizing that you might not be able to make any progress today because of what's going on and needing to end the session or so on. And then kind of finding another date or time.
Kara Fletcher, Ph.D., MSW, RSW (37:26):
Absolutely. I think if I were to have that happen in a couple session, I don't think... Not that I can remember that that has ever happened in a couple session, but I think I would say it's not the, not the right moment for us working together.
Keith Sutton, Psy.D. (37:41):
So what any other pieces that you think would be really important for therapists to know in working with couples where there might be addiction or there might be early recovery.
Kara Fletcher, Ph.D., MSW, RSW (37:55):
I think one big one is don't assume that the addiction is the problem., I've had lots of couples tell me that the second they mention addiction, that's what the therapist has hyper-focused onAnd then it's like the rest of their issues don't exist and so I think that's a really important one to make sure we're clarifying, like, is that the thing that you want to work on or talk about? Or are there other things too? So usually I find with couples, it's like, yes and we want to talk about this and we want to talk about this, this, this, this, this. And so then making sure that I'm being respectful of their goals for therapy..
Keith Sutton, Psy.D. (38:40):
So not just kinda--
Kara Fletcher, Ph.D., MSW, RSW (38:41):
That's a big one because--
Keith Sutton, Psy.D. (38:45):
Kinda just not going off in that direction because they might think that, they might even be afraid to share about the addiction or so on for fear that it's going to hijack the entire therapy.
Kara Fletcher, Ph.D., MSW, RSW (38:56):
Exactly. And I mean, I also work from a, like a harm reduction focus, so I encourage, you know, people to think about where they fall in terms of what they want their substances to look like today, tomorrow, next week, five years from now. And that, you know, I respect whatever that decision is. So I'm not, you know, pushing people towards abstinence if that's not what they're going for. I think in most cases in a couple contexts, that's where people are at is that they want abstinence, but not always. And so things like relapse is I think another good thing to consider is to, to let the couple share that experience with you, and what they make of it and how they understand it as opposed to having a reaction to it, right?
Kara Fletcher, Ph.D., MSW, RSW (39:55):
Like some people very much think relapse is part of recovery and other people think it's, you know, a horrible traumatizing event. And so we have to really work with where they're at in terms of that experience too.
Keith Sutton, Psy.D. (40:15):
But I think that aspect, that you're mentioning about, you know, relapse being something that again, being curious about as a therapist about what that means maybe rather than jumping to conclusion that it's an extreme, like, betrayal, because it could go either way. It could be something that's not as big as a bump as the therapist might be thinking, so really staying with the couple.
Kara Fletcher, Ph.D., MSW, RSW (40:41):
Yes, exactly.
Keith Sutton, Psy.D. (40:44):
Definitely. Well, this is great. And it sounds like you're doing wonderful work and I think this is such an area where, you know, as I was looking, right, there's, there's not a lot of research and particularly, you know, again, also bringing in that EFT, the attachment-based piece. It makes me think of that concept of the hungry ghost. That there's kind of, like, emptiness that's not there that is trying to be filled. And not necessarily that they're, right, switching their addiction to their partner to kind of get them to fill that, but also that there is that kind of aloneness and disconnect and being able to be connected authentically in one's present relationship if it is a committed relationship where there is that depth there. Then, you know, being able to bring that in as part of the recovery process.
Keith Sutton, Psy.D. (41:39):
And can you tell me a little bit about what you've been working on lately?
Kara Fletcher, Ph.D., MSW, RSW (41:43):
So I've been, looking at, couples and relationship functioning where one partner, has started adopting conspiracy theories or misinformation, and looking at what are some kind of therapy potentials or options in working with those couples who feel like where one partner, is no longer living in the same world as the other partner.
Keith Sutton, Psy.D. (42:09):
What are the interventions or what are you doing? I've actually--
Kara Fletcher, Ph.D., MSW, RSW (42:14):
So, right, we're just starting. So we've started with a systematic review and a scoping review of what exists out there. There's very little research currently. And then we did a pilot study where we've been talking to people who feel they've lost their loved ones to conspiracy theories. And so I am curious about trialing something like EFT or an attachment-based therapy. To see, and, you know, in my own practice, just anecdotally, I'm seeing it come up with couples. So looking at, can we just work with people on a very kind of basic attachment level to see what's there in terms of connection. And even core values, and what comes next. So that's, it's all just kind of starting right now, but that's what I'm up to right now.
Keith Sutton, Psy.D. (43:05):
Interesting. And have you been in your own couples that you've worked with, have you been seeing any trends or any kind of--
Kara Fletcher, Ph.D., MSW, RSW (43:13):
So, I mean, I'm in Canada, but we are so influenced by the United States and your news cycle and your politics. And I think since Donald Trump back into, you know, 2016 and then, the COVID pandemic in 2020, there's been an uptick certainly in people coming in saying, "I don't even recognize my husband anymore. He listens only to, like, you know, these podcasts that are espousing very, you know, hard right conspiracy theories. They're going down rabbit holes. They've got these theories about COVID, about vaccines, about all of these things, and I don't even know if I can live with him anymore." So that kind of experience I'm seeing all the time.
Keith Sutton, Psy.D. (44:02):
That's definitely even just coming up just personally knowing, you know, kind of the ancillary, couples that went through that. And it was just they didn't even kind of know the person they were with anymore. The point where--
Kara Fletcher, Ph.D., MSW, RSW (44:15):
So, sometimes it's ending in divorce. But in lots of cases, it's like, "I love this person. They're a good person. I just don't recognize them anymore. So what do I do? " And so that's what we're working on. We're trying to see if we can find ways to work with these couples that is productive and helpful for both people.
Keith Sutton, Psy.D. (44:35):
Great. Well, I look forward to, you know, learning about that and the research that you come up with, because I think that's a huge issue that happens for a lot of people. Not only just in couples, but in families too. All of a sudden things shifting, you know, over a period of time where they have a hard time relating and just the values are so different that, you know, sometimes it feels about just core human values feels so off. Well, great. Well, thank you so much. This is wonderful., I really appreciate you taking the time today.
Kara Fletcher, Ph.D., MSW, RSW (45:13):
My pleasure. Thanks for having me.
Keith Sutton, Psy.D. (45:15):
Okay. Bye-bye.
Kara Fletcher, Ph.D., MSW, RSW (45:17):
Bye.
Keith Sutton, Psy.D. (45:18):
Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on - demand workshops, consultation groups, and online One-Way Mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults with our licensed experienced therapists in person in the Bay Area or throughout California online and our employment opportunities, go to SFIAP.com. To learn more about our associateships and psych assistantships and low-fee treatment through our nonprofit, Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC's website at sf-bacc.org.
Keith Sutton, Psy.D. (46:25):
BACC is a 501 nonprofit, so all donations are tax-deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in - person and online trainings, on- demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach with our lifespan centers, Center for Children, and Center for Adolescents, where all the therapists are working systemically, our Center for Couples, where all the therapists are using emotionally focused couples therapy, and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma, and our Center for ADHD and Oppositional and Conduct Disorder Clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:32):
In the Institute, we have our licensed experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com, and to support our nonprofit, you can go to SF-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501 nonprofit, so all donations are tax deductible. Today, I'll be speaking with Kara Fletcher, PhD MSW RSW, who is the director of the Social Work Research Center at the University of Regina and an associate professor at the University of Regina Faculty of Social Work, Saskatoon Campus.
Keith Sutton, Psy.D. (02:36):
She is also a trained American Association of Marriage and Family Therapist, Couple and Family Therapist. Her program of research seeks to better understand the impacts of mental wellness, substance use, and trauma on couple family and community wellbeing. Her current research is considering the impact of conspiracy theories, misinformation, and political polarization on intimate relationships. Kara recently published Integrative Approaches to Couple and Family Therapy in Canada: A Beginner's Guide. Let's listen to the interview. Well, hi, Kara. Welcome. Thanks for joining us.
Kara Fletcher, Ph.D., MSW, RSW (03:09):
Thank you for having me.
Keith Sutton, Psy.D. (03:11):
Well, I'm so interested to hear about your work. So I was doing some research and looking at research papers on working with couples with addiction and also looking emotionally focused couples therapy. And then I happened upon, I think it might have been your dissertation research and there was another paper that you had done with a previous guest of mine, Heather McIntosh, who does work with complex trauma and couples. So I reached out and was wanting to learn more. And so before we even get into the work that you're doing or the, that you've written about, I always love to hear about kind of people's evolution of their thinking and how you got to doing what you're doing.
Kara Fletcher, Ph.D., MSW, RSW (03:51):
Sure, so I did... When I was doing my master's training, I was training in Montreal in a couple and family therapy clinic. So I was really had a systems training at that point. And I then moved to Vancouver, BC, and I was working out of my master's in an outpatient, addiction and mental health clinic. And I was struck there by how many of my clients wanted to bring in their, either their romantic partner or their family member, into the session with them to talk about their substance use challenges. And when I went to kind of see what was best practice in terms of doing that work, there was very little out there, at the time. This was back in 2009, 2010. And there was a lot of behavioral couples therapy, but nothing really that spoke to how I liked to work with, with couples or with families.
Kara Fletcher, Ph.D., MSW, RSW (04:52):
So at that point that I just started doing couples work and kind of doing what worked at the time and I was using a lot of emotionally focused therapy., and I discovered there was a theoretical extension that someone had proposed using EFT. So that was when I decided to go back to school, do my PhD at McGill University and look at how possible or plausible is this, is the use of EFT in the context of substance use and addictions? And so that's kind of how I got there was knowing I already liked working systemically with couples and families and then really seeing the desire from clients to do that kind of work.
Keith Sutton, Psy.D. (05:35):
Great. Wonderful. I think that when I did my EFT training many years ago, kind of the party line was, it's contraindicated when there's addiction, and so on. And so, that's, I'm really interested. So tell me about what you found and your experience over time in working with couples with addiction.
Kara Fletcher, Ph.D., MSW, RSW (05:56):
I had the same experience that it was contraindicated and I did even at that, at the time when I was bringing in family members have some supervisors being like, "Is this ethical? Like, what are you doing?", and I think one of the things is that I think that comes from the history of how we've worked with addictions. Like we've really come from this kind of fear-based and then behavioral model of understanding addiction. And for me, the evolution was really looking at addiction through the lens of attachment and thinking about all the ways in which people don't set out to get an addict to become addicted to something, right? Really it's, usually initially quite an adaptive choice at managing suffering or pain or whatever's happening for them. And then that, you know, slowly gets out of control for them.
Kara Fletcher, Ph.D., MSW, RSW (06:46):
So if we... I thought if we were conceptualizing it more as an issue of attachment or using that lens, then actually strengthening the couple relationship is a possibility for removing the dependence or lessening the dependence on the substance. So I would say that my research, when I did my doctoral research, I was doing a multiple baseline case study with four different couples. And it was actually quite amazing. First of all, when I went to advertise people, I had a wait list. People wanted to be part of the study. They wanted to participate in this. And then, certainly there were challenges. So I think what I learned was there has to be some level of stability around the substance use for couples' work to make sense. So if someone's just not functioning very well because they're using all of time, they can't really engage fully in couples therapy.
Kara Fletcher, Ph.D., MSW, RSW (07:44):
But, if there is stability and if there is like a core connection in the relationship with it. Which they think is worth working on or addressing, then it's quite hopeful work. People are really into it and wanting to make their relationship stronger and lessen all of this anxiety and I would say it's sometimes hyper-focused on the addictive element.
Keith Sutton, Psy.D. (08:10):
Okay. And were most of the couples in recovery that were coming to you? Were they in active addiction? Were they in early recovery?
Kara Fletcher, Ph.D., MSW, RSW (08:21):
So I think they were all in early recovery, when I met with them. One, two... now I'm just trying to remember now. Two of them relapsed during the course of therapy, but very briefly. And so we were able to kind of get back on track and actually have a productive conversation around relapse and how we think about relapse and what it means. And, again, I think some of the kind of early literature around addiction and, and that idea of, like, codependence created some, challenges in those spaces because, what a lot of the, the person who wasn't using or addicted to substances would say is, like, "I've been told to detach from this person. I've been told not to enable them. I've been told all of these things. And so I'm in this inner conflict where I love them.
Kara Fletcher, Ph.D., MSW, RSW (09:12):
I think they're more than their addiction, there's lots of great things about a relationship, but it's still hard when they, when they relapse or when I can tell that they're craving" or when these things, these dynamics are playing out in the relationship. So it was a mix, but I think certainly we had, two of the couples had, had sustained recovery, throughout the study. And, you saw, like, just the benefit in terms of their relationship. They started kind of sharing feelings and emotions with each other, which had felt too frightening, in the past, which was pretty powerful.
Keith Sutton, Psy.D. (09:52):
Great. And can you talk about that codependent aspect and kind of how you worked with that? And, I don't know if this is a part of your practice now since you've gotten your doctorate and so on. Or working with more couples around this, but, what's your thinking around that aspect of that dirty word of, codependency and enabling and so on, but also, right, an attachment relationship?
Kara Fletcher, Ph.D., MSW, RSW (10:21):
I guess I really, still draw from how Sue Johnson conceptualized dependency and saying that we need to have effective dependence. On each other as humans, right, and in relationships. So I think we have kind of wrongly pathologized dependence, but we're interactional human beings. Everything is relational. And so I think just if someone wants to identify themselves as codependent, that's their call. But, I will often gently suggest that actually dependence itself is adaptive and healthy. It's how we do it that matters, right? And how we are dependent on each other in a ways that are functional and healthy for us, as opposed to, you know, really having someone else take over for you, then that's maybe not the healthiest type of dependence.
Kara Fletcher, Ph.D., MSW, RSW (11:18):
So I try to work with couples towards: can we create effective dependency in this relationship? What does that look like? And then we can compare it to substance use, right? Substance use is not usually an effective dependency, right? It becomes ineffective very quickly. So how can we actually think about that relationship and then the types of relationships we want to have with the people we love in our lives, and to challenge that and what that looks like? And for most of my clients, you know, even now as I'm working, when they really look at it, it really always comes back to attachment and insecurity and feeling like they just want someone who's consistent, responsive, caring, reassuring, et cetera.
Keith Sutton, Psy.D. (12:05):
I guess they conceptualize our thought as, like, the healthy interdependence that there's dependence, but they're also able to be, have boundaries and have independence. And I remember talking to Sue during my externship and talking about models that maybe were like, oh, each person has to go off and get their own therapist and become whole. She's like, that's a way to just flare up the insecure, relationship or the dynamic. But when we have that secure relationship, we can be independent because we have that healthy dependence that's going on.
Kara Fletcher, Ph.D., MSW, RSW (12:37):
Yes. And sometimes starting with the relationship increases that ability, right, to go because of that feels so solid, they feel more like they can go off and get their own therapy or they can go and make a big move in their own kind of independent life. .
Keith Sutton, Psy.D. (12:53):
Can you maybe talk about, or give some examples about, like, you know, what that looks like, that healthy dependence/ you know, kind of codependence kind of in a situation where you've got somebody who... I don't know, we've got maybe one partner who's in recovery, the other one who's maybe not in addiction. Maybe the one who's not in addiction is anxious about the other relapsing or whether there's been lying or so on, and the other one...Or I don't know what a common dynamic is that you experience or notice in couples. I know there's a, of course, a pursuer withdrawer dynamic in EFT.
Kara Fletcher, Ph.D., MSW, RSW (13:33):
I think quite often in these couples, it varies, but I would say there's often a pattern of, the person who's in early recovery is the more withdrawn withdrawer position and then their partner, the more the pursuer. And for good reason, right? There's anxiety that's built up around maybe lack of trust or some sort of injury in their relationship throughout the, you know, course of an addiction. And so, where the changes and I think where EFT works beautifully is recognizing that cycle, recognizing the role that addiction plays in the couple's cycle. And then once they kind of understand those positions, encouraging, especially that more withdrawn partner to take a new position where maybe instead of reaching for a drink or reaching for, I don't know, whatever it was that they were doing, some sort of maladaptive coping strategy.
Kara Fletcher, Ph.D., MSW, RSW (14:35):
What would happen if they just tried reaching for their partner and then working with the partner, how could you be there for them in this consist of responsible, or responsive, sorry, gentle way where you say, "I see you, I hear you. It's hard for you, but I'm not afraid of you struggling," right? So to lessen that fear in the... Because I think that anxiety gets activated so quickly, that the withdrawn partners afraid to say I'm struggling because they don't want to cause their partner to, you know, freak out or become hypervigilant or whatever, right? So that, that I've seen and I, and why I like, you know, EFT specifically and I'm not like a theoretical purist in any way. I integrate a bunch of different pieces in my work, but that I think EFT works so beautifully.
Kara Fletcher, Ph.D., MSW, RSW (15:28):
Like it just makes sense to couples. And then once they are able to do that, then you can do some really powerful enactments in session and have them really both kind of soft and responsive, which is in some cases, the first time that's ever happened in their relationship.
Keith Sutton, Psy.D. (15:51):
Sure. I imagine I'm thinking of someone now who maybe is steeped in working with addiction and they're like, "Oh, no, but you're just trading the addiction because now the person is just going to their partner to manage all their urges or their overwhelm or so on." Do you have any thoughts on that or, or kind of how it's different in a EFT kind of way?
Kara Fletcher, Ph.D., MSW, RSW (16:15):
I think it is different. I mean, I think, I don't think that their partners should be their only resource. Sure. Right? Like I think they should have hopefully lots of good supports in place and I certainly will work with my clients on that. Like what else? Like where can you go? Who can you go to? But if we're thinking again with that attachment lens, and can we be safe havens for one another in this relational way. I don't think we need to pathologize someone going to their partner to say, "I'm struggling." I think it would be very different if they were going to their partner and saying, "You're the only thing that keeps me sober. I can't live without you, " you know? That's not healthy, right? But if it's more like I have never made it a habit to reach out and to say I'm struggling and now I'm practicing this and I'm actually getting a gentle and affirmative response, that makes them want to do it more, right?
Kara Fletcher, Ph.D., MSW, RSW (17:12):
Because it feels good and you feel close and connected and all of those good feelings--You're not alone. Yeah, you're not alone. And so I think that the part. So it's not all or nothing. And in the addiction world, I think, you know, a lot of people who develop substance use disorders have all or nothing thinking so it is about challenging that. But, I think there's lots of benefit to strengthening that love relationship that already exists, right? And building on it.
Keith Sutton, Psy.D. (17:43):
Well, and, you know, and it's such a big part of addiction also is the shame and sometimes the hiding or the secrecy in all those. And, you know, one part of the 12-step programs is having people kind of speak and share and all these things that maybe they kind of were keeping secret and talking to sponsors and so on. And so it's nice to be able to then take those risks to be vulnerable with one's partner to be able to talk about those struggles and actually have them showing up. had somebody on the podcast, Bob Navarro, who does work with addiction couples and Gottman work. And he talked a lot about the trauma that the non-addicted partner, if there's a non-addicted partner, is often I'm struggling with, from the numerous betrayals or relapses or the scary things that might have happened and the overdoses or so on.
Keith Sutton, Psy.D. (18:44):
Can you talk a little bit about that? Because I imagine, like, you're saying the anxiety that they might feel hearing their partner saying they are feeling that urge or going to go relapse or, you know whatever it might be. Can you share any thoughts on that?
Kara Fletcher, Ph.D., MSW, RSW (19:01):
I think that's very true. There's that whole experience, especially if it's gone on for a long time, I think is, there's, there's a lot of trauma that's experienced there. So I think in the same way that the non, you know, substance using or non-addicted partner can support their partner coming to them saying they're struggling, that has to happen the other way around, right? So I'm struggling to trust, I'm fearful, all of those feelings. The other partner has to be able to hold that with them, right? And so we work on that. So to say things like, "I hear you. I understand. It's hard to trust me. I get it. And it's going to take time." As opposed to, like, activating that defensive cycle, right, where you're never going to trust me.
Kara Fletcher, Ph.D., MSW, RSW (19:59):
You're always going to think of me as an addict, or whatever that kind of that defensive action is there. And instead to hear and to have empathy for, the pain that, that still exists, the hurt that still exists, and, like, the need for reassurance that, like, we all need reassurance and we all need consistent, you know, reliable connection. So, they have to be able to provide that for it to work.
Keith Sutton, Psy.D. (20:30):
Well, that validation, that acceptance.
Kara Fletcher, Ph.D., MSW, RSW (20:34):
And so that once... And it's funny because I work a lot with couples where there's infidelity as well, right?
Keith Sutton, Psy.D. (20:41):
Infidelity doubt.
Kara Fletcher, Ph.D., MSW, RSW (20:42):
It's the same thing. It's like, at a certain point, you have to stop the defensive cycle and say, "I get it, and it's going to take time, and I'm sorry, and I'm here.""I'm not going anywhere," you know?
Keith Sutton, Psy.D. (20:55):
And those feelings may come up even months, years later. Of that, you know, kinda being reminded of that betrayal or whatever might happen and--
Kara Fletcher, Ph.D., MSW, RSW (21:06):
And actually I just--
Keith Sutton, Psy.D. (21:07):
Or not being able to turn to them and, be able to say, "I'm scared," or, "It makes me think about this, " like, and getting that reassurance or being seen or held in that.
Kara Fletcher, Ph.D., MSW, RSW (21:16):
And I'm just thinking of a couple I'm working with and recently one of them said, "Hey, I just have to ask you, like, you did this thing last night that reminded me of when you were using. Are you using?" And instead of getting defensive, their partner was like, "No, I'm not using, but I can see how you made that association. And I, you know, I'll try not to... " I can't remember exactly what it was that he had done, but it's like, "I'll try not to do that anymore because I can see that you're connecting that to the... " So he wasn't... It didn't start a defensive cycle. She was able to ask with clarity and he was... He... I didn't have to do anything. He other than, you know, punctuate what had happened. But he--
Keith Sutton, Psy.D. (21:59):
That's great.
Kara Fletcher, Ph.D., MSW, RSW (22:00):
He was able to get in there and respond that way, which was very relieving for her, right?
Keith Sutton, Psy.D. (22:04):
Definitely. And oftentimes when you have that more secure attachment, you feel like even if the person's having this feeling about you, you know, you're still have that connection, so being able to kind of tolerate that. And talk about it rather than going into a panic of needing to defend and explain how you're not this person they're seeing you as.
Kara Fletcher, Ph.D., MSW, RSW (22:24):
Totally.
Keith Sutton, Psy.D. (22:26):
So, and one of the things you were saying is the, you know, that there is the addiction's not inactive addiction. And I'm curious about your thoughts or conceptualizations on when there is a couple where there is addiction, either one or, or more than one, and how you think about that, what you have suggestions or even how you work with that.
Kara Fletcher, Ph.D., MSW, RSW (22:54):
So where, when they're still, like, using pretty frequently? Is that what--
Keith Sutton, Psy.D. (22:58):
When there's, when a couple comes in, maybe they're not even necessarily coming in because of the addiction, but as you're working together, you find out that, you know, this is, this is a big issue in their relationship. .
Kara Fletcher, Ph.D., MSW, RSW (23:09):
I wouldn't... I'm still not,... It would be very unlikely that I would send them away. I really, truly, because I think if they're there, there's pieces that you can still kind of address together. And I think people so often get sent away in these situations where they're like, "We just want someone to talk to about this." So I would say there's a few different things that I think about. One is, if someone's in active addiction, I wouldn't use something like EFT. I think it's too heightening, and it can, you know, if you're not clear in your mind and someone's using EFT with you, I think it can go sideways very quickly and become overactivating and not useful for either partner. So I might get more behavioral in approach with them.
Kara Fletcher, Ph.D., MSW, RSW (24:01):
I might also be really, like, honest. "Okay, you're still... This is what this looks like until this changes, and I'm not telling you to change anything, but until we have a slightly different situation, we're limited in what we can do together. So here's some things we can do. So maybe it's, like, basic communication stuff or, you know, maybe there's a specific thing that they want to kind of target together. Great, we can do that. But, in terms of really looking at relating and their cycle together and their, getting them kind of processing on an emotional level, it might not be the right time for that and I'll be honest about that. So, I'm not there to tell anyone that they have to stop using, right? And it is, I would say, and maybe you've experienced this in your work, but quite often you'll get people in and they're not there for substance use at all, but then you get to talking.
Kara Fletcher, Ph.D., MSW, RSW (25:01):
And you're like, "Okay, so every night you're doing this," how on earth are you clear enough to address some of the other challenges you're having, right? So, I think we have a bigger reaction when it's, you know, more illicit substances than if someone says they're struggling with alcohol or cannabis use. I think that's all embedded in class and race and all of that stuff, right? So I try not to have a big reaction to any of that, but I will be honest in terms of what's possible for our work together.
Keith Sutton, Psy.D. (25:38):
Definitely. I've had situations where I have worked with couples and I've almost thought about the EFT as, like, almost motivational interviewing for change sometimes as they're hearing their partner's experience and the feeling alone, this fear, the longing, and so on of the non-addicted partner, oftentimes that as the other person hears that vulnerability, they feel empathy and then it kinda this dissonance between, "I don't want to be hurting this person I love, but at the same time, I can't, you know, I don't know if I want to not have this use and sometimes even moving someone into treatment, you know, kinda through that process, versus, like, maybe if it was just kinda nagging or annoying or avoidance or someone kinda processes.
Kara Fletcher, Ph.D., MSW, RSW (26:35):
Yes. And you saying that makes me think, too, of, even just the hearing of that, like, hearing their partners say that, like, " I want to be different. I don't know how to get there." That can be powerful enough. That can be therapeutic, or maybe therapeutic frame is then really about supporting that person and having their other partner be a witness to that support, right? Like, that can happen too. But just being clear about what is it we're doing here? Are we all okay with this? Does this make sense?
Keith Sutton, Psy.D. (27:11):
Definitely. In a situation, where maybe there's active use or even two partners actively using, which I think is extremely hard because, you know, oftentimes, even if one is trying to make a change, the other one is, like, it's like if two people are trying to work on their eating or health. Like, one's like, "Oh, I'm going to have ice cream tonight." The other one's like, "Okay, I'll have ice cream too." And they just kinda ping pong off of each other until one of them finally decides, like, okay, I'm making this change regardless of what the other one is doing. But I think that's very hard oftentimes for couples where there's an addiction piece where both are struggling with addiction, smoking, or drinking, or opioids, or whatever is kinda going on.
Kara Fletcher, Ph.D., MSW, RSW (27:54):
Totally. And I have seen couples where that's the case and they joke about, like they met in the AA and it was the 13th step, right? Like getting together or whatever. But if they're both well, they're an ideal couple to work with because they, you know, they've really worked on things already, done a lot of individual growth. But if they're both still in, in active addiction, then it's, that'd be really tricky.
Keith Sutton, Psy.D. (28:19):
Definitely. And so, what are the different ways that you kinda notice in working with couples with addiction about how things show up, how things progress in treatment? Things for therapists to kinda be thinking about in, in their work, if they do work with a couple that's dealing with--
Kara Fletcher, Ph.D., MSW, RSW (28:43):
I think when they come in and they're transparent about the substance use issue, it's almost easier. Because I find that I get a probably fifty fifty, right? And then the others, like, it's like the hidden agenda, like- "He's got an alcohol issue, I need you to help me with that." You know, that kind of, that's actually harder because there's usually a much more shame. Maybe a hyper-focus, so there's some things there. But so I guess that would be the one thing to be aware of is, is there a hidden agenda there? And then, you know, what is the capacity or willingness for change in that area? But if they're both coming in and one partner's, you know, in early recovery or what have you, I'm always just really interested initially in terms of, what's the cycle?
Kara Fletcher, Ph.D., MSW, RSW (29:34):
So how did the addiction show up in the cycle? How does it now? So where are they at in terms of trust with each other? That's usually the big one. And so trust is usually low. And then also there's often the kind of the, like, imbalance in the power dynamic in the couple, the well one and the sick one. And, you know, the functional one and the dysfunctional one and the shame around that. So those are the things that I'm thinking about right away and so making sure that I'm creating good relationship with the person who's likely to feel more shamed. More ganged up upon, you know, more like the dysfunctional identified patient person in the space. Because if you don't have them, you're not going to do anything, right?
Kara Fletcher, Ph.D., MSW, RSW (30:31):
And also, I guess the other big one is anger, right? Sometimes these couples come in and they're angry. They're so angry. So getting them as smoothly as possible to kind of move into their feelings and the other feelings that are there and then getting them talking to each other as soon as possible.
Keith Sutton, Psy.D. (30:53):
And, anger meaning both kind of being angry or more the one that's the pursuer that's kind of--
Kara Fletcher, Ph.D., MSW, RSW (31:00):
More the pursuer usually, but the other one is sometimes angry because they feel like undervalued or like all you see is my addiction or like I'm the failure and you're the, you know, the functioner, functional one and tired of like angry about being in that position all the time, even if there's been a period of like general wellness, right?
Keith Sutton, Psy.D. (31:23):
Well, and, I imagine too, just like other pursuers in other situations oftentimes they're trying to influence their partner in ways that aren't so vulnerable, so maybe criticism or pushing or things like that or you know, kind of, another person might feel nitpicked or so on. So kind of helping them be able to come at that more vulnerability. But I imagine, there's gotta be such a sense of helplessness and powerlessness on the partner without the addiction, trying to get the partner with the addiction to make changes that it might come out much more forcefully, aggressively or so on.
Kara Fletcher, Ph.D., MSW, RSW (32:01):
Absolutely. And I was just also thinking of another dynamic that can come up is, the pursuing partner, you know, it's quit blaming, shaming, you have the addiction, you have the problem. And then over time the, you know, partner with the addiction says, "But you know, you drink wine every night in front of me or like you do this thing that is its own, you know, and then the real fireworks come out, right? So like there's some, there's a real commitment to having one person be the problem, but when you, talking, it's like, okay, this is very interactional there's lots of things that can be done here to kind of help them get talking to each other about the things that are harmful or helpful.
Keith Sutton, Psy.D. (32:50):
Sure, definitely. Or it sounds like it's very one-sided in that case where the person is making changes to kind of help along with the process of the recovery. Not that it's their responsibility completely, but that they're in it together rather than just kind of, you know, they're not going to change. The other person has to make all the changes.
Kara Fletcher, Ph.D., MSW, RSW (33:12):
Exactly.
Keith Sutton, Psy.D. (33:15):
I'm curious about too, with the addiction and, I don't know if you've had different experiences or if you mostly work with folks where there's alcoholism or if there's other substances or so on, just kinda any differences or nuances that you've kind of noticed with folks, in these different processes.
Kara Fletcher, Ph.D., MSW, RSW (33:43):
I think so when I worked in public systems, it was a real wide range of substance use, usually polysubstance use and anything you could think of. Now that I'm mostly doing therapy in the private sector, it tends to be more, alcohol and I would say alcohol and cannabis and cocaine seem to be the top three that people are using or struggling with. In terms of differences, you know, how that plays out in therapy, I don't actually see much of a difference other than the shame around the substance. So we have socially acceptable substances and we have ones that are not socially acceptable. So, I think that shame is very apparent, when we start talking about that. Or, and I'm also thinking too, addiction to prescription medicine is something else I see quite frequently.
Kara Fletcher, Ph.D., MSW, RSW (34:42):
And there's a lot of shame when their use involves illegal activity.
Keith Sutton, Psy.D. (34:53):
And I was thinking too, I don't know if you, how do you or would you or have you dealt with the situation if you've had a client under the influence, coming to a session?
Kara Fletcher, Ph.D., MSW, RSW (35:06):
Actually, I think one of my very first, it was individual therapy. One of my very first clients when I was working in the public sector out in Vancouver came in high on heroin. And I was very green. I was like fresh out of my master's. And first of all, I didn't really know what was going on, and then they shared with me what they had taken. And so we just had, like, a containing conversation in the room. And then, I got them set up in kind of a spare room until with some water and some snacks until they kind of came down. And then they were within walking distance, thankfully. They weren't driving. But basically, they stayed in the building until they were sober enough to safely go home.
Kara Fletcher, Ph.D., MSW, RSW (36:02):
So I think it's funny, because I think that's the only time that happened to me, and it was probably my first or second day of work. So it was very jarring. I was like, "Why, why are they lying on the floor? What's happening here? But oh yeah. So it's like, is this "what my job's going to be like?".
Keith Sutton, Psy.D. (36:25):
And I have very, you know, kinda mixed feelings about, like, of course, if, I don't know, if somebody's drunk or something, like, you know, it's especially depending if you're in a couple session or something, it may not be safe or so on. But, like, sometimes there are people that are, you know, opioid or heroin users that are just maintenance and if they are not using, then they're going through, like, withdrawals.
Kara Fletcher, Ph.D., MSW, RSW (36:46):
Exactly.
Keith Sutton, Psy.D. (36:47):
And or cannabis users that are kind of just, you know, daily every day, you know, kind of using cannabis or so on. And then that question about, like, how do you, you know, addressing and how do you, do you not work with them or, or tell them, you know, to ideally not be using, but sometimes there is that kind of aspect of how you decide what to do. So, I think it's really complex or even, you know, realizing that you might not be able to make any progress today because of what's going on and needing to end the session or so on. And then kind of finding another date or time.
Kara Fletcher, Ph.D., MSW, RSW (37:26):
Absolutely. I think if I were to have that happen in a couple session, I don't think... Not that I can remember that that has ever happened in a couple session, but I think I would say it's not the, not the right moment for us working together.
Keith Sutton, Psy.D. (37:41):
So what any other pieces that you think would be really important for therapists to know in working with couples where there might be addiction or there might be early recovery.
Kara Fletcher, Ph.D., MSW, RSW (37:55):
I think one big one is don't assume that the addiction is the problem., I've had lots of couples tell me that the second they mention addiction, that's what the therapist has hyper-focused onAnd then it's like the rest of their issues don't exist and so I think that's a really important one to make sure we're clarifying, like, is that the thing that you want to work on or talk about? Or are there other things too? So usually I find with couples, it's like, yes and we want to talk about this and we want to talk about this, this, this, this, this. And so then making sure that I'm being respectful of their goals for therapy..
Keith Sutton, Psy.D. (38:40):
So not just kinda--
Kara Fletcher, Ph.D., MSW, RSW (38:41):
That's a big one because--
Keith Sutton, Psy.D. (38:45):
Kinda just not going off in that direction because they might think that, they might even be afraid to share about the addiction or so on for fear that it's going to hijack the entire therapy.
Kara Fletcher, Ph.D., MSW, RSW (38:56):
Exactly. And I mean, I also work from a, like a harm reduction focus, so I encourage, you know, people to think about where they fall in terms of what they want their substances to look like today, tomorrow, next week, five years from now. And that, you know, I respect whatever that decision is. So I'm not, you know, pushing people towards abstinence if that's not what they're going for. I think in most cases in a couple contexts, that's where people are at is that they want abstinence, but not always. And so things like relapse is I think another good thing to consider is to, to let the couple share that experience with you, and what they make of it and how they understand it as opposed to having a reaction to it, right?
Kara Fletcher, Ph.D., MSW, RSW (39:55):
Like some people very much think relapse is part of recovery and other people think it's, you know, a horrible traumatizing event. And so we have to really work with where they're at in terms of that experience too.
Keith Sutton, Psy.D. (40:15):
But I think that aspect, that you're mentioning about, you know, relapse being something that again, being curious about as a therapist about what that means maybe rather than jumping to conclusion that it's an extreme, like, betrayal, because it could go either way. It could be something that's not as big as a bump as the therapist might be thinking, so really staying with the couple.
Kara Fletcher, Ph.D., MSW, RSW (40:41):
Yes, exactly.
Keith Sutton, Psy.D. (40:44):
Definitely. Well, this is great. And it sounds like you're doing wonderful work and I think this is such an area where, you know, as I was looking, right, there's, there's not a lot of research and particularly, you know, again, also bringing in that EFT, the attachment-based piece. It makes me think of that concept of the hungry ghost. That there's kind of, like, emptiness that's not there that is trying to be filled. And not necessarily that they're, right, switching their addiction to their partner to kind of get them to fill that, but also that there is that kind of aloneness and disconnect and being able to be connected authentically in one's present relationship if it is a committed relationship where there is that depth there. Then, you know, being able to bring that in as part of the recovery process.
Keith Sutton, Psy.D. (41:39):
And can you tell me a little bit about what you've been working on lately?
Kara Fletcher, Ph.D., MSW, RSW (41:43):
So I've been, looking at, couples and relationship functioning where one partner, has started adopting conspiracy theories or misinformation, and looking at what are some kind of therapy potentials or options in working with those couples who feel like where one partner, is no longer living in the same world as the other partner.
Keith Sutton, Psy.D. (42:09):
What are the interventions or what are you doing? I've actually--
Kara Fletcher, Ph.D., MSW, RSW (42:14):
So, right, we're just starting. So we've started with a systematic review and a scoping review of what exists out there. There's very little research currently. And then we did a pilot study where we've been talking to people who feel they've lost their loved ones to conspiracy theories. And so I am curious about trialing something like EFT or an attachment-based therapy. To see, and, you know, in my own practice, just anecdotally, I'm seeing it come up with couples. So looking at, can we just work with people on a very kind of basic attachment level to see what's there in terms of connection. And even core values, and what comes next. So that's, it's all just kind of starting right now, but that's what I'm up to right now.
Keith Sutton, Psy.D. (43:05):
Interesting. And have you been in your own couples that you've worked with, have you been seeing any trends or any kind of--
Kara Fletcher, Ph.D., MSW, RSW (43:13):
So, I mean, I'm in Canada, but we are so influenced by the United States and your news cycle and your politics. And I think since Donald Trump back into, you know, 2016 and then, the COVID pandemic in 2020, there's been an uptick certainly in people coming in saying, "I don't even recognize my husband anymore. He listens only to, like, you know, these podcasts that are espousing very, you know, hard right conspiracy theories. They're going down rabbit holes. They've got these theories about COVID, about vaccines, about all of these things, and I don't even know if I can live with him anymore." So that kind of experience I'm seeing all the time.
Keith Sutton, Psy.D. (44:02):
That's definitely even just coming up just personally knowing, you know, kind of the ancillary, couples that went through that. And it was just they didn't even kind of know the person they were with anymore. The point where--
Kara Fletcher, Ph.D., MSW, RSW (44:15):
So, sometimes it's ending in divorce. But in lots of cases, it's like, "I love this person. They're a good person. I just don't recognize them anymore. So what do I do? " And so that's what we're working on. We're trying to see if we can find ways to work with these couples that is productive and helpful for both people.
Keith Sutton, Psy.D. (44:35):
Great. Well, I look forward to, you know, learning about that and the research that you come up with, because I think that's a huge issue that happens for a lot of people. Not only just in couples, but in families too. All of a sudden things shifting, you know, over a period of time where they have a hard time relating and just the values are so different that, you know, sometimes it feels about just core human values feels so off. Well, great. Well, thank you so much. This is wonderful., I really appreciate you taking the time today.
Kara Fletcher, Ph.D., MSW, RSW (45:13):
My pleasure. Thanks for having me.
Keith Sutton, Psy.D. (45:15):
Okay. Bye-bye.
Kara Fletcher, Ph.D., MSW, RSW (45:17):
Bye.
Keith Sutton, Psy.D. (45:18):
Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on - demand workshops, consultation groups, and online One-Way Mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults with our licensed experienced therapists in person in the Bay Area or throughout California online and our employment opportunities, go to SFIAP.com. To learn more about our associateships and psych assistantships and low-fee treatment through our nonprofit, Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC's website at sf-bacc.org.
Keith Sutton, Psy.D. (46:25):
BACC is a 501 nonprofit, so all donations are tax-deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.