The Identified Patient

By Ken Wells - 09/06/2020


Series One: Blog Thirty-Nine

“Death is not the biggest fear we have; our biggest fear is taking the risk to be alive – the risk to be alive and express what we really are” — don Miguel Ruiz

Tim had been in recovery for 10 years from sexual addiction. In the beginning it was tough. Seemed like he could never get traction. For a year, the longest sobriety he achieved was a 3 month chip. The slippery slope of relapse took him all over the map. There were spotty experiences of checking out eye candy, surfing the net for porn, combing through escort sites, and massage parlor drive-bys. At times he would masturbate to all of it. Everything mentioned was against his bottom lines. Of course, there were flaky attempts toward accountability to his partner and support groups. At first he wouldn’t tell anybody, telling himself he wouldn’t do it again so why bother. Then, toward the end of the first year, he got into therapy and decided to take his 12 step program seriously. He got a sponsor and met every week, even calling multiple times a week for consultation and support. He buckled down and worked through each of the steps during the next 14 months. He continued therapy for the next 4 years, doing everything from family of origin work to psychodynamic and experiential work. He engaged his partner for couples therapy, stopped lying to everybody and practiced telling on himself. He literally had turned his life around the past 9 years.

The problem was that in his relationship he always felt like he was one down- sort of what the guys in the group identified as the “identified patient”. On one level, his partner trusted him that he was not engaging old act out behaviors. Yet, at another level, there was this doubt that came across as judgment, accusation or investigation. Every now and then he would be peppered with inquisition about did this person trigger you or there would be insistence to check his phone laced with judgment or accusation of acting out behavior.

At first, Tim figured he deserved all of FBI interrogation stuff because of his history of ducking and diving the truth. It hurt but he figured that’s just the way it would be for now. After 9 years, the judgment, accusation and investigation had improved and lessened significantly.  Yet, during check in and connection with his partner, it seemed to always come down to the question “are you cheating on me” with your addiction or an occasional interrogation about his behavior because his partner just had a hunch something wasn’t right.  Without discussion, it was clear that his partner figured that Tim needed to just get used to it. It was part of the carnage and consequences and that it looked like it was not going to change anytime soon. So Tim was facing the prospect of being one down and periodically being queried and questioned about his acting out behavior that he had not engaged for the past 9 years. He accepted it but honestly was unhappy.

As a therapist, it has been my observation that for Tim and his partner to cultivate deeper emotional intimacy and a more fulfilling sexual life that this dynamic described is not sustainable. For them, the future looms with likely increase in relational distance with growing resentment by both partners and the added possibility of addictive relapse. The dynamic is ripe for a sabotaging self-fulfilling prophesy that usually perpetuates dissatisfaction and further heartache.

It makes sense that Tim’s partner would be suspicious and mistrusting, at times. The intensity of mistrust varies with the histories of acting out, trauma and responses from the partner betrayed and the addict. Often, it takes time for a betrayed partner to experience the stages of healing so necessary to achieve recovery from betrayal. While the experience will always be a painful reality, it does not have to dominate relational perspective.  There is no assembly line schedule to reference for betrayed partner recovery. Of course, the commitment to recovery and ending acting out by the addict influences and impacts the healing of trauma for the partner and achieving healing within the context of the relationship.

That being said, there does come a time in the relationship where moving past the addict being the “identified patient” is necessary in order for resiliency to carry the wounded couple to a place of deeper intimacy and chosen trust. Many couples choose to “heal around” the broken trust, meaning that it becomes acceptable for the addict to always be the “identified patient”. Each couple involved in partner betrayal will make their own way through this dynamic. It has been my experience in working with betrayal with many different addictions that some accept that the addict is the “identified patient”, others break up because of the dynamic and fewer build a deeper trust in the presence of relational vulnerability.  Here are a few observations that I would encourage the addict to consider:

1. It will be imperative for you to separate the shame of your behavior from your sense of self.

Wallowing in the mud from past behavior never cleansed a relationship blemished with betrayal. You will need to take yourself by the nap of the neck and crawl out of the mud hole of self-condemnation. It will require working the 12 steps with a sponsor, doing the work of self-forgiveness which therapy can be most helpful. Experiential, narrative, cognitive approaches are very helpful. Yet, nothing replaces the choice made in your heart to do whatever it takes—to walk to hell and back—to separate the shame from your sense of self. Ultimately, there is no “quick fix”. This journey will require daily conditioning and training—recognizing the mistaken beliefs you tell yourself and consistently re-directing the shame to the behavior without perfection. In order for you to stop being the “identified patient” in your relationship, you will need to stop calling yourself names (I am a drunk, a pervert, a loser) and commit to understanding that your addiction behavior is an aberration and not who you are. You will need to make a deep commitment to yourself that “you are an unrepeatable miracle of the universe” – always have and always will be. This will have be hammered out not by the way you feel but by the actions you take. It will start with you, your attitude and your choices toward action.

2.  Make a commitment to stop personalizing your partner or others’ opinion or behaviors.

This commitment is age old and only comes to fruition with determined conditioning of heart. It’s none of your business how your partner formulated their decision to think of you the way they do in any situation. What matters is how you think about yourself and the truth you are committed to in your heart. In the Four Agreements, Don Miguel Ruiz endorses Toltec wisdom as a path that teaches us to transcend our limiting beliefs and self-sabotaging behavior patterns so we may live a fulfilling and authentic life. It is simple, not easy, to describe and live out this deep commitment. Many people become discouraged and give up. Yet, those who prevail are those whose resilience take them deep into their own brilliance. This is where you make beautiful art from a life devastated by addiction by living out the belief that you are an unrepeatable miracle of the universe. You will always be vulnerable to personalizing thoughts and behaviors of those you love the most, but you do not have to be dominated by them.

3. Practice setting internal boundaries when your partner is triggered with mistrust. 

When your partner becomes reactive with thought that you might be acting out or otherwise on the sly, it does not make it so. You don’t prove your point of innocence with defensiveness or argumentation, either. When you set an internal boundary, you will respond differently to your partner’s reactive judgment of you. It’s a disciplined skill set to calm yourself by inwardly separating from your partner’s emotional response. Experiential therapies like EMDR help sometimes. Some skill sets in life are not rocket science and make sense but take a ton of practice and conditioning to be operative. This skillset may not be spectacular but when practiced as a lifestyle will effectively enable you to better respond to your partner’s emotional reactivity.

4. Validate the fear and anxiety that provoked your partner’s negative emotional response toward you. 

While you may not be guilty as charged by your partner for whatever suspicion of addictive act out, you can offer understanding as to why your partner is suspicious. The reason you struggle to do this is because you have not separated yourself from your past addictive behavior and you try to run from any accusation and suspicion. This is a result of not doing enough work of separating the shame of your past addictive behavior from who you are and what you historically did. This applies even if what you did occurred yesterday. When you don’t do your shame work you will remain reactive and defensive because you will still be operating from the mentality that what you do determines who you are. Shame will need to be replaced with compassion toward self (not excuse making) which can generate compassion and understanding toward your partner’s reaction. This will take conditioning. When you respond to your partner’s anxiety with your own reactivity, it will be helpful and strengthen validation skills for you to circle back and apologize for your own reactivity. It is humbling but very effective.

5. Establish an external boundary with a request and redirect toward reassurance. 

After 9 years of successful sobriety and deepened serenity, our friend Tim has positioned himself to employ an external boundary with his partner. He can request from his partner that rather than judge, accuse and investigate him as liable as charged, that his partner shift to sharing the fear, anxiety underneath the reactivity. Then the partner can ask for reassurance that all is well or not, in order to more effectively manage their emotional reactivity. If the partner does not honor the request, then it will be important to detach from the intrusive behavior and practice not personalizing.

As you can see, fleshing out these steps where the rubber meets the road will involve failure on both sides of the street. Yet, these steps are a map and when you get detoured or knocked down with failure by your own efforts, you can stand up, figured out what happened on your part and get back on track. In order to do this work you will need to practice becoming keenly aware of how and when you gave your power away to reactivity and take it back.  This is necessary to shift from being the “identified patient” to deepening relational intimacy.

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