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Robert Navarra, Psy.D., LMFT, MAC - Guest
Robert Navarra, Psy.D., LMFT, MAC is a Licensed Marriage and Family Therapist, Certified Gottman Therapist and Master Trainer, and holds National Certification as a Master Addiction Counselor. He has trained counselors and therapists nationally and internationally. Dr. Navarra has co-authored several book chapters with Drs. John and Julie Gottman, and co-authored articles on Gottman Therapy for The Encyclopedia of Couple and Family Therapy with Dr. John Gottman. Based on his research at Mental Research Institute in Palo Alto California, Bob created “Roadmap for the Journey: A Path for Couple Recovery”, a two-day workshop for couples in recovery from an addictive disorder. “Roadmap for the Journey” has been a featured workshop at Hazelden Betty Ford and has been given at treatment programs as well as in small, semi-private workshop settings. Bob and John Gottman are currently researching the impact of Roadmap for the Journey in helping couples integrate recovery into their relationship, a missing element in most treatment programs. In collaboration with the Gottman Institute, Bob has also created a one-day training workshop for counselors and therapists, called “Couples and Addiction Recovery.” He also teaches graduate classes on addictive disorders at Santa Clara University. You can learn more about Bob at www.drrobertnavarra.com. |
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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. (00:24):
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 and 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 & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
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(c)(3) nonprofit, so all donations are tax deductible.
Today I'll be speaking with Dr. Robert Navarra, who is a licensed marriage and family therapist, certified Gottman therapist and master trainer, and holds national certification as a master addiction counselor. He has trained counselors and therapists nationally and internationally and has co-authored several book chapters with Dr. John and Julie Gottman and co-authored articles on Gottman therapy for the Encyclopedia of Couples and Family Therapy with Dr. John Gottman. Based on his research at the Mental Research Institute in Palo Alto, California, Bob created Roadmap for the Journey, a Path for Couple Recovery, a two-day workshop for couples in recovery from an addictive disorder roadmap for the Journey has been a featured workshop at Hazleton Betty Ford, and has been given at treatment programs as well as in small semi-private workshop settings. Bob and John Gottman are currently researching the impact of Roadmap for the journey in helping couples integrate recovery into their relationship. In collaboration with the Gottman Institute, Bob has created a one-day training workshop for counselors and therapists called Couples in Addiction Recovery. He also teaches graduate classes on addictive disorders at Santa Clara University. You can learn more about Bob at his [email protected]. Let's listen to the interview. Well, hi Bob. Welcome. Thanks for joining today.
Robert Navarra, PsyD, LMFT, MAC (00:01:53):
Good morning.
Keith Sutton, Psy.D. (00:01:55):
Well, I'm so glad that you could be here. So gosh, Bob, I've known about your work for many years. I forget exactly how I first was introduced to it. I was at the Mental Research Institute of Palo Alto in Palo Alto there, and I know you were doing some stuff with that. I also got very interested in Gottman and did my Gottman level one training with you. And then you've done some talks for our organization association of Family Therapists, Northern California in your research on using Gottman with couples in recovery. And then recently got some consultation with you regarding a couple I'm working with in recovery. So I just thought it was a really interesting subject and would be really great for other people to hear because I think it's a tough scenario and sometimes a lot of couple therapy will say couples therapy is contraindicated in those scenario situations. So yeah, would love to hear more about that. But before we even get into that, tell me a little bit about how you got, doing what you're doing. I'm always interested in folks kind of evolution of their thinking and how they got here.
Robert Navarra, PsyD, LMFT, MAC (00:02:53):
Yeah. Well, thanks for having me on the show. I appreciate that. And I think this is such a, a crucial topic. Specifically the topic I think we're gonna be talking about is how to address substance issues including addiction but not necessarily limited to addiction, but the impact of substances on relationships and how to manage that. It's just a thing that couples therapists typically are uncomfortable managing. And that was exactly the case for me when I studied for my licensure way back when, and I actually had a practice for 40 years. I closed the practice actually last year to focus just on training, consultation, and teaching. Specifically on how to help couples impacted by substances including process addictions, so behavioral challenges. And I also teach at Santa Clara University, so how I got started is about five years into my practice.
I discovered I had literally 80% of my clients at that time had some alcohol or substance-related issue, and I was pretty clueless on how to manage that. Back in the day, once you complete hours, then you meet with the Board of Behavioral Science Examiners. They were called Ben and they interviewed you, and this is what I went through. And one of the interviews, and this is related to your question, is you had to present a case, then they give you a case, what would you do? And so on. Then they asked a bunch of questions, and one of the questions was, is there any group of people that you feel like you don't work well with?
Robert Navarra, PsyD, LMFT, MAC (00:04:41):
I went yeah. Addicts and Alcoholics, and there were three panels of three people, and they looked at me, kind of shook their heads. You know, it's kind of intractable, right? And then fast forward five years later, I'm thinking, ah, it's showing up and I'm not sure what to do. So that's when I began training, and that's what got me interested in the field. When I discovered that there actually is a way to help couples and individuals sort through, is there a substance issue? And if there is, let's talk about it. So that's basically how it started. Then I found the Gottman stuff. This is in 2005. Research-based stuff, of course, and thought this is a perfect match for the research I had done up to that point. So the M.R.I. connection was when I was actually there. Part of the family recovery project with Stephanie Brown and Virginia Lewis, the first research project to determine what happens to couples and families once they get into recovery. So I had a component of that research and out of that came up with a model for couple development over time in recovery, how to help facilitate couples to move into that and how to maintain that recovery into their relationship.
Keith Sutton, Psy.D. (00:06:03):
Wow. Very cool.
Robert Navarra, PsyD, LMFT, MAC (00:06:05):
Yeah.
Keith Sutton, Psy.D. (00:06:07):
Yeah. Tell me about that, those phases of recovery. That's really interesting.
Robert Navarra, PsyD, LMFT, MAC (00:06:12):
Well, what's interesting to me about this is, so my research at M.R.I has continued all these years actually. So it's been quite a journey. Then when I began my Gottman training. I saw the applications, I said a moment ago about some of the interventions, but it felt like I needed to specialize more. So I was invited several times to present at Gottman conferences, which they don't have anymore, unfortunately. But these were people in the certification track, therapists who were learning to be Gottman therapists who were certified already. I presented several times up in Seattle with John and Julie inviting me to present. And basically, that's what caught both their interest was to say, well, “let's see if we can take this relational approach that you're developing and really support therapists and couples to go through these phases, these changes that take place from active addiction to active recovery.”
Keith Sutton, Psy.D. (00:07:16):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:07:18):
So there's a term I'd like to throw out pretty early right now. And it's something that therapists -- typically my experience is -- don't understand or focus on. That is when there's a substance issue and somebody actually gets into recovery. There's a concept of the trauma of recovery. And here is the phase. So when there's active addiction, we know a lot about the impact of ACTU active addiction on couple systems,
Robert Navarra, PsyD, LMFT, MAC (00:07:50):
We know a lot about that. What we didn't know until we got to the Family Recovery Project at M.R.I is what happens to them after they get into recovery, and one of the things we've learned is that the first year of recovery is incredibly difficult.
Keith Sutton, Psy.D. (00:08:04):
Mm-Hmm.
Robert Navarra, PsyD, LMFT, MAC (00:08:05):
So the therapist needs to assess our substance or compulsive behaviors problematic currently in this relationship. And we need to talk about whatever those concerns are. And if there has been a history of addiction or problematic substance, something then has that something they've ever talked about, even if the person got into recovery.
Keith Sutton, Psy.D. (00:08:30):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:08:32):
And as part of the assessment, I think that needs to happen. Like you're working with a couple where the person's actually in recovery, and you're working with a couple, or even the individual you could ask, is this something that two of you have ever talked about, the impact of this thing on you?
Keith Sutton, Psy.D. (00:08:45):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:08:47):
Yeah. And typically, no.
Robert Navarra, PsyD, LMFT, MAC (00:08:50):
As a couple where they both got into recovery 17 years previous to beginning therapy. So 17 years of continuous sobriety and recovery together, and their relationship was just riddled with all sorts of conflict. It turned out that they never talked about the impact of their drug-using days when the relationship started. That's what we processed–events that happened 17 years previously, which never got dealt with. And it worked very effectively to move them through, to sort of reestablish their relationship having dealt with the stuff they never talked about.
Keith Sutton, Psy.D. (00:09:28):
Yeah. Kind of all those maybe old resentments or, or kind of, you know, those traumatic or attachment injuries during those times in the relationship going forward.
Robert Navarra, PsyD, LMFT, MAC (00:09:40):
Exactly. You know, here's a great example of that, Keith. So they came in one time and described a conflict they had, and the conflict was this: they were two different cars, and he now, mind you, both of them are in recovery. He asked her, “Which way are you gonna go home?” And she told him “Yeah.” And then she ended up going home a different way. That triggered him exponentially. And what that was about when we actually processed is he said, you know, “I think what happened for me is what we got to is that there were so many lies during her active drug use days. I think when I found she didn't do what she said she was gonna do it just brought all that right back.” So we basically have kind of a PTSD-like reaction.
Keith Sutton, Psy.D. (00:10:34):
Yeah. Like an emotional flashback.
Robert Navarra, PsyD, LMFT, MAC (00:10:36):
Yes. That's actually a great way to put it.
Keith Sutton, Psy.D. (00:10:39):
Definitely. Those old feelings that haven't been processed, kind of getting triggered. And that was great that he was able to kind of identify or connect those dots.
Robert Navarra, PsyD, LMFT, MAC (00:10:48):
Yeah, exactly. And this is what needed to happen to acknowledge where they've been. So that they can connect with each other now and where they wanna go.
Keith Sutton, Psy.D. (00:10:58):
Interesting. I just started with a couple that I'm working with and similar kind of thing that he had quit drinking and went into therapy. But they're still kind of struggling, and she feels like he's not emotionally there–vulnerable. He's going through the motions and the hoops, but she still doesn't feel him because they really haven't talked about that and his depression and what all has been going on. So there's still that emotional distance, even though he's sober at this time.
Robert Navarra, PsyD, LMFT, MAC (00:11:26):
Wow. This is a great point. You're highlighting something that's really crucial, I think. So back to the stages. So when couples are given an opportunity to understand what's happened in their relationship as a result of substance misuse or addiction, and if we put addiction in as sort of the frame right now. So the way I work with couples when there's been addiction or any significant major mental health or even a physical issue is to externalize this thing, in this case addiction, and set up a scenario where we say, “let's talk about how addiction has invaded your relationship.” And I'm not a narrative therapist, but it's a narrative frame that says, ‘we're externalizing this thing.’ Why I think that's important is it provides an opportunity for each partner to be validated in how they've been impacted by this thing called addiction rather than the blame game with the person with the addiction.
Keith Sutton, Psy.D. (00:12:36):
Yeah. How it's affected the addict and how it's also affected their partner if only one of them is struggling with addiction.
Robert Navarra, PsyD, LMFT, MAC (00:12:45):
That's right. And this is the basic frame that I do. I say, “minimally our work here≠whether this is addiction in the past that never has been talked about, or something is happening right now, or you're newly in recovery–it's the same process. It is to say, ‘let's talk about addiction as this thing that's invaded your relationship.’” So we've got recovery with partner one and partner two, that's two recoveries. And then the third recovery is the relationship recovery. And this is the part that creates controversy in the field.
Keith Sutton, Psy.D. (00:13:21):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:13:23):
Do you know why?
Keith Sutton, Psy.D. (00:13:24):
No. Tell me.
Robert Navarra, PsyD, LMFT, MAC (00:13:27):
This is surprising to a lot of people, a lot of therapists. The overall bias mostly is that when somebody gets into recovery, it's really important to not muck that up with doing any kind of couples anything. Each person needs to focus on their individual recovery. Now, I was clinical director of a drug and alcohol treatment program years and years ago, and that's how I was trained. This goes back many, many years ago. But what I discovered in my practice is that we need to talk about what's happening and we need to talk about what the impact has been on the relationship because it's right here. It's in the room with us, you know?
Keith Sutton, Psy.D. (00:14:12):
Definitely. Well, you can't escape it. I worked at a drug and alcohol outpatient program for adolescents and so much of the family stuff really needed to be talked about or worked on, or a kid would come back from rehab and the parents would throw a party and there'd be alcohol there.
Robert Navarra, PsyD, LMFT, MAC (00:14:27):
Oh my gosh.
Keith Sutton, Psy.D. (00:14:27):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:14:28):
Isn't that an amazing story?
Keith Sutton, Psy.D. (00:14:29):
Yeah. These things were not talked about or sometimes even not dealt with in the treatment program because the person was focused on individually helping with their sobriety and not really looking at the system. So in the program I was in, which is actually what kind of really inspired me around systems work is that we really looked at the system helping the families and the teenagers that we were working with to be able to work together and support each other. And not inadvertently sometimes enable relapses or whatever it might be.
Robert Navarra, PsyD, LMFT, MAC (00:15:00):
Boy, this is such an important thing you're saying cuz that systemic work is exactly where I think this, where it needs to happen. And that's not the treatment paradigm right now. That's pervasive. So I'm sort of on a mission here to look at changing how we do recovery and it's gaining traction. So I was invited to give several couples workshops. I developed two workshops, one for couples in recovery called Roadmap for the Journey. And it's basically about a 10-hour workshop built over two days typically, or sometimes longer. I can spread it out. So I was invited to give this workshop for couples at Betty Fort Hazleton several years ago. This is in Minnesota, so the mothership.
Robert Navarra, PsyD, LMFT, MAC (00:15:54):
And what's really cool is that the director of that renewal center at the time said he invited me to do this. Right. So he said, mind if I sit in? And so I asked the couples, is it okay? Sure. Great. So at the end of this workshop, it was a Friday through Sunday kind of thing, he said, whoa, now I understand why this is so important to have couples talk about what's happened and how to go forward. Why are we not doing this? And I said, yes. Why are we not doing this? It turns out, Keith, that couples impacted by addictive disorders have the single highest divorce rate of any comorbidity.
Keith Sutton, Psy.D. (00:16:37):
I'm sure.
Robert Navarra, PsyD, LMFT, MAC (00:16:38):
Unless that statistics changed the last five years, and I don't think it has. And why is that? It's because the baggage that follows couples into recovery is not dealt with, not addressed. So somebody gets into recovery, the therapists, they go, well, good, I'm glad. Now we can talk about other things. You may need to talk about other things, but to not talk about the impact of addiction and to not talk about the trauma of recovery and all the changes that are taking place and the uncertainty of all this stuff is leading, I think, to this high divorce rate, high separation rate even after recovery.
Keith Sutton, Psy.D. (00:17:15):
Well, and I think it's so hard too for couples to make any change whether it's like we're gonna eat better. It's like one pulls out some ice cream and the other one's like, oh, okay, I'm gonna do it too. Or a couple, like the one I was working with, struggling with Oxy and painkillers, that try to be clean and then the other one would relapse and they'd be like, oh, well if they're relapsing, I'm relapsing too. And just really struggling to get sober into recovery because they kept kind of bouncing off each other and really struggling to have that resolved. Which is really hard because the addiction brain.
Robert Navarra, PsyD, LMFT, MAC (00:17:57):
Yeah. So here's the part that I think is really important for therapists to know and understand. So we're talking about stages in your initial assessment with couples, and we can talk about how strategies for doing assessments too. Yeah. But in your initial assessment, when it comes to substances and problematic process behaviors, shall we say, you have to figure out where on the continuum as this couple or this individual were to the point. Where are they following on the continuum of substance use here? It could be non-problematic, or it could be problematic without it necessarily being a use disorder at about DSM five. Or it could be a DSM five diagnosis of a use disorder, mild or moderate. And here's the part that I think could be very confusing for therapists. That is not the same as addiction. So you may have people that are meeting the criteria for a use disorder with alcohol or cocaine or cannabis–doesn't matter. And it's problematic, but it has not moved into an addiction yet.
Robert Navarra, PsyD, LMFT, MAC (00:19:09):
When we get to the severe end of somebody meeting six plus symptoms and maybe the moderate end too. It may indicate that a person's moved into an addictive disorder, which means there have been fundamental changes in their brain. So is addiction a disease? Yes, it's indisputable that addiction is a disease because we know the parts of the brain that are impacted. We can see that there are changes in the structure and the function in the brain and neurotransmitter system. So I don't think that's controversial. I think it's a disease. But most people that walk into the client's office, if there's problematic substance use, probably don't meet that criteria. They probably don't have the disease of addiction. That doesn't mean that isn't something we're talking about, and figuring out what's going on that's problematic. And if somebody's got the genetic predisposition for addiction, and there's other life circumstances that are sort of padding things towards that direction, then you say, well, you're on your way, potentially, here's the risk associated with your level of use and your history, and let's talk about that.
Keith Sutton, Psy.D. (00:20:23):
Definitely. Well, and I think oftentimes, the relationship is oftentimes a motivator for moving into recovery. And I've almost thought about it like motivational interviewing. When I interviewed Scott Miller on his common factors research that he talked about working in a drug and alcohol treatment program and feeling like, “oh, why didn't these people come in so early?” A lot of them are homeless or cirrhosis. But he talked about how it's oftentimes the relationship–their partner has left them, their family has kicked them out, their kids won't talk to them anymore. That is what moves them into treatment. The person is experiencing the negative consequences, kind of on an individual level.
Robert Navarra, PsyD, LMFT, MAC (00:21:08):
Yeah. Well the interesting research on this is that as for couples therapists out there, or individually oriented therapy as well, If both partners are, let's say, using at about the same level, and it's problematic and may even be addictive, they're not likely to report that as problematic in the relationship. So the research on it says it doesn't show up in the office. You have to ask where it shows up or when it shows up in the office. Is one person using in ways that the other partner is not comfortable with? Now we're naming it.
Robert Navarra, PsyD, LMFT, MAC (00:21:41):
This is the challenge therapist. I get this question a lot. Well, what do you do when one partner's concerned about their partner's use? And they're not seeing it the same way. That's exactly the grist for the mill that we need to integrate into these therapy sessions to say, well, you have different perspectives on this, and let's talk about what those perspectives are. This is where psychoeducation comes in, to let them know when to be concerned.
Keith Sutton, Psy.D. (00:22:13):
Let me, let me go back. If you could maybe state those different phases of recovery just to help me kind of organize what are the different phases?
Robert Navarra, PsyD, LMFT, MAC (00:22:26):
Yeah. So it's more or less described this way. Interestingly, the DSM five is actually inaccurate when we talk about early recovery and ongoing recovery in that, what we know is that the first year of recovery is incredibly difficult for the couple and for everyone. And that the relapse rates are more than 50% relapse, so closer to like a 60% relapse rate for the first year of recovery. So it's the fits and starts of recovery sometimes. What's interesting to me is that after one year of recovery, the research indicates that it continues. Recovery is about 60%, over 60 something percent of people who have a year of recovery stay sober. So you go, that's pretty good. Yeah. Then here's a really good thing for therapists to know is that if somebody gets up to three years of continuous recovery, the research indicates that the three to five-year mark, the numbers are about the same, is considered the durable point of recovery. This means if you get three to five years, I kind of lean more towards the five years, but technically that three year mark, 86% of people that reach that level of continuous recovery stay sober the rest of their lives.
Keith Sutton, Psy.D. (00:24:05):
Wow.
Robert Navarra, PsyD, LMFT, MAC (00:24:06):
That's why it's considered durable. That's a good sign. 15% relapse and those that do relapse, there's a percentage of people that get right back into recovery. Like 16% of those folks at relapse get back right into recovery. So it's more like a slip than an actual relapse. So the prognosis is not bad for addiction recovery once the structure is in place, if people can stick to it.
Keith Sutton, Psy.D. (00:24:38):
Okay. So are those the different phases the first year? The one year to three years and then three plus?
Robert Navarra, PsyD, LMFT, MAC (00:24:48):
That would be one way to conceptualize it. The DSM has stable recovery at a shorter period of time. And that's why I think it's really important for therapists to say, “No, that first year is gonna be difficult and challenging.” There's a lot of trauma that gets triggered in terms of fears and concerns and are you using.
Robert Navarra, PsyD, LMFT, MAC (00:25:14):
That kind of stuff. So if we can work on that together to establish three recoveries, what are you doing for your own recovery partner? The one with the addiction perhaps, but also what are you doing to recover from the impact of this thing called addiction? If that's what's happened, let's talk about how the two of you can work together as a couple to integrate recovery into your relationship so that you have individual and couple recovery coexisting. And that's what my workshop is exactly about that.
Keith Sutton, Psy.D. (00:25:56):
That they're both doing work.
Robert Navarra, PsyD, LMFT, MAC (00:25:59):
Yes. I think that's incredibly important.
Keith Sutton, Psy.D. (00:26:03):
Yeah. When I worked at a treatment program they used to say, “if you're not working on your recovery, you're working on your relapse.”
Robert Navarra, PsyD, LMFT, MAC (00:26:11):
That's good. That's a catchy saying.
Keith Sutton, Psy.D. (00:26:14):
You can't really be complacent. You have to be putting in at work. Sometimes I think about it like standing on one of those little ground escalator things at the airport. If you just stop walking, you're gonna slowly kind of work them backward.
Robert Navarra, PsyD, LMFT, MAC (00:26:29):
I like that. You know, it's also interesting, I think to kind of help partners see that your experience impacted by this thing called addiction is something that needs to actually be talked about. And when you externalize it as something that has invaded the relationship and they both have a way to talk about it, then I think that just kind of moves the needle on healing and gets them to go forward as a couple.
Keith Sutton, Psy.D. (00:27:01):
Yeah, definitely. I think what I've heard in the past is that some folks have said you can't really do couples therapy because it's almost like somebody continuing in an affair. Because oftentimes when there's relapse, it feels like a betrayal. And like you're saying, it's hard to have trust and there's that kind of hyper vigilance or anxiety–that, “oh no, is the person gonna relapse? Are they gonna slip? Are they lying to me?” So oftentimes it's hard to really kind of get into that vulnerability when there's kind of repeated traumas. What are your thoughts on that?
Robert Navarra, PsyD, LMFT, MAC (00:27:41):
Yeah, so I think this is a good place to reference Stephanie Brown's work. Mm-Hmm. Just a prolific researcher therapist writer in terms of the amount of materials she's put out there has been amazing. So I trained with Stephanie years ago. I think her position is really important in that the emphasis is not on just ‘let me try this again.’ The goal would be to have couples talk about what's happening in the relationship. So problematic substance use is not a reason to discontinue therapy, couples therapy with the session with, yeah. To discontinue the goal would be to say, we need to talk about what's happening in this relationship. And even if there's evidence of active addiction, what the research indicates is that couples work is one of the most effective ways to identify addiction and to move people into recovery.
Robert Navarra, PsyD, LMFT, MAC (00:28:41):
You go, whoa. So it's not contraindicated. No, it's not automatically contraindicated, nor is working with an individual with a substance use problem of some kind that is not a reason to discontinue therapy. That is a reason to continue therapy. You're talking about stages of change. And that's exactly what this is about. For pre-contemplation to what I'm not a problem too. What might I do about that? What are my choices? What are my options? What am I willing to do? What am I not willing to do? And that's the grist for the mill at that point.
Keith Sutton, Psy.D. (00:29:14):
Well, and also too, I found that whether addiction–or I also do a lot of work with ADHD or things like that–when somebody's coming in for a problem, when they're sent in by their partner to work on this issue or whatever, oftentimes they're really not as engaged. But there's still more in that kind of pre-contemplative kind of stage of change. But when you bring the partner in and they're talking about all these things, it's like they're seeing it that's in the face of kind of all the ways that it's affecting. It might not be talked about at home, might be just kind of led to like little jabs or little passive aggression statements and not really actually talked about the impact and really seeing the impact that it's having on loved ones. Oftentimes I think that can be very motivating to kind of go into that stage of, ‘I need to do something about this.’
Robert Navarra, PsyD, LMFT, MAC (00:30:11):
I think you need to give couples language and a way to conceptualize this stuff. And so, what I'm thinking about a couple I worked with many years ago where he definitely had alcohol use disorder severe, so he is in recovery for that. But then he also had an opioid addiction, right? And so they sort of joined me at the point where he just had been and recovery from alcohol use disorder probably for about six months or so, and then he relapsed on Vicodin. And the story, Keith, is that in the session, she said, “I found a Vicodin pill on our driveway,” and the husband denied that it was his. Okay, well who's is it? He goes, “well, I think maybe it's the neighbors that rolled down the street.” So hear these stories and poor guy was just desperate. Because what we have to remember is that if somebody has an addiction, they have behavior that they can't manage. And they don't understand why. So you have to kind of default as the therapist to say, ‘let's just assume that there's tremendous shame.’
Keith Sutton, Psy.D. (00:31:27):
Exactly. That's where my mind went.
Robert Navarra, PsyD, LMFT, MAC (00:31:29):
So this is where the education part comes in. When I said, well–I'll say his name is John. “So John, it looks like you relapsed on Vicodin here and let's talk about,” let's just assume that that's what's happened and he said, “yeah. Okay.” So he acknowledged it. What's significant is that the wife didn't understand the nature of addiction and she sort of simulated this like holding a pill up and saying, how could you love this more than me? Now that is a perfect, perfect opportunity for a therapist to jump in and say, “so let's talk about what addiction actually is.” Mm-Hmm. Addiction is basically the stop mechanism broken in the brain. We know that addiction takes place over three phases of changes that take place in the brain. So there's a neurobiology, and when you understand that addiction is, it's a funny way to put it, but involuntary behavior. Because that stop mechanism is broken until people understand that they don't know why they're doing the things they're doing or their partner's doing the thing they're doing. So it is a medical diagnosis that we can actually identify and addiction is very treatable. I wanna communicate that to every therapist out there. Addiction is treatable.
Keith Sutton, Psy.D. (00:32:57):
Now, and actually you were saying the three kind of stages or changes in the biology. What, what are those three?
Robert Navarra, PsyD, LMFT, MAC (00:33:05):
Yeah, so Nora Alco did this at the National Institute for Drug Abuse, and a lot of research has taken place in particular like what happens in the brain. We used to think it was just more of a Pavlovian thing. So the reward system gets hijacked, but there's much more to it as it turns out. So briefly: binge and intoxication is the first stage. This is where people just use a lot of the substance. That's not addiction, that's binging. Binge intoxication. But what happens is there's this genetic vulnerability which is gonna contribute, increase, or decrease the likelihood of this thing moving forward. I guess the basics would be to say what the substance does is it releases dopamine. So it's a neuro neurotransmitter associated with pleasure, with feeling good. It floods the synaptic cleft, which is the space between neurons with dopamine much more than what other pleasurable things might trigger in terms of a lovely meal or being with someone you love or activity that you really enjoy, or dopamine being released. Well this substance predictably increases the amount of dopamine and experiences a pleasure associated with that begin to alter the reward pathway.
Keith Sutton, Psy.D. (00:34:30):
Okay.
Robert Navarra, PsyD, LMFT, MAC (00:34:31):
So binge and intoxication could be defined as it starts to alter the reward pathway. You could use words like this begins to hijack the reward system which leads to the second phase which is basically negative affective and withdrawal. And what that means is that the person doesn't feel normal unless they're using, because their brain has adapted to what is required to get a certain feeling. And more and more of the substance or the behaviors required to get up to that level.
Keith Sutton, Psy.D. (00:35:06):
Sure. That's where the technical tolerance comes in.
Robert Navarra, PsyD, LMFT, MAC (00:35:10):
That's right.
Keith Sutton, Psy.D. (00:35:12):
The feeling, the need for it to feel normal or even baseline.
Robert Navarra, PsyD, LMFT, MAC (00:35:17):
That's right. That's what happens. So, ‘I don't feel normal unless I'm using.’ So there's a brain disorder that's developing, and the person with it thinks the solution is more of the substance to feel normal, which makes sense.
Keith Sutton, Psy.D. (00:35:29):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:35:31):
So the technical term for this would be the hedonic set point, the point at which we feel pleasure in life. The needle moves and now it's higher which means getting to that hedonic set point where I feel normal, even much less good is based on my ability to have this substance to get me to that point Because my brain has adapted.
Keith Sutton, Psy.D. (00:35:57):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:35:58):
So what happens in that bench intoxication phase is that the D two receptors, dopamine receptors, and the brain start shutting down because the brain's going, ‘Whoa, this is too much, too much going on here.’ So more and more of the substances needed, the tolerance you were talking about is related to that.
Keith Sutton, Psy.D. (00:36:16):
Yes.
Robert Navarra, PsyD, LMFT, MAC (00:36:17):
And then that second phase has to do with the neuromodulation being goofed up. That means the tension between the reward that we experience in the brain and the anti gets out of sync for the person using. It suppresses the stress system when they stop using their stress system rebounds, and that's why they feel horrible.
Keith Sutton, Psy.D. (00:36:43):
Okay.
Robert Navarra, PsyD, LMFT, MAC (00:36:45):
And so you go, okay, so the modulation part is ‘you're outta sync’ is what you're telling the client.
Robert Navarra, PsyD, LMFT, MAC (00:36:53):
Then the prefrontal cortex gets involved. So here's the third phase. So this is basically being obsessed with the substance. The prefrontal cortex, which would normally say, it's not a good idea to drink and drive, especially with my kids in the car, but period.
Keith Sutton, Psy.D. (00:37:11):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:37:11):
Or it's probably not a good idea to do this thing–it's probably not a good idea to look at porn at work. So that might be a brain that is working better.
Keith Sutton, Psy.D. (00:37:23):
<Laugh> Sure, sure.
Robert Navarra, PsyD, LMFT, MAC (00:37:24):
But when the prefrontal cortex gets involved and goes, ‘no, no, you need this, you need this to survive,’ here's where the rationalization for all sorts of behaviors that you look at and go, “what were you thinking?”
Keith Sutton, Psy.D. (00:37:36):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:37:37):
And the prefrontal cortex has to do with impulse control judgment, and that gets hijacked. So people that you're wondering like, “What were you thinking when you did that? Why would you drink the night before a DUI hearing?”
Robert Navarra, PsyD, LMFT, MAC (00:37:54):
And why they would do that? It’s that the prefrontal cortex says, “Man, you're nervous and you know what to do, and you're nervous and you're scared cuz tomorrow's court hearing, you know, blah, blah, blah. Well, one drink to calm my nerves, that's it. One drink.” And to the person where the prefrontal cortex has been hijacked, that makes perfect sense in the moment.
Robert Navarra, PsyD, LMFT, MAC (00:38:13):
And you're thinking as a therapist, “what were you thinking?” And that term is called hypofrontality which means, “okay, eh, you're not thinking things through all the way because that part of the brain's been hijacked too.”
Keith Sutton, Psy.D. (00:38:28):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:38:30):
Thus, the stop mechanism's broken.
Keith Sutton, Psy.D. (00:38:33):
So that's where you get into the addiction and where just the behaviors add more and more to the shame, which makes a person feel worse, and then they keep using more to deal with those feeling bad. Every time kind of the smoke clears from the substances, then they look around at the wreckage and then it's just too much. And so they have to use again.
Robert Navarra, PsyD, LMFT, MAC (00:38:56):
Right. And when people understand the neurobiology of addiction, they go, ‘oh, that really helps deal with the shame a tremendous amount.’ And it's, you know, sometimes the argument as well, that's just kind of making excuses or is it really a disease. Again, the research indicates that, well, most of the time when you're dealing as a therapist with clients where there's substance issue, it probably hasn't reached that point. But it may be on its way. If it has reached that point, then I think it's important for people to know that nine or 10% of folks with an addiction, that's how I got there.
Keith Sutton, Psy.D. (00:39:33):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:39:34):
So my couple, when I saw about the Vicodin that rolled, that rolled down the street into the driveway, one scenario, one version of what happened when I reviewed the neurobiology, that the stop mechanism’s broken, and let's talk about the impact that that's had on you. So I talked to the wife and I have a very strong position on working with partners that I would like to talk about, and codependency is a term that's used a lot. It can be useful if there's a certain context that you understand what it means to the client, but we have to be careful with that word, I think.
Keith Sutton, Psy.D. (00:40:12):
Yeah. It's a dirty word, but sometimes it's a helpful concept, but it can be pathologizing.
Robert Navarra, PsyD, LMFT, MAC (00:40:19):
Exactly. Keith, you just nailed it, man. So some people identify that as a recovery issue and that could be helpful. What I would encourage therapists to do is to, if the client's using that term, say, “Well, would you help me understand when you say codependency, what do you mean by that?” And we can get to behaviors that are maybe not healthy. The problem is that if we limit the recovery issues for the partner to just being co-dependent, it's really not addressing what I think is underneath all of this anyway which is PTSD, which is what you said earlier.
Keith Sutton, Psy.D. (00:40:56):
Yeah. Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:40:57):
And so I say it's really likely that as a partner of someone with an addictive disorder, you've experienced trauma.
Keith Sutton, Psy.D. (00:41:09):
I was actually gonna ask about this too, the trauma aspect that plays into addiction.
Robert Navarra, PsyD, LMFT, MAC (00:41:18):
Oh, no, that's good. Well, in terms of trauma addiction, as a concept, what therapist is gonna disagree with the statement, ‘therapists need to be trauma-informed’? No one's gonna disagree with that for the most part. But when you get to addiction, we need to really incorporate that concept and say, ‘let's contextualize this.’ So rather than limiting the language to codependency, let's talk about trauma. And so externalizing addiction provides a way for a person to talk about what their experience has been like. I actually have interventions to talk about trauma that happened during the act of addiction. It's an intervention I do in my couple's workshop and it's in my other workshop where I do training for therapists on how to help couples talk about trauma without blaming the person with the addiction.
Robert Navarra, PsyD, LMFT, MAC (00:42:09):
And so they say what the impact of this thing was at the time, and they express their hurt, their pain, and their trauma. And that's built right into the therapeutic goals with this couple. And there's another term that I like a lot that has not caught on yet, and I hope it will. So I hope every therapist that hears this will consider using this with their clients. So you're working with a partner in the moment as a couple or an individual and you say, addiction brings trauma and PTSD post-traumatic stress disorder is probably something you heard of. Let me tell you what it is and whether you can relate to some aspects of it. The other concept that I'm talking about now is secondhand harm. Now I see PTSD and secondhand harm as terms to augment the recovery frame for the partner. I don't wanna limit it to codependency, which is pathologizing–just like you said earlier, I think that's exactly how I feel about this.
Keith Sutton, Psy.D. (00:43:16):
Well, my codependency is usually coming from love and care and fear.
Robert Navarra, PsyD, LMFT, MAC (00:43:19):
Yeah.
Keith Sutton, Psy.D. (00:43:20):
And so oftentimes trying to help their partner, although sometimes unwittingly enabling their partner. It's oftentimes out of love and like you're saying that trauma of these things happening and not trying to protect them from getting fired from work or protect them from doing something wrong or getting in trouble or whatever it might be and trying to change them oftentimes.
Robert Navarra, PsyD, LMFT, MAC (00:43:44):
Yeah. Exactly. So the idea would be to normalize those emotions and to let both parties know that there's trauma that they both have experienced. There's an intervention I actually designed as I started to say in the couple recovery group that I do called Heart Healing Emotions from Addiction Recovery and Trauma. And what it is is partners taking, and I take a lot of time to set this up. Time to think about a time they've been traumatized by the addiction. So let's say the partner of the person with the addiction might say something like, “Last holiday, last Valentine's Day was really traumatic. You know, we went out for dinner and what I remember is you drinking and drinking and drinking, and then whatever events unfolded.” Now that intervention is set up so that the person describes what they recall, what they felt, and then I give a written sheet or a handout to the listener to say, how do you think this event impacted our relationship? How do you think this event impacted our family?
Robert Navarra, PsyD, LMFT, MAC (00:45:09):
And there's a series of questions where the listener is in this diotic frame is having partners talk to each other instead of the therapist. That's a playbook right outta the Gottman playbook. So it's a diotic frame, and they're talking to each other about the impact of this thing. If it starts to move into blame–“How could you do this? I thought you loved me.” Like the woman with the Vicodin pill simulated Vicodin pill the therapist intervenes, hit stop. You talk about what you're feeling right now and describe yourself, not your partner.
Keith Sutton, Psy.D. (00:45:39):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:45:40):
“When I think about that dinner, I feel hurt, I feel angry.” Now, that's okay. We can talk about that. Rather than, “you don't love me, what's wrong with you? How could this be more important?”
Keith Sutton, Psy.D. (00:45:51):
Yeah. Rather than that kind of what might feel like an attack talking about the impact. And that, and for people that don't know Gottman so much, there's lots of great kind of scripts or the dreams within conflict where they're basically kind of interviewing each other about their feelings about a certain subject when they're in disagreement or whatever it might be. So that's nice that you kind of created a script to kind of interview the other about their trauma.
Robert Navarra, PsyD, LMFT, MAC (00:46:21):
Yeah. It was really interesting going, well, I wonder what's gonna happen. So you developed these things, right? I developed these things. And then I put it in a clinical practice and I've actually done workshops literally in treatment programs where I have them do this. So I give the presentation where usually role play, how to do this with a lot of humor, then the couples break out, and then they actually do this exercise. But the thing that's also interesting to me, Keith, is it's not just the partner of the one, it it not the non-addictive partner who's doing the speaking, it's also the addictive partner. So literally do the same exercise for the person with addiction. And the instructions are, ‘what do you recall was an impact of a particularly difficult event as a result of your use that you'd be willing to talk about that was traumatic for you?’ And so the non-addictive partner starts asking questions, “what is the event?” There was an event that I heard as I did this in one of the treatment programs where the guy was describing, and he's the one with the alcohol use disorder severe, describing how he totaled his car. And the context for this is that this is a car that he built with his father.
Keith Sutton, Psy.D. (00:47:42):
Oh wow.
Robert Navarra, PsyD, LMFT, MAC (00:47:44):
Sort of back in the day, maybe 10 years previously, and his father has had died subsequent to that. So what happened is that when he totaled the car, it wasn't about the materialism of the car, so to speak, although that is something, it was the emotional significance that this had. So tears are flowing down this guy's face, you know, he totaled the car under the influence. The wife had no idea that he was traumatized by his own addiction. And I think that's important for therapists to know.
Keith Sutton, Psy.D. (00:48:15):
Definitely.
Robert Navarra, PsyD, LMFT, MAC (00:48:16):
And so she had no idea, and this was an incredible healing moment for them, for her to see the pain he experienced as a result of his own addiction. So she's not the only victim here.
Keith Sutton, Psy.D. (00:48:26):
Yeah, definitely. That kind of the other person on kind of in EFT terms like the withdrawal is also experiencing that pain and being able to see that they're both struggling and having that kind of distance between them because of the addiction.
Robert Navarra, PsyD, LMFT, MAC (00:48:43):
Yeah. Yeah.
Keith Sutton, Psy.D. (00:48:44):
Also kind of to touch on quickly because I know that there's so much research on the ACEs study and kind of trauma and trauma's relationship to addiction. So I imagine so many of the couples that you end up working with are, that are in the situation, also have some history of trauma that's playing in there since folks with PTSD and Complex PTSD have a higher likelihood for addiction.
Robert Navarra, PsyD, LMFT, MAC (00:49:11):
Yeah, exactly. You know, when I do trainings for therapists, we will look at sort of the heritage of trauma. So let's say the person, and this may or may not be true but it tends to be, the person with the addiction grows up in a family where there's maybe a fair amount of dysfunction or addiction. Because this genetic predisposition thing is a real thing. So it's likely that that's been the case. So there's trauma that starts there as a child. Then there's trauma that begins when the person starts using addictively at some point in their life, then they're in a relationship. And maybe that's when the addiction kicks in or not, or maybe prior to getting together. But then there's trauma that the addiction brings into the relationship, now we got that. And then hopefully a person gets into recovery and now we have trauma associated with that.
Keith Sutton, Psy.D. (00:50:00):
Sure.
Robert Navarra, PsyD, LMFT, MAC (00:50:00):
And so the therapist needs to say, I think things like, well there's a history of trauma that begins here. So family of origin stuff and then addiction has also brought trauma into your personal life and your relationship life. And now recovery is bringing trauma to the both of you. And by trauma, I mean the uncertainty of what now and what about all these feelings I have.
Keith Sutton, Psy.D. (00:50:24):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:50:25):
And am I supposed to not be angry because you're in recovery and if I express my anger, are you gonna relapse? You know, there's all sorts of things. So it's really difficult for couples to get their footing going forward. And I think as therapists, we need to provide a structure to have these conversations, to manage the impact of trauma, to normalize their reactions.
Keith Sutton, Psy.D. (00:50:45):
Yes.
Robert Navarra, PsyD, LMFT, MAC (00:50:46):
And it's been very powerful. It's worked really well, I have to say.
Keith Sutton, Psy.D. (00:50:50):
Well, and two, I imagine when the couple is feeling connected in that way and kind of the addiction is externalized and they're able to see how each one is hurt by that they can also come together and then potentially the relationship can be a resource for when one is feeling the urge to use and talking with their partner about their urge that may be triggering to the partner. They might get scared, or again, if they've got more of that security, they might turn towards each other and talk through that or support that. Sometimes I talk about with couples, say one's trying to quit smoking and the other one smells smoke on them rather than kind of glaring at them and saying, “Hey, you messed up” or something “you're not supposed to smoke.”
Keith Sutton, Psy.D. (00:51:34):
Finding out like, “it seems like you’ve relapsed.” Instead saying, “you must be having a hard time.” Where there's something that's going on there, again, depending if the person might just feel hurt and re-traumatized or so on. Or they might be able to see it as rather than kind of not obeying or following the rules or whatever it might be, but having a hard time and something slipping, whatever it might be, and seeing the person in in the kind of in distress.
Robert Navarra, PsyD, LMFT, MAC (00:52:05):
Mm-Hmm.
Keith Sutton, Psy.D. (00:52:06):
Rather than the client.
Robert Navarra, PsyD, LMFT, MAC (00:52:08):
Yeah. Well I think the concept is to name these things. And so if we look at the proverbial elephant in the living room, this is often a term used to describe when there's addiction and other things. But addiction that nobody can talk about. So the therapist initially needs to provide a structure to say, “are you doing couples therapy?” and “You're here because you're arguing it a lot and you feel like you've lost touch.” And then in your assessment it looks like alcohol or some substances showing up as a problem or some process behavior of some kind. Then you need to include that in your treatment plan to say, well, it looks like this is showing up on the radar. One partner says, “I don't have a drinking problem or a use problem.” And then you say, well, this is something for us to talk about how you both perceive this, and then the education part can help move the needle in that stages of change. Kind of say, well, “you are drinking at levels that would be considered harmful based on science.”
Keith Sutton, Psy.D. (00:53:09):
Okay. So we're almost out of time. You were mentioning ‘assessment’ and I was wondering if you can speak a little more about that.
Robert Navarra, PsyD, LMFT, MAC (00:53:17):
Sure. So the thing that I've noticed and I was definitely in the same category as therapists are reluctant to work with folks that might have substance issues and yet there they are sitting across from us. So I think every therapist really has a responsibility to have fundamentally some aspects of assessment in terms of, ‘well what am I dealing with here?’ So I wanna give your listeners some ideas about what seems to be very successful and it's sort of a protocol that would help therapists to make decisions about, ‘okay, now what do I do with this couple or this individual?’ There might be something going on. So one of the things that often happens is therapists are reluctant to even ask the question and because it might feel awkward or might feel invasive, or I don't know what to do if they say yes.
Robert Navarra, PsyD, LMFT, MAC (00:54:06):
For a number of reasons. So what I'm suggesting is that that absolutely needs to be built into every intake. So it's really crucial, I believe in that first session or the first two sessions, if not the first to kind of say ‘why are you here? How can I help you?’ And they identify that if substances are not mentioned at all or behaviors that might be problematic, I think it's important early on to say, so I do this with every client, every couple I work with but let me ask you about your relationship with substances, including alcohol. And if you're working with a couple, there's a two sort of a double focus you can take in asking the questions if you're working individually with a partner in couples therapy.
Robert Navarra, PsyD, LMFT, MAC (00:54:52):
Or you could generically kind of put this out to the couple, if they're in front of you, you could say, have either one of you ever expressed or had concerns about the use of alcohol or other substances? And it's just kind of a routine question. So that's putting it out there. And what we don't wanna do is to avoid the question. Another common response, this tends to be what I hear from a number of therapists, they say, “well, I really feel like I need to develop a rapport before I ask that question.” You're developing a rapport when you ask the question. You say, this is part of what I do, and how the therapist asks it is important. So you don't wanna say things like you don't have problems with substances, do you?
Robert Navarra, PsyD, LMFT, MAC (00:55:33):
You assume that the person's using substances of some kind, you just assume it, right? So when you get beyond the substance question, you could say, and or any other behaviors that might feel kind of out of control at times, like how much time is spent on the internet, like gambling, like the amount of time spent looking at pornography or whatever. So you're putting some behavioral process questions and it's just out there right from the get-go. Then I've got a really good question that kind of summarizes motivational interviewing in one question. And the question would be this, if it shows up and one or both partners or the individual, there's some indication that there's something going on with substances or behaviors, a great question to ask would be, “on a scale of one to 10, how concerned are you about ‘fill in the blanks’?” “Your use of cannabis? Your use of methamphetamines, whatever,” on a scale of one to 10, 10 being I couldn't be more concerned, one is I'm not concerned at all. Then the follow up questions are what is gonna give the counselor a sort of a thread, perhaps, of where that person might be on their stages of change. And so let me roleplay that with you if you're up for it.
Keith Sutton, Psy.D. (00:56:56):
Of course.
Robert Navarra, PsyD, LMFT, MAC (00:56:56):
All right. So let's say you're the client and you're saying you're concerned about your alcohol use, right?
Keith Sutton, Psy.D. (00:57:01):
So yeah, I'd say my concern is around a six or a seven.
Robert Navarra, PsyD, LMFT, MAC (00:57:05):
Okay. Here's the follow up questions. Okay. So what places you at six?
Keith Sutton, Psy.D. (00:57:12):
You know, I guess I've been having some trouble sleep in. I've been, you know, drinking to go to bed and I don't feel great in the morning. A little slower, things like that. And it's more than I'd like to be drinking.
Robert Navarra, PsyD, LMFT, MAC (00:57:24):
Okay. So you're noticing an increase in drinking, perhaps in the evening that's impacting your ability to sleep and function the next day as well as you'd like?
Keith Sutton, Psy.D. (00:57:33):
Well it was more like using it to sleep and stuff. Cause things have been very stressful and I just, you know, I usually didn't drink daily, but it's kind of been like that ever since the pandemic.
Robert Navarra, PsyD, LMFT, MAC (00:57:45):
Yeah. Sure. Okay. That's a really common experience as it turns out. So here's the follow up questions, Keith. So what would it take to increase that concern? What would it take just for you to be worried? Even more worried or concerned I should say?
Keith Sutton, Psy.D. (00:58:04):
I mean, I feel like I could do something about it if I really kind of decide to. And so I guess, yeah, if I tried to stop or cut back or something then, and I couldn't do it, that'd be concerning.
Robert Navarra, PsyD, LMFT, MAC (00:58:17):
Okay. All righty. And what would it take to lower that number so you'd have less concern?
Keith Sutton, Psy.D. (00:58:25):
Yeah, I mean, if I wasn't drinking every night, things like that, if I was feeling a little more refreshed and not getting in this cycle of kind of drinking to sleep and then feeling not great in the morning.
Robert Navarra, PsyD, LMFT, MAC (00:58:38):
Okay. All righty. Great. So we just did a very provisional assessment, and what I've learned from the client is that if we look at stages of change, pre-contemplation, I don't have a problem, contemplation preparation, I might be ready to do something about it. What might that be? Then I would place this client that you just role played in that contemplation stage that goes, now there's something going on here. The therapy then could indicate. So more information is needed on what's actually happening, how long this has been going on, and is there family history. So there's other things to gather in terms of information. But on the stages of change, this looks like an opportunity potentially at this point to say, well, we can certainly explore your relationship with alcohol and what it might take to change it so that you feel more comfortable with it.
Robert Navarra, PsyD, LMFT, MAC (00:59:23):
Yeah, and if it looks like there's more problematic behavior associated with that historically and even currently, then that would be sort of different trajectory to kind of say, let's look at how this seems to be escalating so that there's a way to work with wherever that person's at. So that would be the context. So it's an amazingly powerful question. With the two follow ups, what would it take to increase, decrease? Just to kind of situate where that person might be in the stages of change. It's a really good tool, and that creates a conversation. And just to remind everyone is that the goal is not to get your client to stop doing, that goal is to explore and have a conversation about what's going on and is how is this working and how is it not working? And what would you like to have happen?
Keith Sutton, Psy.D. (01:00:10):
Well,I imagine too it would also depend on what the client's coming in for. I think the assessment, of course, would be really good to figure out where they're at, but I almost had a thought of like climb being like, well, I'm not really here for that. I'm here because we're getting in fights all the time, or we're separated right now, or something like that. And how much do you think this plays into what's going on? Or how important is this to address or something. I kind of come from a strategic family therapy background where getting hired to work on something, which sometimes I might, they might talk about this, but like, ‘it's not a problem.’ Or ‘we don't need to deal with that here.’ But it's helpful to know from the assessment later, as it starts kind of becoming more and more like every fight they've been drinking. I remember you mentioned this and kind of tying it back to like maybe we need to deal with this to help with the problem you're coming in for.
Robert Navarra, PsyD, LMFT, MAC (01:01:07):
I think you just said it so well, this is a great question, or a great observation. So people say, I'm not here for that. And you would say, “no, you're here because you wanted to work with your partner on such and such,” or “you're here because you're struggling with depression, anxiety.” So this may or may not be relevant to that concern. That's what we're sorting through. So if it's not an issue, then we will have explored it. So once again, you're reiterating, ‘No, no, this is part of my standard protocol.’ And then you get to make decisions, I say to the client in terms of what you wanna do with all this. So that's okay. But it's important for me to ask and it would be negligent of me not to ask. Because if it is playing a role, then we wouldn't wanna know that in addition to the other concerns you have, so they're not mutually exclusive. And almost always, clients will say, “oh, okay” if you explain to a client why you're doing something.
Keith Sutton, Psy.D. (01:02:05):
It's like a narrative therapy or more of the post-modern where you're being transparent why you're bringing this up. And I think too, like you're saying, the way that you say it also matters a lot. I oftentimes, when I'm supervising, rather than saying, “oh, is it okay if I asked you about your alcohol user this or that, or whatever,” maybe the person might be like, “well, I didn't have an issue, but now maybe there is something.” I find that, when something might be uncomfortable or when things were uncomfortable for me, I'd kind of think about like, ‘what would a medical doctor do?’ They'd just be like, ‘Okay. How's your drink? How's your this?’ And just matter of fact, that it matter of course, and just kind of going with it. It kind of goes a lot smoothly and people just kind of respond, ‘oh yeah, this is what we're doing.’ Like this is just totally normal here.
Robert Navarra, PsyD, LMFT, MAC (01:02:53):
So if I had take a highlighter pen on what I feel is important in our conversation today about this, I would say what you just said ranks up at the top. You're creating a conversational tone about something. Let me find out where you're at. And then it's not a bad idea for therapists to understand when to be concerned with drinking. At what point is it problematic? And that's changing all the time. The current studies are really looking at any use of alcohol potentially is problematic, even so-called “safe levels.” So that's sort of a different discussion. But minimally, I think what you just said is really, really important to create a conversation. The other assessment tool that undoubtedly many of your will listeners out there would've heard of is the CAGE.
Robert Navarra, PsyD, LMFT, MAC (01:03:36):
It's an, an acronym for the four questions that have a very high hit rate for identifying problematic behaviors, not just with alcohol, but with anything. So C A G E, C: have you ever tried to cut down on how much time you spend fill in the blanks? Sure. A: have you ever felt annoyed with somebody expressing concern about your use of whatever? G: you ever feel guilty about your use through the amount of time you spend, fill in the blanks? And then E stands for eye-opener, which means do you ever start the day with? Now this works for substances of all kinds. This works with behaviors and this works with alcohol, which was originally designed. This goes back many years now as a pretty helpful screen, basically.
Keith Sutton, Psy.D. (01:04:33):
Trying to get a sense if there is some issue there or something's going on.
Robert Navarra, PsyD, LMFT, MAC (01:04:38):
Yeah, exactly. So that's really good. And then the other tool–I'm gonna give you a link–is the audit. So the audit is a screen widely recognized universally actually. The alcohol use. Alcohol use, oh my goodness. You're gonna edit this. Keith?
Robert Navarra, PsyD, LMFT, MAC (01:05:07):
Alcohol. Oh, here we go. The audit stands for the Alcohol Use Disorders Identification Test.
Keith Sutton, Psy.D. (01:05:14):
Perfect.
Robert Navarra, PsyD, LMFT, MAC (01:05:16):
Okay. And there's a wonderful free resource that your listeners can get. It's the manual and the audit was developed by the World Health Organization. So it's non-pro proprietary, and you're able to use this freely without worrying about infringing on intellectual property or anything. And what's cool about that is there are manuals and options in English, Spanish Hindi, Japanese, Thai, and the cross-cultural sensitivity translates really well. It was developed in six different countries, and I've used it, I've given trainings and workshops in South Korea where they actually have a Korean audit. It's modified now. The advantage of the audit over the CAGE when it comes to alcohol, the audit's only relevant for alcohol. So it's not used for other substances. But what's cool about the audit is it looks at low, medium, high risk drinking and then like, harmful and hazardous. Hazardous and then harmful. So it's a 10 item questionnaire, it's just easy to give the person, you could ask the questions, but frankly it's just easier to give this little intake sheet that you could give them.
Keith Sutton, Psy.D. (01:06:38):
Good. Good.
Robert Navarra, PsyD, LMFT, MAC (01:06:39):
Yeah. And when they complete that, what you're gonna get is, ‘oh, it looks like your score is consistent with somebody who typically experiences problematic relationships or health issues,’ or something like that. Or you're drinking within what would be considered safe zones of drinking.
Keith Sutton, Psy.D. (01:06:55):
And I know too that I think recently doctors are using kind of like how many drinks per week and there's kind of a number something that is related to the health effects of alcohol or so. And the number of drinks per day or so on and asking questions that raise consciousness.
Robert Navarra, PsyD, LMFT, MAC (01:07:14):
That's right. And so what I can tell you just cut to the quick, so that the general recommendations now, because it's actually changing and there's some recent studies, even though there's unofficial change in the policy with the AMA and so on, the general guidelines are, it's probably safe drinking for many people under many circumstances for people of all gender identifications as with one drink, maybe two max. And that's very different than the previous guidelines that were given for is differences for men and women in the sex you're born with concepts. The gender fluidity concept doesn't fly here. It's more like just biologically. The female body, male body processes alcohol differently and there's reasons for that.
Keith Sutton, Psy.D. (01:08:03):
Definitely, yeah. I think another piece too, I don't know if you do this, but I know when I'm trying to assess and I talk to somebody, I might not do this in the first session, or it depends on kind of where we are, say like, “oh, I drink like three times a week.” I'll be like, “okay, well tell me about yesterday. Did you drink the day before?” And finding out kind of what they're drinking. But then when you go through the last week of drinking or smoking weed or whatever it might be, you start getting more of the story and then a little bit more kind of depth of it. Especially if you know somebody there, it seems like there's some issues or so on there.
Robert Navarra, PsyD, LMFT, MAC (01:08:39):
Such a good point.
Keith Sutton, Psy.D. (01:08:40):
But that's kind of a nice one cuz they're like, well, “I did do this on Friday,” and they're like, “well, it's a tough week or something,” or like, “oh gosh, I guess, yeah, it's more than two like it was the Superbowl,” you know? And then you start getting at the plot pickings.
Robert Navarra, PsyD, LMFT, MAC (01:08:55):
There you go.
Keith Sutton, Psy.D. (01:08:57):
But it's kind of a nice way to do it and just like explore. And oftentimes clients, again, depending on the rapport, are good with that.
Robert Navarra, PsyD, LMFT, MAC (01:09:04):
Yeah. Well, actually I'm glad you said that because it is assessments ongoing, right? So if there's problematic use, it's really hard to talk about it and sometimes it's just a matter of education. They're not aware that they're drinking or using at levels that could be problematic.
Keith Sutton, Psy.D. (01:09:20):
Yeah, yeah, definitely.
Robert Navarra, PsyD, LMFT, MAC (01:09:21):
So if you're talking about alcohol, it's also important to define what you mean by a drink. And so we do alcoholic.
Keith Sutton, Psy.D. (01:09:28):
You're like, “oh, I had one drink last night.” “Oh, what did you drink?” “Oh, I had like a martini.” “Like how many shots?” “Like oh three.” And it's like, “okay, there you go.” A little more information there.
Robert Navarra, PsyD, LMFT, MAC (01:09:38):
So just for the record, so equal amounts of alcohol are found in an ounce and a half of distilled spirits, five ounces of wine and 12 ounces of beer, say a can of beer or a bottle of beer. Not IPA so much, but you just go, those are rough estimates. And I've had clients go, “oh, I only have one drink.” Well, what's in your drink? “Well, I've got a big slushy cup and fill it with ice, and then I top it with vodka and put a drop of orange juice in it.” So when we break it down, it's probably like six drinks.
Keith Sutton, Psy.D. (01:10:09):
Yeah. Yeah.
Robert Navarra, PsyD, LMFT, MAC (01:10:10):
And you know, as we're going through this, the other evaluation tool that I think is really helpful is to ask or to get a sense of, cause you can't necessarily get this in one or two questions, is to what degree is this person's behavior organized around obtaining, maintaining, sometimes hiding behavior around the substance use? Without even asking how much the person drinks. You can get a sense sometimes in the narrative and by asking questions and just listening carefully. How much time is spent on that activity? And then you ask the how much questions maybe at that point.
Keith Sutton, Psy.D. (01:10:54):
Definitely.
Robert Navarra, PsyD, LMFT, MAC (01:10:55):
And then finally you know, in the state of California, but this is true probably in almost every state for therapist anyway, some version of this, therapists are responsible for three things in evaluation, whatever it is you're treating the person for, what are my evaluation tools? So we just went over a couple of them. The audit is a screen, the CAGE is a screen, the clinical interview is a screen. So these are evaluation tools that lead to an assessment, which you might need to, that you're likely to take a number of sessions to figure out. So what are my tools for evaluation? How do I piece that together in a way that allows me to give an assessment? And the third part is, what's my treatment based on my assessment? That's probably gonna be an ongoing kind of assessment thing.
Keith Sutton, Psy.D. (01:11:44):
Yeah. And you're saying in the state of California, meaning like if you were working with somebody, they came in for something else and you did not assess for the alcohol or you did not come up with a treatment. You're saying that's something that would be an issue board worthy or so on.
Robert Navarra, PsyD, LMFT, MAC (01:12:01):
Well, it, yeah. I mean, I don't know. I would say it could be, I would suppose. I've had a client where she said, “I was treated for an eating disorder when I was a young woman.” And she goes, “not one therapist, not one treatment program.” She was in two asked me anything about my alcohol use. So we addressed the eating disorder stuff, but not my alcohol use. So you go, well, therapist, what's sort of the standard of care?
Keith Sutton, Psy.D. (01:12:32):
Standard of care.
Robert Navarra, PsyD, LMFT, MAC (01:12:32):
Yeah. I think the standard of care is say we need to evaluate and to know when to refer or to say more is needed. And these are just screens, so you cannot diagnose someone based on a screen. You know, all you can say is your score is here, or the stories I'm hearing are kind of consistent with what might be a problematic use with substances. And it's something I think is important for us to talk about in addition to whatever the person comes in with.
Keith Sutton, Psy.D. (01:12:57):
Yeah. And I think that's one of the trainings that are mandatory in California to get license, is to get training in substance abuse right.
Robert Navarra, PsyD, LMFT, MAC (01:13:07):
Yeah. So those are the things I wanted to add. And I also, actually, you just gave me a great segue, Keith because there's a class called Couples and Addiction Recovery Training that I gave. And it was sponsored by the Gottman Institute. And John and Julie Gottman gave a talk on treating affairs and trauma, and it was a four day weekend. So they did the first three days, and then I was on day four, doing this, and I was recorded. And Berkeleys goes back a couple of years ago. And then the Gottman Institute basically turned it into an online class. So that is something that's available to listeners if they're interested in a six and a half hour training with tools, manual, and all how to do assessments and how to work with couples in recovery. I'm saying another option would be to go on my website and to register for that class, because then you have an option to do a 90 minute training with me or Q and A or case consultation. Once you complete the class, then you're also eligible to get eight CEUs for that.
Keith Sutton, Psy.D. (01:14:18):
Oh, nice.
Robert Navarra, PsyD, LMFT, MAC (01:14:19):
So if you sign up on my website, you can do that. You could sign up on the Gottman website if you're not interested in the CEUs or in a 90 minute consult or Q and A kind of thing. And then finally, I do also offer a workshop for couples in recovery from addiction. It's called Roadmap for the Journey. I was asked by the Gottman Institute to design this workshop, which I did, and I've given in treatment programs. I've been invited by Betty Ford Hazleton three times now. I'm presenting again a workshop for their couples in Minnesota this summer sometime. And I have a live online version.
Keith Sutton, Psy.D. (01:14:58):
Oh, perfect.
Robert Navarra, PsyD, LMFT, MAC (01:14:59):
It works very, very well. It's a total of 10 hours of content and couples get the manual and recovery card decks are part of the workshop materials.
Keith Sutton, Psy.D. (01:15:12):
Perfect.
Robert Navarra, PsyD, LMFT, MAC (01:15:12):
And then finally the last plug is I also have a free class that's just an hour, but it's a free class for therapists or couples on using the card decks that are used to sort of talk about different aspects of recovery. And so it's an actual, it's built right into my workshop and it's part of my training in the couples in addiction recovery training, how to use the tools of that card deck and what they, you don't need the card deck to actually do this. The concept, there's four different concepts that partners have conversations about, but there's a structure with the card deck that makes it a little bit easier. So that free class is found on my website as well. And then there's a paid class. It's a short sort of an overview of couple recovery.
Keith Sutton, Psy.D. (01:16:01):
Okay. Perfect. Well, I'll definitely be linking to your website in the bio, so that'll be perfect.
Robert Navarra, PsyD, LMFT, MAC (01:16:09):
Cool. And I think that covers it in terms of providing a little bit more information.
Keith Sutton, Psy.D. (01:16:13):
Okay. Well, great. Well, thanks, I'm glad we're able to cover everything today and I really appreciate you're doing wonderful work. I think this is such an area of need, so I think this is really perfect. Thank you so much for taking the time.
Robert Navarra, PsyD, LMFT, MAC (01:16:27):
Thanks Keith, for having me on. I appreciate it.
Keith Sutton, Psy.D. (01:16:29):
Take care.
Robert Navarra, PsyD, LMFT, MAC (01:16:30):
Bye-Bye.
Keith Sutton, Psy.D. (01:16:32):
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 sfbacc.org. BACC is a 501(c)(3) 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 and 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 & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
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(c)(3) nonprofit, so all donations are tax deductible.
Today I'll be speaking with Dr. Robert Navarra, who is a licensed marriage and family therapist, certified Gottman therapist and master trainer, and holds national certification as a master addiction counselor. He has trained counselors and therapists nationally and internationally and has co-authored several book chapters with Dr. John and Julie Gottman and co-authored articles on Gottman therapy for the Encyclopedia of Couples and Family Therapy with Dr. John Gottman. Based on his research at the Mental Research Institute in Palo Alto, California, Bob created Roadmap for the Journey, a Path for Couple Recovery, a two-day workshop for couples in recovery from an addictive disorder roadmap for the Journey has been a featured workshop at Hazleton Betty Ford, and has been given at treatment programs as well as in small semi-private workshop settings. Bob and John Gottman are currently researching the impact of Roadmap for the journey in helping couples integrate recovery into their relationship. In collaboration with the Gottman Institute, Bob has created a one-day training workshop for counselors and therapists called Couples in Addiction Recovery. He also teaches graduate classes on addictive disorders at Santa Clara University. You can learn more about Bob at his [email protected]. Let's listen to the interview. Well, hi Bob. Welcome. Thanks for joining today.
Robert Navarra, PsyD, LMFT, MAC (00:01:53):
Good morning.
Keith Sutton, Psy.D. (00:01:55):
Well, I'm so glad that you could be here. So gosh, Bob, I've known about your work for many years. I forget exactly how I first was introduced to it. I was at the Mental Research Institute of Palo Alto in Palo Alto there, and I know you were doing some stuff with that. I also got very interested in Gottman and did my Gottman level one training with you. And then you've done some talks for our organization association of Family Therapists, Northern California in your research on using Gottman with couples in recovery. And then recently got some consultation with you regarding a couple I'm working with in recovery. So I just thought it was a really interesting subject and would be really great for other people to hear because I think it's a tough scenario and sometimes a lot of couple therapy will say couples therapy is contraindicated in those scenario situations. So yeah, would love to hear more about that. But before we even get into that, tell me a little bit about how you got, doing what you're doing. I'm always interested in folks kind of evolution of their thinking and how they got here.
Robert Navarra, PsyD, LMFT, MAC (00:02:53):
Yeah. Well, thanks for having me on the show. I appreciate that. And I think this is such a, a crucial topic. Specifically the topic I think we're gonna be talking about is how to address substance issues including addiction but not necessarily limited to addiction, but the impact of substances on relationships and how to manage that. It's just a thing that couples therapists typically are uncomfortable managing. And that was exactly the case for me when I studied for my licensure way back when, and I actually had a practice for 40 years. I closed the practice actually last year to focus just on training, consultation, and teaching. Specifically on how to help couples impacted by substances including process addictions, so behavioral challenges. And I also teach at Santa Clara University, so how I got started is about five years into my practice.
I discovered I had literally 80% of my clients at that time had some alcohol or substance-related issue, and I was pretty clueless on how to manage that. Back in the day, once you complete hours, then you meet with the Board of Behavioral Science Examiners. They were called Ben and they interviewed you, and this is what I went through. And one of the interviews, and this is related to your question, is you had to present a case, then they give you a case, what would you do? And so on. Then they asked a bunch of questions, and one of the questions was, is there any group of people that you feel like you don't work well with?
Robert Navarra, PsyD, LMFT, MAC (00:04:41):
I went yeah. Addicts and Alcoholics, and there were three panels of three people, and they looked at me, kind of shook their heads. You know, it's kind of intractable, right? And then fast forward five years later, I'm thinking, ah, it's showing up and I'm not sure what to do. So that's when I began training, and that's what got me interested in the field. When I discovered that there actually is a way to help couples and individuals sort through, is there a substance issue? And if there is, let's talk about it. So that's basically how it started. Then I found the Gottman stuff. This is in 2005. Research-based stuff, of course, and thought this is a perfect match for the research I had done up to that point. So the M.R.I. connection was when I was actually there. Part of the family recovery project with Stephanie Brown and Virginia Lewis, the first research project to determine what happens to couples and families once they get into recovery. So I had a component of that research and out of that came up with a model for couple development over time in recovery, how to help facilitate couples to move into that and how to maintain that recovery into their relationship.
Keith Sutton, Psy.D. (00:06:03):
Wow. Very cool.
Robert Navarra, PsyD, LMFT, MAC (00:06:05):
Yeah.
Keith Sutton, Psy.D. (00:06:07):
Yeah. Tell me about that, those phases of recovery. That's really interesting.
Robert Navarra, PsyD, LMFT, MAC (00:06:12):
Well, what's interesting to me about this is, so my research at M.R.I has continued all these years actually. So it's been quite a journey. Then when I began my Gottman training. I saw the applications, I said a moment ago about some of the interventions, but it felt like I needed to specialize more. So I was invited several times to present at Gottman conferences, which they don't have anymore, unfortunately. But these were people in the certification track, therapists who were learning to be Gottman therapists who were certified already. I presented several times up in Seattle with John and Julie inviting me to present. And basically, that's what caught both their interest was to say, well, “let's see if we can take this relational approach that you're developing and really support therapists and couples to go through these phases, these changes that take place from active addiction to active recovery.”
Keith Sutton, Psy.D. (00:07:16):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:07:18):
So there's a term I'd like to throw out pretty early right now. And it's something that therapists -- typically my experience is -- don't understand or focus on. That is when there's a substance issue and somebody actually gets into recovery. There's a concept of the trauma of recovery. And here is the phase. So when there's active addiction, we know a lot about the impact of ACTU active addiction on couple systems,
Robert Navarra, PsyD, LMFT, MAC (00:07:50):
We know a lot about that. What we didn't know until we got to the Family Recovery Project at M.R.I is what happens to them after they get into recovery, and one of the things we've learned is that the first year of recovery is incredibly difficult.
Keith Sutton, Psy.D. (00:08:04):
Mm-Hmm.
Robert Navarra, PsyD, LMFT, MAC (00:08:05):
So the therapist needs to assess our substance or compulsive behaviors problematic currently in this relationship. And we need to talk about whatever those concerns are. And if there has been a history of addiction or problematic substance, something then has that something they've ever talked about, even if the person got into recovery.
Keith Sutton, Psy.D. (00:08:30):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:08:32):
And as part of the assessment, I think that needs to happen. Like you're working with a couple where the person's actually in recovery, and you're working with a couple, or even the individual you could ask, is this something that two of you have ever talked about, the impact of this thing on you?
Keith Sutton, Psy.D. (00:08:45):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:08:47):
Yeah. And typically, no.
Robert Navarra, PsyD, LMFT, MAC (00:08:50):
As a couple where they both got into recovery 17 years previous to beginning therapy. So 17 years of continuous sobriety and recovery together, and their relationship was just riddled with all sorts of conflict. It turned out that they never talked about the impact of their drug-using days when the relationship started. That's what we processed–events that happened 17 years previously, which never got dealt with. And it worked very effectively to move them through, to sort of reestablish their relationship having dealt with the stuff they never talked about.
Keith Sutton, Psy.D. (00:09:28):
Yeah. Kind of all those maybe old resentments or, or kind of, you know, those traumatic or attachment injuries during those times in the relationship going forward.
Robert Navarra, PsyD, LMFT, MAC (00:09:40):
Exactly. You know, here's a great example of that, Keith. So they came in one time and described a conflict they had, and the conflict was this: they were two different cars, and he now, mind you, both of them are in recovery. He asked her, “Which way are you gonna go home?” And she told him “Yeah.” And then she ended up going home a different way. That triggered him exponentially. And what that was about when we actually processed is he said, you know, “I think what happened for me is what we got to is that there were so many lies during her active drug use days. I think when I found she didn't do what she said she was gonna do it just brought all that right back.” So we basically have kind of a PTSD-like reaction.
Keith Sutton, Psy.D. (00:10:34):
Yeah. Like an emotional flashback.
Robert Navarra, PsyD, LMFT, MAC (00:10:36):
Yes. That's actually a great way to put it.
Keith Sutton, Psy.D. (00:10:39):
Definitely. Those old feelings that haven't been processed, kind of getting triggered. And that was great that he was able to kind of identify or connect those dots.
Robert Navarra, PsyD, LMFT, MAC (00:10:48):
Yeah, exactly. And this is what needed to happen to acknowledge where they've been. So that they can connect with each other now and where they wanna go.
Keith Sutton, Psy.D. (00:10:58):
Interesting. I just started with a couple that I'm working with and similar kind of thing that he had quit drinking and went into therapy. But they're still kind of struggling, and she feels like he's not emotionally there–vulnerable. He's going through the motions and the hoops, but she still doesn't feel him because they really haven't talked about that and his depression and what all has been going on. So there's still that emotional distance, even though he's sober at this time.
Robert Navarra, PsyD, LMFT, MAC (00:11:26):
Wow. This is a great point. You're highlighting something that's really crucial, I think. So back to the stages. So when couples are given an opportunity to understand what's happened in their relationship as a result of substance misuse or addiction, and if we put addiction in as sort of the frame right now. So the way I work with couples when there's been addiction or any significant major mental health or even a physical issue is to externalize this thing, in this case addiction, and set up a scenario where we say, “let's talk about how addiction has invaded your relationship.” And I'm not a narrative therapist, but it's a narrative frame that says, ‘we're externalizing this thing.’ Why I think that's important is it provides an opportunity for each partner to be validated in how they've been impacted by this thing called addiction rather than the blame game with the person with the addiction.
Keith Sutton, Psy.D. (00:12:36):
Yeah. How it's affected the addict and how it's also affected their partner if only one of them is struggling with addiction.
Robert Navarra, PsyD, LMFT, MAC (00:12:45):
That's right. And this is the basic frame that I do. I say, “minimally our work here≠whether this is addiction in the past that never has been talked about, or something is happening right now, or you're newly in recovery–it's the same process. It is to say, ‘let's talk about addiction as this thing that's invaded your relationship.’” So we've got recovery with partner one and partner two, that's two recoveries. And then the third recovery is the relationship recovery. And this is the part that creates controversy in the field.
Keith Sutton, Psy.D. (00:13:21):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:13:23):
Do you know why?
Keith Sutton, Psy.D. (00:13:24):
No. Tell me.
Robert Navarra, PsyD, LMFT, MAC (00:13:27):
This is surprising to a lot of people, a lot of therapists. The overall bias mostly is that when somebody gets into recovery, it's really important to not muck that up with doing any kind of couples anything. Each person needs to focus on their individual recovery. Now, I was clinical director of a drug and alcohol treatment program years and years ago, and that's how I was trained. This goes back many, many years ago. But what I discovered in my practice is that we need to talk about what's happening and we need to talk about what the impact has been on the relationship because it's right here. It's in the room with us, you know?
Keith Sutton, Psy.D. (00:14:12):
Definitely. Well, you can't escape it. I worked at a drug and alcohol outpatient program for adolescents and so much of the family stuff really needed to be talked about or worked on, or a kid would come back from rehab and the parents would throw a party and there'd be alcohol there.
Robert Navarra, PsyD, LMFT, MAC (00:14:27):
Oh my gosh.
Keith Sutton, Psy.D. (00:14:27):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:14:28):
Isn't that an amazing story?
Keith Sutton, Psy.D. (00:14:29):
Yeah. These things were not talked about or sometimes even not dealt with in the treatment program because the person was focused on individually helping with their sobriety and not really looking at the system. So in the program I was in, which is actually what kind of really inspired me around systems work is that we really looked at the system helping the families and the teenagers that we were working with to be able to work together and support each other. And not inadvertently sometimes enable relapses or whatever it might be.
Robert Navarra, PsyD, LMFT, MAC (00:15:00):
Boy, this is such an important thing you're saying cuz that systemic work is exactly where I think this, where it needs to happen. And that's not the treatment paradigm right now. That's pervasive. So I'm sort of on a mission here to look at changing how we do recovery and it's gaining traction. So I was invited to give several couples workshops. I developed two workshops, one for couples in recovery called Roadmap for the Journey. And it's basically about a 10-hour workshop built over two days typically, or sometimes longer. I can spread it out. So I was invited to give this workshop for couples at Betty Fort Hazleton several years ago. This is in Minnesota, so the mothership.
Robert Navarra, PsyD, LMFT, MAC (00:15:54):
And what's really cool is that the director of that renewal center at the time said he invited me to do this. Right. So he said, mind if I sit in? And so I asked the couples, is it okay? Sure. Great. So at the end of this workshop, it was a Friday through Sunday kind of thing, he said, whoa, now I understand why this is so important to have couples talk about what's happened and how to go forward. Why are we not doing this? And I said, yes. Why are we not doing this? It turns out, Keith, that couples impacted by addictive disorders have the single highest divorce rate of any comorbidity.
Keith Sutton, Psy.D. (00:16:37):
I'm sure.
Robert Navarra, PsyD, LMFT, MAC (00:16:38):
Unless that statistics changed the last five years, and I don't think it has. And why is that? It's because the baggage that follows couples into recovery is not dealt with, not addressed. So somebody gets into recovery, the therapists, they go, well, good, I'm glad. Now we can talk about other things. You may need to talk about other things, but to not talk about the impact of addiction and to not talk about the trauma of recovery and all the changes that are taking place and the uncertainty of all this stuff is leading, I think, to this high divorce rate, high separation rate even after recovery.
Keith Sutton, Psy.D. (00:17:15):
Well, and I think it's so hard too for couples to make any change whether it's like we're gonna eat better. It's like one pulls out some ice cream and the other one's like, oh, okay, I'm gonna do it too. Or a couple, like the one I was working with, struggling with Oxy and painkillers, that try to be clean and then the other one would relapse and they'd be like, oh, well if they're relapsing, I'm relapsing too. And just really struggling to get sober into recovery because they kept kind of bouncing off each other and really struggling to have that resolved. Which is really hard because the addiction brain.
Robert Navarra, PsyD, LMFT, MAC (00:17:57):
Yeah. So here's the part that I think is really important for therapists to know and understand. So we're talking about stages in your initial assessment with couples, and we can talk about how strategies for doing assessments too. Yeah. But in your initial assessment, when it comes to substances and problematic process behaviors, shall we say, you have to figure out where on the continuum as this couple or this individual were to the point. Where are they following on the continuum of substance use here? It could be non-problematic, or it could be problematic without it necessarily being a use disorder at about DSM five. Or it could be a DSM five diagnosis of a use disorder, mild or moderate. And here's the part that I think could be very confusing for therapists. That is not the same as addiction. So you may have people that are meeting the criteria for a use disorder with alcohol or cocaine or cannabis–doesn't matter. And it's problematic, but it has not moved into an addiction yet.
Robert Navarra, PsyD, LMFT, MAC (00:19:09):
When we get to the severe end of somebody meeting six plus symptoms and maybe the moderate end too. It may indicate that a person's moved into an addictive disorder, which means there have been fundamental changes in their brain. So is addiction a disease? Yes, it's indisputable that addiction is a disease because we know the parts of the brain that are impacted. We can see that there are changes in the structure and the function in the brain and neurotransmitter system. So I don't think that's controversial. I think it's a disease. But most people that walk into the client's office, if there's problematic substance use, probably don't meet that criteria. They probably don't have the disease of addiction. That doesn't mean that isn't something we're talking about, and figuring out what's going on that's problematic. And if somebody's got the genetic predisposition for addiction, and there's other life circumstances that are sort of padding things towards that direction, then you say, well, you're on your way, potentially, here's the risk associated with your level of use and your history, and let's talk about that.
Keith Sutton, Psy.D. (00:20:23):
Definitely. Well, and I think oftentimes, the relationship is oftentimes a motivator for moving into recovery. And I've almost thought about it like motivational interviewing. When I interviewed Scott Miller on his common factors research that he talked about working in a drug and alcohol treatment program and feeling like, “oh, why didn't these people come in so early?” A lot of them are homeless or cirrhosis. But he talked about how it's oftentimes the relationship–their partner has left them, their family has kicked them out, their kids won't talk to them anymore. That is what moves them into treatment. The person is experiencing the negative consequences, kind of on an individual level.
Robert Navarra, PsyD, LMFT, MAC (00:21:08):
Yeah. Well the interesting research on this is that as for couples therapists out there, or individually oriented therapy as well, If both partners are, let's say, using at about the same level, and it's problematic and may even be addictive, they're not likely to report that as problematic in the relationship. So the research on it says it doesn't show up in the office. You have to ask where it shows up or when it shows up in the office. Is one person using in ways that the other partner is not comfortable with? Now we're naming it.
Robert Navarra, PsyD, LMFT, MAC (00:21:41):
This is the challenge therapist. I get this question a lot. Well, what do you do when one partner's concerned about their partner's use? And they're not seeing it the same way. That's exactly the grist for the mill that we need to integrate into these therapy sessions to say, well, you have different perspectives on this, and let's talk about what those perspectives are. This is where psychoeducation comes in, to let them know when to be concerned.
Keith Sutton, Psy.D. (00:22:13):
Let me, let me go back. If you could maybe state those different phases of recovery just to help me kind of organize what are the different phases?
Robert Navarra, PsyD, LMFT, MAC (00:22:26):
Yeah. So it's more or less described this way. Interestingly, the DSM five is actually inaccurate when we talk about early recovery and ongoing recovery in that, what we know is that the first year of recovery is incredibly difficult for the couple and for everyone. And that the relapse rates are more than 50% relapse, so closer to like a 60% relapse rate for the first year of recovery. So it's the fits and starts of recovery sometimes. What's interesting to me is that after one year of recovery, the research indicates that it continues. Recovery is about 60%, over 60 something percent of people who have a year of recovery stay sober. So you go, that's pretty good. Yeah. Then here's a really good thing for therapists to know is that if somebody gets up to three years of continuous recovery, the research indicates that the three to five-year mark, the numbers are about the same, is considered the durable point of recovery. This means if you get three to five years, I kind of lean more towards the five years, but technically that three year mark, 86% of people that reach that level of continuous recovery stay sober the rest of their lives.
Keith Sutton, Psy.D. (00:24:05):
Wow.
Robert Navarra, PsyD, LMFT, MAC (00:24:06):
That's why it's considered durable. That's a good sign. 15% relapse and those that do relapse, there's a percentage of people that get right back into recovery. Like 16% of those folks at relapse get back right into recovery. So it's more like a slip than an actual relapse. So the prognosis is not bad for addiction recovery once the structure is in place, if people can stick to it.
Keith Sutton, Psy.D. (00:24:38):
Okay. So are those the different phases the first year? The one year to three years and then three plus?
Robert Navarra, PsyD, LMFT, MAC (00:24:48):
That would be one way to conceptualize it. The DSM has stable recovery at a shorter period of time. And that's why I think it's really important for therapists to say, “No, that first year is gonna be difficult and challenging.” There's a lot of trauma that gets triggered in terms of fears and concerns and are you using.
Robert Navarra, PsyD, LMFT, MAC (00:25:14):
That kind of stuff. So if we can work on that together to establish three recoveries, what are you doing for your own recovery partner? The one with the addiction perhaps, but also what are you doing to recover from the impact of this thing called addiction? If that's what's happened, let's talk about how the two of you can work together as a couple to integrate recovery into your relationship so that you have individual and couple recovery coexisting. And that's what my workshop is exactly about that.
Keith Sutton, Psy.D. (00:25:56):
That they're both doing work.
Robert Navarra, PsyD, LMFT, MAC (00:25:59):
Yes. I think that's incredibly important.
Keith Sutton, Psy.D. (00:26:03):
Yeah. When I worked at a treatment program they used to say, “if you're not working on your recovery, you're working on your relapse.”
Robert Navarra, PsyD, LMFT, MAC (00:26:11):
That's good. That's a catchy saying.
Keith Sutton, Psy.D. (00:26:14):
You can't really be complacent. You have to be putting in at work. Sometimes I think about it like standing on one of those little ground escalator things at the airport. If you just stop walking, you're gonna slowly kind of work them backward.
Robert Navarra, PsyD, LMFT, MAC (00:26:29):
I like that. You know, it's also interesting, I think to kind of help partners see that your experience impacted by this thing called addiction is something that needs to actually be talked about. And when you externalize it as something that has invaded the relationship and they both have a way to talk about it, then I think that just kind of moves the needle on healing and gets them to go forward as a couple.
Keith Sutton, Psy.D. (00:27:01):
Yeah, definitely. I think what I've heard in the past is that some folks have said you can't really do couples therapy because it's almost like somebody continuing in an affair. Because oftentimes when there's relapse, it feels like a betrayal. And like you're saying, it's hard to have trust and there's that kind of hyper vigilance or anxiety–that, “oh no, is the person gonna relapse? Are they gonna slip? Are they lying to me?” So oftentimes it's hard to really kind of get into that vulnerability when there's kind of repeated traumas. What are your thoughts on that?
Robert Navarra, PsyD, LMFT, MAC (00:27:41):
Yeah, so I think this is a good place to reference Stephanie Brown's work. Mm-Hmm. Just a prolific researcher therapist writer in terms of the amount of materials she's put out there has been amazing. So I trained with Stephanie years ago. I think her position is really important in that the emphasis is not on just ‘let me try this again.’ The goal would be to have couples talk about what's happening in the relationship. So problematic substance use is not a reason to discontinue therapy, couples therapy with the session with, yeah. To discontinue the goal would be to say, we need to talk about what's happening in this relationship. And even if there's evidence of active addiction, what the research indicates is that couples work is one of the most effective ways to identify addiction and to move people into recovery.
Robert Navarra, PsyD, LMFT, MAC (00:28:41):
You go, whoa. So it's not contraindicated. No, it's not automatically contraindicated, nor is working with an individual with a substance use problem of some kind that is not a reason to discontinue therapy. That is a reason to continue therapy. You're talking about stages of change. And that's exactly what this is about. For pre-contemplation to what I'm not a problem too. What might I do about that? What are my choices? What are my options? What am I willing to do? What am I not willing to do? And that's the grist for the mill at that point.
Keith Sutton, Psy.D. (00:29:14):
Well, and also too, I found that whether addiction–or I also do a lot of work with ADHD or things like that–when somebody's coming in for a problem, when they're sent in by their partner to work on this issue or whatever, oftentimes they're really not as engaged. But there's still more in that kind of pre-contemplative kind of stage of change. But when you bring the partner in and they're talking about all these things, it's like they're seeing it that's in the face of kind of all the ways that it's affecting. It might not be talked about at home, might be just kind of led to like little jabs or little passive aggression statements and not really actually talked about the impact and really seeing the impact that it's having on loved ones. Oftentimes I think that can be very motivating to kind of go into that stage of, ‘I need to do something about this.’
Robert Navarra, PsyD, LMFT, MAC (00:30:11):
I think you need to give couples language and a way to conceptualize this stuff. And so, what I'm thinking about a couple I worked with many years ago where he definitely had alcohol use disorder severe, so he is in recovery for that. But then he also had an opioid addiction, right? And so they sort of joined me at the point where he just had been and recovery from alcohol use disorder probably for about six months or so, and then he relapsed on Vicodin. And the story, Keith, is that in the session, she said, “I found a Vicodin pill on our driveway,” and the husband denied that it was his. Okay, well who's is it? He goes, “well, I think maybe it's the neighbors that rolled down the street.” So hear these stories and poor guy was just desperate. Because what we have to remember is that if somebody has an addiction, they have behavior that they can't manage. And they don't understand why. So you have to kind of default as the therapist to say, ‘let's just assume that there's tremendous shame.’
Keith Sutton, Psy.D. (00:31:27):
Exactly. That's where my mind went.
Robert Navarra, PsyD, LMFT, MAC (00:31:29):
So this is where the education part comes in. When I said, well–I'll say his name is John. “So John, it looks like you relapsed on Vicodin here and let's talk about,” let's just assume that that's what's happened and he said, “yeah. Okay.” So he acknowledged it. What's significant is that the wife didn't understand the nature of addiction and she sort of simulated this like holding a pill up and saying, how could you love this more than me? Now that is a perfect, perfect opportunity for a therapist to jump in and say, “so let's talk about what addiction actually is.” Mm-Hmm. Addiction is basically the stop mechanism broken in the brain. We know that addiction takes place over three phases of changes that take place in the brain. So there's a neurobiology, and when you understand that addiction is, it's a funny way to put it, but involuntary behavior. Because that stop mechanism is broken until people understand that they don't know why they're doing the things they're doing or their partner's doing the thing they're doing. So it is a medical diagnosis that we can actually identify and addiction is very treatable. I wanna communicate that to every therapist out there. Addiction is treatable.
Keith Sutton, Psy.D. (00:32:57):
Now, and actually you were saying the three kind of stages or changes in the biology. What, what are those three?
Robert Navarra, PsyD, LMFT, MAC (00:33:05):
Yeah, so Nora Alco did this at the National Institute for Drug Abuse, and a lot of research has taken place in particular like what happens in the brain. We used to think it was just more of a Pavlovian thing. So the reward system gets hijacked, but there's much more to it as it turns out. So briefly: binge and intoxication is the first stage. This is where people just use a lot of the substance. That's not addiction, that's binging. Binge intoxication. But what happens is there's this genetic vulnerability which is gonna contribute, increase, or decrease the likelihood of this thing moving forward. I guess the basics would be to say what the substance does is it releases dopamine. So it's a neuro neurotransmitter associated with pleasure, with feeling good. It floods the synaptic cleft, which is the space between neurons with dopamine much more than what other pleasurable things might trigger in terms of a lovely meal or being with someone you love or activity that you really enjoy, or dopamine being released. Well this substance predictably increases the amount of dopamine and experiences a pleasure associated with that begin to alter the reward pathway.
Keith Sutton, Psy.D. (00:34:30):
Okay.
Robert Navarra, PsyD, LMFT, MAC (00:34:31):
So binge and intoxication could be defined as it starts to alter the reward pathway. You could use words like this begins to hijack the reward system which leads to the second phase which is basically negative affective and withdrawal. And what that means is that the person doesn't feel normal unless they're using, because their brain has adapted to what is required to get a certain feeling. And more and more of the substance or the behaviors required to get up to that level.
Keith Sutton, Psy.D. (00:35:06):
Sure. That's where the technical tolerance comes in.
Robert Navarra, PsyD, LMFT, MAC (00:35:10):
That's right.
Keith Sutton, Psy.D. (00:35:12):
The feeling, the need for it to feel normal or even baseline.
Robert Navarra, PsyD, LMFT, MAC (00:35:17):
That's right. That's what happens. So, ‘I don't feel normal unless I'm using.’ So there's a brain disorder that's developing, and the person with it thinks the solution is more of the substance to feel normal, which makes sense.
Keith Sutton, Psy.D. (00:35:29):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:35:31):
So the technical term for this would be the hedonic set point, the point at which we feel pleasure in life. The needle moves and now it's higher which means getting to that hedonic set point where I feel normal, even much less good is based on my ability to have this substance to get me to that point Because my brain has adapted.
Keith Sutton, Psy.D. (00:35:57):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:35:58):
So what happens in that bench intoxication phase is that the D two receptors, dopamine receptors, and the brain start shutting down because the brain's going, ‘Whoa, this is too much, too much going on here.’ So more and more of the substances needed, the tolerance you were talking about is related to that.
Keith Sutton, Psy.D. (00:36:16):
Yes.
Robert Navarra, PsyD, LMFT, MAC (00:36:17):
And then that second phase has to do with the neuromodulation being goofed up. That means the tension between the reward that we experience in the brain and the anti gets out of sync for the person using. It suppresses the stress system when they stop using their stress system rebounds, and that's why they feel horrible.
Keith Sutton, Psy.D. (00:36:43):
Okay.
Robert Navarra, PsyD, LMFT, MAC (00:36:45):
And so you go, okay, so the modulation part is ‘you're outta sync’ is what you're telling the client.
Robert Navarra, PsyD, LMFT, MAC (00:36:53):
Then the prefrontal cortex gets involved. So here's the third phase. So this is basically being obsessed with the substance. The prefrontal cortex, which would normally say, it's not a good idea to drink and drive, especially with my kids in the car, but period.
Keith Sutton, Psy.D. (00:37:11):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:37:11):
Or it's probably not a good idea to do this thing–it's probably not a good idea to look at porn at work. So that might be a brain that is working better.
Keith Sutton, Psy.D. (00:37:23):
<Laugh> Sure, sure.
Robert Navarra, PsyD, LMFT, MAC (00:37:24):
But when the prefrontal cortex gets involved and goes, ‘no, no, you need this, you need this to survive,’ here's where the rationalization for all sorts of behaviors that you look at and go, “what were you thinking?”
Keith Sutton, Psy.D. (00:37:36):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:37:37):
And the prefrontal cortex has to do with impulse control judgment, and that gets hijacked. So people that you're wondering like, “What were you thinking when you did that? Why would you drink the night before a DUI hearing?”
Robert Navarra, PsyD, LMFT, MAC (00:37:54):
And why they would do that? It’s that the prefrontal cortex says, “Man, you're nervous and you know what to do, and you're nervous and you're scared cuz tomorrow's court hearing, you know, blah, blah, blah. Well, one drink to calm my nerves, that's it. One drink.” And to the person where the prefrontal cortex has been hijacked, that makes perfect sense in the moment.
Robert Navarra, PsyD, LMFT, MAC (00:38:13):
And you're thinking as a therapist, “what were you thinking?” And that term is called hypofrontality which means, “okay, eh, you're not thinking things through all the way because that part of the brain's been hijacked too.”
Keith Sutton, Psy.D. (00:38:28):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:38:30):
Thus, the stop mechanism's broken.
Keith Sutton, Psy.D. (00:38:33):
So that's where you get into the addiction and where just the behaviors add more and more to the shame, which makes a person feel worse, and then they keep using more to deal with those feeling bad. Every time kind of the smoke clears from the substances, then they look around at the wreckage and then it's just too much. And so they have to use again.
Robert Navarra, PsyD, LMFT, MAC (00:38:56):
Right. And when people understand the neurobiology of addiction, they go, ‘oh, that really helps deal with the shame a tremendous amount.’ And it's, you know, sometimes the argument as well, that's just kind of making excuses or is it really a disease. Again, the research indicates that, well, most of the time when you're dealing as a therapist with clients where there's substance issue, it probably hasn't reached that point. But it may be on its way. If it has reached that point, then I think it's important for people to know that nine or 10% of folks with an addiction, that's how I got there.
Keith Sutton, Psy.D. (00:39:33):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:39:34):
So my couple, when I saw about the Vicodin that rolled, that rolled down the street into the driveway, one scenario, one version of what happened when I reviewed the neurobiology, that the stop mechanism’s broken, and let's talk about the impact that that's had on you. So I talked to the wife and I have a very strong position on working with partners that I would like to talk about, and codependency is a term that's used a lot. It can be useful if there's a certain context that you understand what it means to the client, but we have to be careful with that word, I think.
Keith Sutton, Psy.D. (00:40:12):
Yeah. It's a dirty word, but sometimes it's a helpful concept, but it can be pathologizing.
Robert Navarra, PsyD, LMFT, MAC (00:40:19):
Exactly. Keith, you just nailed it, man. So some people identify that as a recovery issue and that could be helpful. What I would encourage therapists to do is to, if the client's using that term, say, “Well, would you help me understand when you say codependency, what do you mean by that?” And we can get to behaviors that are maybe not healthy. The problem is that if we limit the recovery issues for the partner to just being co-dependent, it's really not addressing what I think is underneath all of this anyway which is PTSD, which is what you said earlier.
Keith Sutton, Psy.D. (00:40:56):
Yeah. Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:40:57):
And so I say it's really likely that as a partner of someone with an addictive disorder, you've experienced trauma.
Keith Sutton, Psy.D. (00:41:09):
I was actually gonna ask about this too, the trauma aspect that plays into addiction.
Robert Navarra, PsyD, LMFT, MAC (00:41:18):
Oh, no, that's good. Well, in terms of trauma addiction, as a concept, what therapist is gonna disagree with the statement, ‘therapists need to be trauma-informed’? No one's gonna disagree with that for the most part. But when you get to addiction, we need to really incorporate that concept and say, ‘let's contextualize this.’ So rather than limiting the language to codependency, let's talk about trauma. And so externalizing addiction provides a way for a person to talk about what their experience has been like. I actually have interventions to talk about trauma that happened during the act of addiction. It's an intervention I do in my couple's workshop and it's in my other workshop where I do training for therapists on how to help couples talk about trauma without blaming the person with the addiction.
Robert Navarra, PsyD, LMFT, MAC (00:42:09):
And so they say what the impact of this thing was at the time, and they express their hurt, their pain, and their trauma. And that's built right into the therapeutic goals with this couple. And there's another term that I like a lot that has not caught on yet, and I hope it will. So I hope every therapist that hears this will consider using this with their clients. So you're working with a partner in the moment as a couple or an individual and you say, addiction brings trauma and PTSD post-traumatic stress disorder is probably something you heard of. Let me tell you what it is and whether you can relate to some aspects of it. The other concept that I'm talking about now is secondhand harm. Now I see PTSD and secondhand harm as terms to augment the recovery frame for the partner. I don't wanna limit it to codependency, which is pathologizing–just like you said earlier, I think that's exactly how I feel about this.
Keith Sutton, Psy.D. (00:43:16):
Well, my codependency is usually coming from love and care and fear.
Robert Navarra, PsyD, LMFT, MAC (00:43:19):
Yeah.
Keith Sutton, Psy.D. (00:43:20):
And so oftentimes trying to help their partner, although sometimes unwittingly enabling their partner. It's oftentimes out of love and like you're saying that trauma of these things happening and not trying to protect them from getting fired from work or protect them from doing something wrong or getting in trouble or whatever it might be and trying to change them oftentimes.
Robert Navarra, PsyD, LMFT, MAC (00:43:44):
Yeah. Exactly. So the idea would be to normalize those emotions and to let both parties know that there's trauma that they both have experienced. There's an intervention I actually designed as I started to say in the couple recovery group that I do called Heart Healing Emotions from Addiction Recovery and Trauma. And what it is is partners taking, and I take a lot of time to set this up. Time to think about a time they've been traumatized by the addiction. So let's say the partner of the person with the addiction might say something like, “Last holiday, last Valentine's Day was really traumatic. You know, we went out for dinner and what I remember is you drinking and drinking and drinking, and then whatever events unfolded.” Now that intervention is set up so that the person describes what they recall, what they felt, and then I give a written sheet or a handout to the listener to say, how do you think this event impacted our relationship? How do you think this event impacted our family?
Robert Navarra, PsyD, LMFT, MAC (00:45:09):
And there's a series of questions where the listener is in this diotic frame is having partners talk to each other instead of the therapist. That's a playbook right outta the Gottman playbook. So it's a diotic frame, and they're talking to each other about the impact of this thing. If it starts to move into blame–“How could you do this? I thought you loved me.” Like the woman with the Vicodin pill simulated Vicodin pill the therapist intervenes, hit stop. You talk about what you're feeling right now and describe yourself, not your partner.
Keith Sutton, Psy.D. (00:45:39):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:45:40):
“When I think about that dinner, I feel hurt, I feel angry.” Now, that's okay. We can talk about that. Rather than, “you don't love me, what's wrong with you? How could this be more important?”
Keith Sutton, Psy.D. (00:45:51):
Yeah. Rather than that kind of what might feel like an attack talking about the impact. And that, and for people that don't know Gottman so much, there's lots of great kind of scripts or the dreams within conflict where they're basically kind of interviewing each other about their feelings about a certain subject when they're in disagreement or whatever it might be. So that's nice that you kind of created a script to kind of interview the other about their trauma.
Robert Navarra, PsyD, LMFT, MAC (00:46:21):
Yeah. It was really interesting going, well, I wonder what's gonna happen. So you developed these things, right? I developed these things. And then I put it in a clinical practice and I've actually done workshops literally in treatment programs where I have them do this. So I give the presentation where usually role play, how to do this with a lot of humor, then the couples break out, and then they actually do this exercise. But the thing that's also interesting to me, Keith, is it's not just the partner of the one, it it not the non-addictive partner who's doing the speaking, it's also the addictive partner. So literally do the same exercise for the person with addiction. And the instructions are, ‘what do you recall was an impact of a particularly difficult event as a result of your use that you'd be willing to talk about that was traumatic for you?’ And so the non-addictive partner starts asking questions, “what is the event?” There was an event that I heard as I did this in one of the treatment programs where the guy was describing, and he's the one with the alcohol use disorder severe, describing how he totaled his car. And the context for this is that this is a car that he built with his father.
Keith Sutton, Psy.D. (00:47:42):
Oh wow.
Robert Navarra, PsyD, LMFT, MAC (00:47:44):
Sort of back in the day, maybe 10 years previously, and his father has had died subsequent to that. So what happened is that when he totaled the car, it wasn't about the materialism of the car, so to speak, although that is something, it was the emotional significance that this had. So tears are flowing down this guy's face, you know, he totaled the car under the influence. The wife had no idea that he was traumatized by his own addiction. And I think that's important for therapists to know.
Keith Sutton, Psy.D. (00:48:15):
Definitely.
Robert Navarra, PsyD, LMFT, MAC (00:48:16):
And so she had no idea, and this was an incredible healing moment for them, for her to see the pain he experienced as a result of his own addiction. So she's not the only victim here.
Keith Sutton, Psy.D. (00:48:26):
Yeah, definitely. That kind of the other person on kind of in EFT terms like the withdrawal is also experiencing that pain and being able to see that they're both struggling and having that kind of distance between them because of the addiction.
Robert Navarra, PsyD, LMFT, MAC (00:48:43):
Yeah. Yeah.
Keith Sutton, Psy.D. (00:48:44):
Also kind of to touch on quickly because I know that there's so much research on the ACEs study and kind of trauma and trauma's relationship to addiction. So I imagine so many of the couples that you end up working with are, that are in the situation, also have some history of trauma that's playing in there since folks with PTSD and Complex PTSD have a higher likelihood for addiction.
Robert Navarra, PsyD, LMFT, MAC (00:49:11):
Yeah, exactly. You know, when I do trainings for therapists, we will look at sort of the heritage of trauma. So let's say the person, and this may or may not be true but it tends to be, the person with the addiction grows up in a family where there's maybe a fair amount of dysfunction or addiction. Because this genetic predisposition thing is a real thing. So it's likely that that's been the case. So there's trauma that starts there as a child. Then there's trauma that begins when the person starts using addictively at some point in their life, then they're in a relationship. And maybe that's when the addiction kicks in or not, or maybe prior to getting together. But then there's trauma that the addiction brings into the relationship, now we got that. And then hopefully a person gets into recovery and now we have trauma associated with that.
Keith Sutton, Psy.D. (00:50:00):
Sure.
Robert Navarra, PsyD, LMFT, MAC (00:50:00):
And so the therapist needs to say, I think things like, well there's a history of trauma that begins here. So family of origin stuff and then addiction has also brought trauma into your personal life and your relationship life. And now recovery is bringing trauma to the both of you. And by trauma, I mean the uncertainty of what now and what about all these feelings I have.
Keith Sutton, Psy.D. (00:50:24):
Yeah.
Robert Navarra, PsyD, LMFT, MAC (00:50:25):
And am I supposed to not be angry because you're in recovery and if I express my anger, are you gonna relapse? You know, there's all sorts of things. So it's really difficult for couples to get their footing going forward. And I think as therapists, we need to provide a structure to have these conversations, to manage the impact of trauma, to normalize their reactions.
Keith Sutton, Psy.D. (00:50:45):
Yes.
Robert Navarra, PsyD, LMFT, MAC (00:50:46):
And it's been very powerful. It's worked really well, I have to say.
Keith Sutton, Psy.D. (00:50:50):
Well, and two, I imagine when the couple is feeling connected in that way and kind of the addiction is externalized and they're able to see how each one is hurt by that they can also come together and then potentially the relationship can be a resource for when one is feeling the urge to use and talking with their partner about their urge that may be triggering to the partner. They might get scared, or again, if they've got more of that security, they might turn towards each other and talk through that or support that. Sometimes I talk about with couples, say one's trying to quit smoking and the other one smells smoke on them rather than kind of glaring at them and saying, “Hey, you messed up” or something “you're not supposed to smoke.”
Keith Sutton, Psy.D. (00:51:34):
Finding out like, “it seems like you’ve relapsed.” Instead saying, “you must be having a hard time.” Where there's something that's going on there, again, depending if the person might just feel hurt and re-traumatized or so on. Or they might be able to see it as rather than kind of not obeying or following the rules or whatever it might be, but having a hard time and something slipping, whatever it might be, and seeing the person in in the kind of in distress.
Robert Navarra, PsyD, LMFT, MAC (00:52:05):
Mm-Hmm.
Keith Sutton, Psy.D. (00:52:06):
Rather than the client.
Robert Navarra, PsyD, LMFT, MAC (00:52:08):
Yeah. Well I think the concept is to name these things. And so if we look at the proverbial elephant in the living room, this is often a term used to describe when there's addiction and other things. But addiction that nobody can talk about. So the therapist initially needs to provide a structure to say, “are you doing couples therapy?” and “You're here because you're arguing it a lot and you feel like you've lost touch.” And then in your assessment it looks like alcohol or some substances showing up as a problem or some process behavior of some kind. Then you need to include that in your treatment plan to say, well, it looks like this is showing up on the radar. One partner says, “I don't have a drinking problem or a use problem.” And then you say, well, this is something for us to talk about how you both perceive this, and then the education part can help move the needle in that stages of change. Kind of say, well, “you are drinking at levels that would be considered harmful based on science.”
Keith Sutton, Psy.D. (00:53:09):
Okay. So we're almost out of time. You were mentioning ‘assessment’ and I was wondering if you can speak a little more about that.
Robert Navarra, PsyD, LMFT, MAC (00:53:17):
Sure. So the thing that I've noticed and I was definitely in the same category as therapists are reluctant to work with folks that might have substance issues and yet there they are sitting across from us. So I think every therapist really has a responsibility to have fundamentally some aspects of assessment in terms of, ‘well what am I dealing with here?’ So I wanna give your listeners some ideas about what seems to be very successful and it's sort of a protocol that would help therapists to make decisions about, ‘okay, now what do I do with this couple or this individual?’ There might be something going on. So one of the things that often happens is therapists are reluctant to even ask the question and because it might feel awkward or might feel invasive, or I don't know what to do if they say yes.
Robert Navarra, PsyD, LMFT, MAC (00:54:06):
For a number of reasons. So what I'm suggesting is that that absolutely needs to be built into every intake. So it's really crucial, I believe in that first session or the first two sessions, if not the first to kind of say ‘why are you here? How can I help you?’ And they identify that if substances are not mentioned at all or behaviors that might be problematic, I think it's important early on to say, so I do this with every client, every couple I work with but let me ask you about your relationship with substances, including alcohol. And if you're working with a couple, there's a two sort of a double focus you can take in asking the questions if you're working individually with a partner in couples therapy.
Robert Navarra, PsyD, LMFT, MAC (00:54:52):
Or you could generically kind of put this out to the couple, if they're in front of you, you could say, have either one of you ever expressed or had concerns about the use of alcohol or other substances? And it's just kind of a routine question. So that's putting it out there. And what we don't wanna do is to avoid the question. Another common response, this tends to be what I hear from a number of therapists, they say, “well, I really feel like I need to develop a rapport before I ask that question.” You're developing a rapport when you ask the question. You say, this is part of what I do, and how the therapist asks it is important. So you don't wanna say things like you don't have problems with substances, do you?
Robert Navarra, PsyD, LMFT, MAC (00:55:33):
You assume that the person's using substances of some kind, you just assume it, right? So when you get beyond the substance question, you could say, and or any other behaviors that might feel kind of out of control at times, like how much time is spent on the internet, like gambling, like the amount of time spent looking at pornography or whatever. So you're putting some behavioral process questions and it's just out there right from the get-go. Then I've got a really good question that kind of summarizes motivational interviewing in one question. And the question would be this, if it shows up and one or both partners or the individual, there's some indication that there's something going on with substances or behaviors, a great question to ask would be, “on a scale of one to 10, how concerned are you about ‘fill in the blanks’?” “Your use of cannabis? Your use of methamphetamines, whatever,” on a scale of one to 10, 10 being I couldn't be more concerned, one is I'm not concerned at all. Then the follow up questions are what is gonna give the counselor a sort of a thread, perhaps, of where that person might be on their stages of change. And so let me roleplay that with you if you're up for it.
Keith Sutton, Psy.D. (00:56:56):
Of course.
Robert Navarra, PsyD, LMFT, MAC (00:56:56):
All right. So let's say you're the client and you're saying you're concerned about your alcohol use, right?
Keith Sutton, Psy.D. (00:57:01):
So yeah, I'd say my concern is around a six or a seven.
Robert Navarra, PsyD, LMFT, MAC (00:57:05):
Okay. Here's the follow up questions. Okay. So what places you at six?
Keith Sutton, Psy.D. (00:57:12):
You know, I guess I've been having some trouble sleep in. I've been, you know, drinking to go to bed and I don't feel great in the morning. A little slower, things like that. And it's more than I'd like to be drinking.
Robert Navarra, PsyD, LMFT, MAC (00:57:24):
Okay. So you're noticing an increase in drinking, perhaps in the evening that's impacting your ability to sleep and function the next day as well as you'd like?
Keith Sutton, Psy.D. (00:57:33):
Well it was more like using it to sleep and stuff. Cause things have been very stressful and I just, you know, I usually didn't drink daily, but it's kind of been like that ever since the pandemic.
Robert Navarra, PsyD, LMFT, MAC (00:57:45):
Yeah. Sure. Okay. That's a really common experience as it turns out. So here's the follow up questions, Keith. So what would it take to increase that concern? What would it take just for you to be worried? Even more worried or concerned I should say?
Keith Sutton, Psy.D. (00:58:04):
I mean, I feel like I could do something about it if I really kind of decide to. And so I guess, yeah, if I tried to stop or cut back or something then, and I couldn't do it, that'd be concerning.
Robert Navarra, PsyD, LMFT, MAC (00:58:17):
Okay. All righty. And what would it take to lower that number so you'd have less concern?
Keith Sutton, Psy.D. (00:58:25):
Yeah, I mean, if I wasn't drinking every night, things like that, if I was feeling a little more refreshed and not getting in this cycle of kind of drinking to sleep and then feeling not great in the morning.
Robert Navarra, PsyD, LMFT, MAC (00:58:38):
Okay. All righty. Great. So we just did a very provisional assessment, and what I've learned from the client is that if we look at stages of change, pre-contemplation, I don't have a problem, contemplation preparation, I might be ready to do something about it. What might that be? Then I would place this client that you just role played in that contemplation stage that goes, now there's something going on here. The therapy then could indicate. So more information is needed on what's actually happening, how long this has been going on, and is there family history. So there's other things to gather in terms of information. But on the stages of change, this looks like an opportunity potentially at this point to say, well, we can certainly explore your relationship with alcohol and what it might take to change it so that you feel more comfortable with it.
Robert Navarra, PsyD, LMFT, MAC (00:59:23):
Yeah, and if it looks like there's more problematic behavior associated with that historically and even currently, then that would be sort of different trajectory to kind of say, let's look at how this seems to be escalating so that there's a way to work with wherever that person's at. So that would be the context. So it's an amazingly powerful question. With the two follow ups, what would it take to increase, decrease? Just to kind of situate where that person might be in the stages of change. It's a really good tool, and that creates a conversation. And just to remind everyone is that the goal is not to get your client to stop doing, that goal is to explore and have a conversation about what's going on and is how is this working and how is it not working? And what would you like to have happen?
Keith Sutton, Psy.D. (01:00:10):
Well,I imagine too it would also depend on what the client's coming in for. I think the assessment, of course, would be really good to figure out where they're at, but I almost had a thought of like climb being like, well, I'm not really here for that. I'm here because we're getting in fights all the time, or we're separated right now, or something like that. And how much do you think this plays into what's going on? Or how important is this to address or something. I kind of come from a strategic family therapy background where getting hired to work on something, which sometimes I might, they might talk about this, but like, ‘it's not a problem.’ Or ‘we don't need to deal with that here.’ But it's helpful to know from the assessment later, as it starts kind of becoming more and more like every fight they've been drinking. I remember you mentioned this and kind of tying it back to like maybe we need to deal with this to help with the problem you're coming in for.
Robert Navarra, PsyD, LMFT, MAC (01:01:07):
I think you just said it so well, this is a great question, or a great observation. So people say, I'm not here for that. And you would say, “no, you're here because you wanted to work with your partner on such and such,” or “you're here because you're struggling with depression, anxiety.” So this may or may not be relevant to that concern. That's what we're sorting through. So if it's not an issue, then we will have explored it. So once again, you're reiterating, ‘No, no, this is part of my standard protocol.’ And then you get to make decisions, I say to the client in terms of what you wanna do with all this. So that's okay. But it's important for me to ask and it would be negligent of me not to ask. Because if it is playing a role, then we wouldn't wanna know that in addition to the other concerns you have, so they're not mutually exclusive. And almost always, clients will say, “oh, okay” if you explain to a client why you're doing something.
Keith Sutton, Psy.D. (01:02:05):
It's like a narrative therapy or more of the post-modern where you're being transparent why you're bringing this up. And I think too, like you're saying, the way that you say it also matters a lot. I oftentimes, when I'm supervising, rather than saying, “oh, is it okay if I asked you about your alcohol user this or that, or whatever,” maybe the person might be like, “well, I didn't have an issue, but now maybe there is something.” I find that, when something might be uncomfortable or when things were uncomfortable for me, I'd kind of think about like, ‘what would a medical doctor do?’ They'd just be like, ‘Okay. How's your drink? How's your this?’ And just matter of fact, that it matter of course, and just kind of going with it. It kind of goes a lot smoothly and people just kind of respond, ‘oh yeah, this is what we're doing.’ Like this is just totally normal here.
Robert Navarra, PsyD, LMFT, MAC (01:02:53):
So if I had take a highlighter pen on what I feel is important in our conversation today about this, I would say what you just said ranks up at the top. You're creating a conversational tone about something. Let me find out where you're at. And then it's not a bad idea for therapists to understand when to be concerned with drinking. At what point is it problematic? And that's changing all the time. The current studies are really looking at any use of alcohol potentially is problematic, even so-called “safe levels.” So that's sort of a different discussion. But minimally, I think what you just said is really, really important to create a conversation. The other assessment tool that undoubtedly many of your will listeners out there would've heard of is the CAGE.
Robert Navarra, PsyD, LMFT, MAC (01:03:36):
It's an, an acronym for the four questions that have a very high hit rate for identifying problematic behaviors, not just with alcohol, but with anything. So C A G E, C: have you ever tried to cut down on how much time you spend fill in the blanks? Sure. A: have you ever felt annoyed with somebody expressing concern about your use of whatever? G: you ever feel guilty about your use through the amount of time you spend, fill in the blanks? And then E stands for eye-opener, which means do you ever start the day with? Now this works for substances of all kinds. This works with behaviors and this works with alcohol, which was originally designed. This goes back many years now as a pretty helpful screen, basically.
Keith Sutton, Psy.D. (01:04:33):
Trying to get a sense if there is some issue there or something's going on.
Robert Navarra, PsyD, LMFT, MAC (01:04:38):
Yeah, exactly. So that's really good. And then the other tool–I'm gonna give you a link–is the audit. So the audit is a screen widely recognized universally actually. The alcohol use. Alcohol use, oh my goodness. You're gonna edit this. Keith?
Robert Navarra, PsyD, LMFT, MAC (01:05:07):
Alcohol. Oh, here we go. The audit stands for the Alcohol Use Disorders Identification Test.
Keith Sutton, Psy.D. (01:05:14):
Perfect.
Robert Navarra, PsyD, LMFT, MAC (01:05:16):
Okay. And there's a wonderful free resource that your listeners can get. It's the manual and the audit was developed by the World Health Organization. So it's non-pro proprietary, and you're able to use this freely without worrying about infringing on intellectual property or anything. And what's cool about that is there are manuals and options in English, Spanish Hindi, Japanese, Thai, and the cross-cultural sensitivity translates really well. It was developed in six different countries, and I've used it, I've given trainings and workshops in South Korea where they actually have a Korean audit. It's modified now. The advantage of the audit over the CAGE when it comes to alcohol, the audit's only relevant for alcohol. So it's not used for other substances. But what's cool about the audit is it looks at low, medium, high risk drinking and then like, harmful and hazardous. Hazardous and then harmful. So it's a 10 item questionnaire, it's just easy to give the person, you could ask the questions, but frankly it's just easier to give this little intake sheet that you could give them.
Keith Sutton, Psy.D. (01:06:38):
Good. Good.
Robert Navarra, PsyD, LMFT, MAC (01:06:39):
Yeah. And when they complete that, what you're gonna get is, ‘oh, it looks like your score is consistent with somebody who typically experiences problematic relationships or health issues,’ or something like that. Or you're drinking within what would be considered safe zones of drinking.
Keith Sutton, Psy.D. (01:06:55):
And I know too that I think recently doctors are using kind of like how many drinks per week and there's kind of a number something that is related to the health effects of alcohol or so. And the number of drinks per day or so on and asking questions that raise consciousness.
Robert Navarra, PsyD, LMFT, MAC (01:07:14):
That's right. And so what I can tell you just cut to the quick, so that the general recommendations now, because it's actually changing and there's some recent studies, even though there's unofficial change in the policy with the AMA and so on, the general guidelines are, it's probably safe drinking for many people under many circumstances for people of all gender identifications as with one drink, maybe two max. And that's very different than the previous guidelines that were given for is differences for men and women in the sex you're born with concepts. The gender fluidity concept doesn't fly here. It's more like just biologically. The female body, male body processes alcohol differently and there's reasons for that.
Keith Sutton, Psy.D. (01:08:03):
Definitely, yeah. I think another piece too, I don't know if you do this, but I know when I'm trying to assess and I talk to somebody, I might not do this in the first session, or it depends on kind of where we are, say like, “oh, I drink like three times a week.” I'll be like, “okay, well tell me about yesterday. Did you drink the day before?” And finding out kind of what they're drinking. But then when you go through the last week of drinking or smoking weed or whatever it might be, you start getting more of the story and then a little bit more kind of depth of it. Especially if you know somebody there, it seems like there's some issues or so on there.
Robert Navarra, PsyD, LMFT, MAC (01:08:39):
Such a good point.
Keith Sutton, Psy.D. (01:08:40):
But that's kind of a nice one cuz they're like, well, “I did do this on Friday,” and they're like, “well, it's a tough week or something,” or like, “oh gosh, I guess, yeah, it's more than two like it was the Superbowl,” you know? And then you start getting at the plot pickings.
Robert Navarra, PsyD, LMFT, MAC (01:08:55):
There you go.
Keith Sutton, Psy.D. (01:08:57):
But it's kind of a nice way to do it and just like explore. And oftentimes clients, again, depending on the rapport, are good with that.
Robert Navarra, PsyD, LMFT, MAC (01:09:04):
Yeah. Well, actually I'm glad you said that because it is assessments ongoing, right? So if there's problematic use, it's really hard to talk about it and sometimes it's just a matter of education. They're not aware that they're drinking or using at levels that could be problematic.
Keith Sutton, Psy.D. (01:09:20):
Yeah, yeah, definitely.
Robert Navarra, PsyD, LMFT, MAC (01:09:21):
So if you're talking about alcohol, it's also important to define what you mean by a drink. And so we do alcoholic.
Keith Sutton, Psy.D. (01:09:28):
You're like, “oh, I had one drink last night.” “Oh, what did you drink?” “Oh, I had like a martini.” “Like how many shots?” “Like oh three.” And it's like, “okay, there you go.” A little more information there.
Robert Navarra, PsyD, LMFT, MAC (01:09:38):
So just for the record, so equal amounts of alcohol are found in an ounce and a half of distilled spirits, five ounces of wine and 12 ounces of beer, say a can of beer or a bottle of beer. Not IPA so much, but you just go, those are rough estimates. And I've had clients go, “oh, I only have one drink.” Well, what's in your drink? “Well, I've got a big slushy cup and fill it with ice, and then I top it with vodka and put a drop of orange juice in it.” So when we break it down, it's probably like six drinks.
Keith Sutton, Psy.D. (01:10:09):
Yeah. Yeah.
Robert Navarra, PsyD, LMFT, MAC (01:10:10):
And you know, as we're going through this, the other evaluation tool that I think is really helpful is to ask or to get a sense of, cause you can't necessarily get this in one or two questions, is to what degree is this person's behavior organized around obtaining, maintaining, sometimes hiding behavior around the substance use? Without even asking how much the person drinks. You can get a sense sometimes in the narrative and by asking questions and just listening carefully. How much time is spent on that activity? And then you ask the how much questions maybe at that point.
Keith Sutton, Psy.D. (01:10:54):
Definitely.
Robert Navarra, PsyD, LMFT, MAC (01:10:55):
And then finally you know, in the state of California, but this is true probably in almost every state for therapist anyway, some version of this, therapists are responsible for three things in evaluation, whatever it is you're treating the person for, what are my evaluation tools? So we just went over a couple of them. The audit is a screen, the CAGE is a screen, the clinical interview is a screen. So these are evaluation tools that lead to an assessment, which you might need to, that you're likely to take a number of sessions to figure out. So what are my tools for evaluation? How do I piece that together in a way that allows me to give an assessment? And the third part is, what's my treatment based on my assessment? That's probably gonna be an ongoing kind of assessment thing.
Keith Sutton, Psy.D. (01:11:44):
Yeah. And you're saying in the state of California, meaning like if you were working with somebody, they came in for something else and you did not assess for the alcohol or you did not come up with a treatment. You're saying that's something that would be an issue board worthy or so on.
Robert Navarra, PsyD, LMFT, MAC (01:12:01):
Well, it, yeah. I mean, I don't know. I would say it could be, I would suppose. I've had a client where she said, “I was treated for an eating disorder when I was a young woman.” And she goes, “not one therapist, not one treatment program.” She was in two asked me anything about my alcohol use. So we addressed the eating disorder stuff, but not my alcohol use. So you go, well, therapist, what's sort of the standard of care?
Keith Sutton, Psy.D. (01:12:32):
Standard of care.
Robert Navarra, PsyD, LMFT, MAC (01:12:32):
Yeah. I think the standard of care is say we need to evaluate and to know when to refer or to say more is needed. And these are just screens, so you cannot diagnose someone based on a screen. You know, all you can say is your score is here, or the stories I'm hearing are kind of consistent with what might be a problematic use with substances. And it's something I think is important for us to talk about in addition to whatever the person comes in with.
Keith Sutton, Psy.D. (01:12:57):
Yeah. And I think that's one of the trainings that are mandatory in California to get license, is to get training in substance abuse right.
Robert Navarra, PsyD, LMFT, MAC (01:13:07):
Yeah. So those are the things I wanted to add. And I also, actually, you just gave me a great segue, Keith because there's a class called Couples and Addiction Recovery Training that I gave. And it was sponsored by the Gottman Institute. And John and Julie Gottman gave a talk on treating affairs and trauma, and it was a four day weekend. So they did the first three days, and then I was on day four, doing this, and I was recorded. And Berkeleys goes back a couple of years ago. And then the Gottman Institute basically turned it into an online class. So that is something that's available to listeners if they're interested in a six and a half hour training with tools, manual, and all how to do assessments and how to work with couples in recovery. I'm saying another option would be to go on my website and to register for that class, because then you have an option to do a 90 minute training with me or Q and A or case consultation. Once you complete the class, then you're also eligible to get eight CEUs for that.
Keith Sutton, Psy.D. (01:14:18):
Oh, nice.
Robert Navarra, PsyD, LMFT, MAC (01:14:19):
So if you sign up on my website, you can do that. You could sign up on the Gottman website if you're not interested in the CEUs or in a 90 minute consult or Q and A kind of thing. And then finally, I do also offer a workshop for couples in recovery from addiction. It's called Roadmap for the Journey. I was asked by the Gottman Institute to design this workshop, which I did, and I've given in treatment programs. I've been invited by Betty Ford Hazleton three times now. I'm presenting again a workshop for their couples in Minnesota this summer sometime. And I have a live online version.
Keith Sutton, Psy.D. (01:14:58):
Oh, perfect.
Robert Navarra, PsyD, LMFT, MAC (01:14:59):
It works very, very well. It's a total of 10 hours of content and couples get the manual and recovery card decks are part of the workshop materials.
Keith Sutton, Psy.D. (01:15:12):
Perfect.
Robert Navarra, PsyD, LMFT, MAC (01:15:12):
And then finally the last plug is I also have a free class that's just an hour, but it's a free class for therapists or couples on using the card decks that are used to sort of talk about different aspects of recovery. And so it's an actual, it's built right into my workshop and it's part of my training in the couples in addiction recovery training, how to use the tools of that card deck and what they, you don't need the card deck to actually do this. The concept, there's four different concepts that partners have conversations about, but there's a structure with the card deck that makes it a little bit easier. So that free class is found on my website as well. And then there's a paid class. It's a short sort of an overview of couple recovery.
Keith Sutton, Psy.D. (01:16:01):
Okay. Perfect. Well, I'll definitely be linking to your website in the bio, so that'll be perfect.
Robert Navarra, PsyD, LMFT, MAC (01:16:09):
Cool. And I think that covers it in terms of providing a little bit more information.
Keith Sutton, Psy.D. (01:16:13):
Okay. Well, great. Well, thanks, I'm glad we're able to cover everything today and I really appreciate you're doing wonderful work. I think this is such an area of need, so I think this is really perfect. Thank you so much for taking the time.
Robert Navarra, PsyD, LMFT, MAC (01:16:27):
Thanks Keith, for having me on. I appreciate it.
Keith Sutton, Psy.D. (01:16:29):
Take care.
Robert Navarra, PsyD, LMFT, MAC (01:16:30):
Bye-Bye.
Keith Sutton, Psy.D. (01:16:32):
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