Resiliency-Focused Couple Therapy
A Multidisciplinary Model
By David E. Greenan
Abstract: With a focus on resiliency, this article presents a three-phase systemic treatment model for working with high conflict couples. Initially informed by the work of Salvador Minuchin, the author uses joining and enactments with the couple to identify circular behavioral problems that maintain homeostasis. Using the teachings of Sakyong Mipham Rinpoche, the therapist in the middle phase of treatment introduces mindfulness practices to quiet the central nervous system, and then incorporates aspects of John Gottman’s communication exercises for skill-building and resolution of conflict. In the final stage of treatment, Diana Fosha’s Accelerated Experiential Dynamic Psychotherapy concepts are implemented. The couple is encouraged to identify their defensive behaviors that preclude intimacy and to metaprocess with one another their experiences of core affect.
Introduction: The Healing Journey of Intimate Connections
In the early 1980’s, I was an actor living in New York City which was the epicenter of the AIDS epidemic. I was horrified and scared of what was happening all around me as friends and colleagues in the theatre community contracted pneumonia one day and died the next. Torn between wanting to flee and wanting to help, I learned about an innovative care program at St. Vincent’s Medical Center. Rather than quarantine young men who had the disease, they provided hands on end-of-life care. In order to serve the rapidly increasing numbers of men being diagnosed with the disease and to provide a supportive community for their partners and friends who were often isolated due to homophobia, a Sister of Charity, Patrice Murphy, had the courage to create a hospice program that not only provided services for the men with AIDS but also bereavement support services that honored their invisible partners and friends.
Over the course of several months, I trained to be a volunteer. I began to be “a buddy” for men who were no longer capable of living independently. Through this one-on-one time with men whom I was assigned to help and in supporting my friends who had contracted the illness, I experienced a lessening of my own fear and isolation that I was experiencing during the epidemic. Eventually I began to co-lead bereavements groups for partners and friends at the hospital. My world view changed as I experienced the power of connections and community to reduce both shame and the seemingly unbearable aloneness as survivors connected with other men and women in these groups. We made a film, The Hidden Grievers (1987), to document this innovative work which later became a training film for other hospice programs throughout North America.
Although I had a successful career as an actor at that time, I was inspired by the healing power of these therapeutic connections that these groups provided. I decided to go back to school to earn a doctorate in Counseling Psychology at Teachers College, Columbia University. Not surprisingly given my volunteer experiences in hospice care, I found myself drawn to psychological modalities such as group therapy that provided an environ for the healing potential of community to address isolation and shame. Repeatedly in my clinical training at Teachers College with Dr. Debra Noumair and in my continuing volunteer work at St. Vincent’s and Gay Men’s Health Crisis, I witnessed the power of groups to be a corrective antidote for internalized shame and to mobilize people’s inherent strengths as they discovered their resiliency in the face of profound loss.
As I continued my training in Counseling Psychology, first in an internship and then in a postdoctoral fellowship at NYU/Bellevue Hospital Center, I had the opportunity to be mentored by several people who held similar strong beliefs in the efficacy of both dyadic and group interventions to heal trauma in the face of unbearable aloneness.
Diana Fosha was then consulting to NYU/Bellevue, training interns with the theory and illustrating that theory with taped clinical sessions in what would eventually become her Accelerated Experiential Dynamic Psychotherapy (AEDP, 2000) model of treatment. What resonated so deeply for me was not only her empathy for patients but her ability to focus on the resiliency and strength of people struggling to heal extraordinary failures of attachment relationships in their lives. Her insistence on the clinical necessity of metaprocessing core affect that surfaced in these therapeutic interactions between the therapist and patient, combined with her demonstration of the transformative power of these clinical interventions to elicit healing connections to self and other, would become a cornerstone of my work as I later developed this resiliency-focused couple systems model of treatment.
The following year, in my postdoctoral fellowship, I had the opportunity to work with another person who changed the direction of my life. Through the NYU Family Studies and my family systems training with Dr. Linda Carter, I was introduced to Salvador Minuchin, one of the founders of family therapy. Jewish, Argentine and wise, he embodied everything that I aspired to be in my new profession. He had created his own innovative model of family therapy, Structural Family Therapy (1974), with a focus on empowering disenfranchised poor families as he activated their dormant strengths. Through his institute, he and his senior staff that included Ema Genijovich were consulting to Bellevue Hospital’s outpatient drug treatment program. The federal government had funded a study of perinatal women with histories of substance abuse to ascertain what if any clinical interventions might be effective to retain them in treatment and preclude the placement of their children into the foster-care system. Challenging the prevailing drug treatment philosophy that substance abuse is a disease that required the isolation of a patient in a therapeutic community, he advocated that these “homeless” women should not only have their children in treatment with them but that their significant others who supported their recovery should also be included in the day treatment program (Gushue, Greenan & Brazaitis, 2005; Minuchin, Minuchin & Colapinto, 2007). The focus of the consultation was on the resiliency of these marginalized women and identifying clinical interventions to empower them. In the way that synchronicity often works when we are open to such opportunities, he was just starting a new family therapy training group as I entered my postdoc year of training at NYU/Bellevue. I applied to study with him. I was accepted. My life changed in ways that I never could have imagined.
Similar to Fosha’s work that I had observed in the previous year, my training with Minuchin inspired me as he focused on context, not psychopathology, as a precursor and determinant of human behavior. That physical and mental disabilities could challenge people was not arguable for him but what was so innovative was Minuchin’s curiosity on how context either contributed to or resolved the family’s presenting problem. As I observed him create connections between people, I could see a treatment map emerge informed by his belief in the essential resiliency of people. Both Fosha and Minuchin hold fundamental beliefs in the essential strength of all human beings, if we can create connections for them to feel safe and valued.
Phase I: Structural Family Therapy as the Initial Cornerstone of Resiliency-Focused Couple Therapy
During the next ten years, I studied and worked with Dr Minuchin. For the last seven of those years, I was executive director of The Minuchin Center for the Family. Minuchin’s focus on the resiliency of families and the use of enactments as a means of identifying what complementary interactive behaviors keep a family stuck in predictable circular behavioral patterns became a benchmark of the way I learned to join with families (Greenan & Tunnell, 2003). Twenty years later, I continue to use enactments to identify what complementary behaviors within the family, and in the relationships that the family has with other systems such as health and education, organize and maintain symptoms. Equally important for me, from the initial moment I meet with a family, I’m curious about exploring where are the strengths that can be activated to resolve their presenting problem. Identifying these inherent strengths is probably the singularly most important intervention that a therapist can make to give a family courage and hope.
The primary focus of the Minuchin Center’s work was consulting with organizations that served poor inner-city families. Focusing on how context rather than psychopathology organized human behavior was a novel concept for disenfranchised populations. His beliefs empowered people that had traditionally struggled to be seen as resilient. For instance, with the perinatal women whom I had worked with at Bellevue, bringing in extended biological and non-related family who supported a woman’s recovery and her desire to mother her infant served to expand her identity. She went from a clinical case description of a homeless, unfit mother lacking in resources, to a new narrative of a potentially competent caring woman who given the resources could effectively parent her children. In addition, we found that if we included key representatives of the multiple agencies that she interacted with in treatment (i.e., health care system, child welfare and housing), we could co-construct a treatment plan with the woman that she would comply with. This was significant on many levels. A population that historically had been seen as untreatable transformed into responsible mothers-in-recovery. It reversed the multiple pathological labels attached to the women as the family-focused drug treatment program reduced the chances of recidivism rates and diminished the risk of child placement.
Strengths and Limitations of Structural Family Therapy
After seven years as executive director of the Minuchin Center, I began private practice and joined the faculty of Teachers College, creating a year-long family therapy training practicum for the doctoral students modeled on Minuchin’s structural philosophy. The change from agency-focused work to a clinic setting providing long-term care gave me the advantage of seeing families for more extended periods of time. For the first time, I found myself in a position to track families so I could assess the effectiveness of family treatment.
From the families we saw at Teachers College, I identified a subset population that seemed to remain stuck in their predictable patterns despite the short-term benefits of family treatment. These families were characterized by high levels of conflict that often led to emotional and/or physical violence. Their recidivism rate was high. Once their complementary behavioral patterns were identified in treatment, they responded favorably to interventions that interrupted their behavioral patterns in session. However, once they left treatment, they would regress to their more familiar behavioral patterns whenever emotional triggers occurred. What the couples in the families seemed to have in common were individual histories of earlier traumatic attachment losses. These traumas often had occurred during their formative years when caregivers were either absent and/or abusive. For these families, adult intimate relationships brought “online” early traumatized parts of the self. When this occurred, the part of them that was the mature adult self seemed to go “offline” (Schwartz, 1995).
Phase II: The Second Cornerstone: Mindfulness Practice and Communication Skill-building
I felt stuck. I had trained as a psychologist and family therapist to look at systems—not individuals—as the patient, and to think of the people within the system as parts of the whole. I struggled as I experienced the need to address the attachment trauma that held the adult individuals hostage and challenged the viability and stability of the family system.
Initially, as I joined with these families, I would explore with the adults what feelings were being activated by the interaction when the couple was in conflict. I used my skills that I had learned in work with Diana Fosha and her senior faculty to help each individual identify what younger parts of the self might be activated by the current relational conflict. This could be effective. What I wasn’t prepared for was how many of these couples would then take this highly sensitive, vulnerable information and use it as ammunition against the other in their next argument.
The old adage that we partner with some version of our own family-of-origin system is true. I needed a treatment modality that created a safety zone so that each partner could feel secure to explore their earlier, often childhood-based traumatic experiences, that were inevitably reawakened within the context of their adult intimate relationships.
Concurrent with these realizations, in the aftermath of 9/11, I had become interested in somatic techniques to quiet and soothe the central nervous system. Not only were my foundations shaken as I witnessed the attacks on New York City, but I found that many of my patients were also traumatized. Through the writings of Ana Pema Chodron (1997), I was introduced to her philosophy and to the writings of her teachers, Sakyong Mipham Rinpoche (2003) and Chogyam Trungpa Rinpoche(1984). The Sakyong (2013), the current Tibetan lineage holder of Shambhala Buddhism, has elaborated and expanded upon his father’s teachings on the basic goodness of all sentient beings and the use of meditation to access this core state. In reading the Sakyong’s teachings, I was struck with how his work and that of Minuchin and Fosha complemented one another. As I studied and practiced with the Sakyong, I experienced the ability of mindfulness practice to quiet the central nervous system (Siegel, 2011) and to uncover the defenses that keep all of us disconnected and in conflict. The emphasis on individual and collective compassion that mindfulness practice can awaken in each of us was entry point to address the “fight, flight, freeze” response that I observed in many of my families.
I began to introduce mindfulness practice to couples by first giving them some psycho-education, referencing literature and research that has been done about the harmful effects of the fight-flight-freeze response (Siegel, 2011). While fight/flight or freeze may be an appropriate response when one’s life is endangered, we often unconsciously have that response when we emotionally become activated in our intimate relationships. This physiological response can trigger a sense memory of earlier traumatic events (Solomon & Tatkin, 2011). For example, my partner raises his voice in anger because once again I’ve left the bathroom a mess. If I have a prior history of abuse that associates a loud male voice with physical violence, my natural physiological response may be to tense up with my partner in preparation for a perceived impending physical assault. And at that point, we’re off to the races as I either yell back at him or retreat in a sulk, depending upon what defenses I have learned and stored.
Guided Meditation Exercise Protocol
I began to explore with high conflict couples the benefits of mindfulness practice. After an initial introduction to the benefits of mindfulness practice to lower an individual’s stress and interrupt cycles of abuse, I obtain the couple’s agreement to learn this technique as a first step in the acquisition of skills to interrupt cycles of trauma.
Using a gentle, modulated slow voice, I then begin the instruction. I ask them to close their eyes, if they feel comfortable doing that. Initially, I ask each person to position themselves in an upright seated posture. There are people who may resist or feel unsafe closing their eyes. I respect each person’s hesitation and simply ask them to do what feels comfortable and safe. For some traumatized individuals, simply resting their eyes in a downward gaze 3 or 4 feet in front of them will suffice. After several sessions, most people are able to follow the instructions.
Then I ask them to plant their feet firmly on the floor and to locate their sitz bones in their buttocks by gently rocking side to side. Having centered themselves on their sitz bones, I ask them to extend their spines upwards so that they experience a long strong tall back, with their head seeming to float on top of their spine.
To encourage a sense of groundedness, I suggest they focus on the heaviness of their feet and legs, perhaps imagining that their feet go down through the floor into the earth.
Then I ask each person to begin to follow their breath as it comes into their nasal passages and down through their chest, expanding into the abdominal area. Slow deep breathing is important to quiet the mind and body as shallow chest breathing is often characteristic of people whose CNS is geared up for a physical challenge. Three-part breathing as I teach in this mindfulness practice is intended to literally calm the entire body by letting go of any unnecessary muscular tension and focusing one’s attention on the breath. I encourage the participants to follow their breath as it enters the nasal passages and goes down into their lungs. I then ask them to image their breath going deeper into their lower abdomen so that they actually experience their abdomen and lower back slightly expanding as the breath deepens and expands the torso. And then I ask them to observe the natural contraction that occurs as they exhale.
Many people have trouble both deepening and slowing down their breathing. It’s helpful to ask someone with shallow breathing to rest their hand on their abdomen and feel the expansion of their belly as they breathe into their lower abdomen. Slowing down the breath can also be encouraged by instructing them to exhale on a count that is twice as long as it takes for them to inhale. “So, if you inhale on a count of five, see if you can exhale on a count of ten.” In the introductory stage, it may take several minutes to help someone both deepen and slow down their breathing rhythm. Once people have learned the technique, the entire exercise takes no longer than ten minutes.
I continue to use psycho-education during the exercise. I might say at this point that the object of the mindfulness practice is to NOT to stop thinking or having thoughts. “By focusing on the breath, we shift our attention away from our thoughts to our minds, as we learn to rest our minds on the breath.”
I may continue to do more psycho-education. Using some of the Sakyong’s (2013) imagery, I might say,
The mind is like a wild horse. The horse is easily spooked. The horse and the rider must develop trust and become synchronized, so that the horse can be guided and the rider is stable. Otherwise, the horse will be startled, and canter off willy-nilly, throwing the rider off. The mind is similar. The goal is not to stop our thoughts but to train ourselves to not be seduced by our thoughts; to be able to choose when and what we want to focus our minds on. In that way the mind is like a muscle that can be trained to follow our directions.”
Another image I use from the Sakyong’s writings (2003) is,
Thoughts are like clouds in the sky. We watch the clouds pass through the sky without trying to hold on to them. Our thoughts can be similar. We observe them without perseverating or allowing ourselves to be seduced by them. We notice a thought and can label it, ‘thinking.’ And then go back to focus our attention on our breath.”
Therapists can play around with different images that work for you. These are two that I have found highly effective for people new to mindfulness practice. Getting people to let go of their attention to the mind’s chatter and to quiet their minds by directing their attention to their breath, requires repeated exposures.
I generally practice the exercise as I lead the participants. The grounding and focusing that occurs helps me to be fully present as I too transition into the session. I keep my eyes open to monitor the effectiveness of the instructions and to notice if people are able to both deepen and slow down their breathing.
Once the breathing has become regulated, I help them focus on relaxing the large muscle groups of the body. I ask each person to focus their attention initially on the muscles in the face.
Be aware of any tightness you might feel in your jaw, around your lips, eyes or forehead. If you’re aware of any unnecessary tightness, see if you can breathe into that place and let go of it as you exhale. Then breathe into the open spaciousness of the body. Now, focus your attention on the large muscles of the neck and shoulders, two other areas where we can store a lot of feelings. If you’re aware of any tightness in those muscles, see if you can breathe into that area and release the feeling as you exhale. Now rest your mind once again on the breath as you inhale.”
I then ask each person to focus their attention on the large muscles in the abdomen and the muscles that wrap around their lower back.
Be aware of any tightness or feelings that might be crammed into these muscles. If you feel any tightness in either your abdomen or lower back, see if you can dissolve and exhale the tension out of your body as you direct your attention to those areas. Release the “dis-ease” as you exhale.”
Continuing to focus on the large muscle groups, I ask them to direct their attention now to the thighs and buttocks, to see if there is any unnecessary tension in those muscles. I too am mindful of my own body as I’m leading the practice, and find that I may be unnecessarily gripping muscles in my legs, a signal that my CNS is activated. I encourage them to let go of any tension felt in the thighs, then to do the same with the calves of the legs and even their feet, an area of the body that often holds tension.
Before moving to the next stage of mindfulness, I ask them to scan their bodies once again to see if there is any residue of tension.
Beginning with the mind, scan your body to see if you are holding on to any unnecessary residue of tension. Each time you exhale, let go of any tightness and then breathe into the open spaciousness of your body. Let go of any residue of tension that you might feel in your mind, face, your neck, shoulders, abdomen and lower back. See if you have any remnant of tension in your lower body and, if so, let it dissolve out of the body on the out breath.”
Introduction of the Concepts of Basic Goodness and Resiliency
With the participants still in a seated meditative position, I now begin to introduce an essential concept that informs this resiliency-focused systemic model. It is a basic value that guides the Sakyong’s mindfulness practice. The essential goodness and resiliency of all human beings is also a central value to the practice of Minuchin’s Structural Family Therapy and Fosha’s AEDP. This phase of the mindfulness practice can be a huge leap for many people, particularly for families and couples caught in cycles where each demonizes the other, often activating childhood traumas.
The key that opens the door to these “hidden treasures” (Genijovich, personal conversation) is most easily accessed by helping someone first develop compassion for the self. As treatment progresses and the adults experience this softening of defenses, they can deepen the work and their connection to one another as they extend compassion to their partners. However, in these early stages of treatment, I focus initially on the development of compassion for the self. Only after each partner has demonstrated the ability to hold the self with loving kindness do I encourage them to extend the principle of loving acceptance to include one another.
To encourage the experience of loving kindness toward the self I ask each person, if it feels comfortable, to place a hand over their heart center.
The heart center is in many cultures the seat of wisdom, the place where thoughts and our intuitive intelligence come together. Pay attention to your wisdom center to see what message it might have for you. Often the wisdom we receive is very different from the chatter of our thoughts.”
This can often be a novel experience for people who are out of touch with their bodies and who spend little if any time contemplating their emotional processes. Many of us in Western society are so busy with our career and families that focusing and listening to our bodies and hearts gets the lowest priority. At this point of treatment, I often will introduce themes previously touched upon and relevant for each person. “Can you gently hold that part of you that wants to run away, or is so frightened that you lash out in anger?” Knowing that the ability for each person to identify their basic goodness is an essential component of the treatment, I might say, “Can you honor that part of you that wants to make a better life? Or, can you simply acknowledge yourself for having the strength and courage to come into therapy?” Most importantly, I’m introducing a theme that will inform the entire treatment as I help each person to identify their strengths. Even a highly critical internalized voice can be seen as a defense that once served a purpose. I’m encouraging each person to let go of a self-blame cycle, and to connect to the core self that wants to feel safe and loved. I also suggest at this time in the exercise that they may want to set an intention for what they want to take from this session.
To conclude this practice, I ask each person to then become aware of their body sitting on the chair, to listen to the sound of my voice and the sounds in the room and outside the room, and to open their eyes when they feel comfortable.
What I do next is informed by Diana Fosha’s initial phases of treatment in AEDP (2000). I metaprocess with each person what the mindfulness exercise was like for them. I’m interested in both their physical and emotional experiences. At this early stage of treatment, I want each of them to begin to be curious rather than reactive to their emotional states. I’ve found over many years of doing family therapy that high conflict couples are vigilant of the other and go from zero to sixty quickly as their autonomic nervous systems respond to perceived dangers. In these couples, the CNS gears quickly to a fight/flight/freeze state. Without the benefit of techniques to slow down and reflect, it’s easy for them to enter into a downward emotional spiral that often leads to violence.
Basic Communication Skills
In addition to mindfulness practice, another skill-building exercise that I do that helps couples de-escalate violence and become more mindful of their psychological and physiological responses to one another is the introduction of speaker/listener exercises as developed by John Gottman (1976). High conflict couples not only go emotionally from zero to sixty in a split second but they often talk over one another, jumping from one topic to another. Or they use inflammatory blaming language as they attempt to gather ammunition to support their side of the argument. They rarely speak in “I” language in these heated arguments and there is little or no space for thoughtfulness as each rushes to have their say.
Gottman’s research (2004) and his couple communication skill-building exercises are very helpful at this stage of treatment. His basic speaker/listener exercises (1976) initially helps couples to slow down their communication as I encourage them to speak in simple sentences, using only “I” statements. Each partner takes turns at listening and speaking. Rather than bringing up every perceived wrong in their relationship, I encourage them to stay on their chosen topic of disagreement. The speaker must use “I” statements that express what he likes and wants. And equally important, he must limit himself to one or two simple sentences each time that he speaks. The listener must repeat what she has heard as near to verbatim as possible, using the words of the speaker, without editorializing. Although tedious at first, high conflict couples benefit from the space that these exercises provide for each to think and breathe as they discuss a topic that historically might have escalated out of control quickly.
As each partner learns to speak in simple sentences, using “I” language, the other partner learns to quiet the mind and to listen, knowing that she too will have an opportunity to be heard. In the course of learning these basic communication skills, couples learn how inflammatory their language can get and how often they use blaming language and veer off topic. The couple alternates back and forth, usually for no longer than 20 minutes, until they have either resolved their differences or at least had an opportunity to express their feelings.
Phase III: AEDP in the ‘Here and Now’ of Communication-skill Building, and the Healing Power of the Couple’s Metaprocessing
At this stage of treatment, once the couple have started to practice mindfulness and demonstrated their ability to successfully use basic communication skills, the CNS of the couple system noticeably quiets down as each partner becomes more grounded and reflective. I deepen the work as I continue to use AEDP metaprocessing skills . At strategic intervals in the speaker/listener exercise, I will begin to help each person identify what feelings are underneath the “story” that each is telling. It’s often the subtext of any given conflict that creates the escalation. Though details are important, and how the couple has negotiated such issues as the distribution of labor, or recognized their differences in needs for intimacy, it’s their ability to recognize the trauma of what’s underneath the content of their argument that enables them to make changes in their interactive style as a couple.
If the work of disassembling defensive behaviors is done before safety is established, I find that I run the risk of having the affective work be used as ammunition by one partner against the other. This experience, rather than healing, can further traumatize the couple as each feels unsafe to do the work in the presence of his partner.
I once had a couple reveal in an early stage of treatment vulnerable feelings related to early childhood traumatic experiences. The husband disclosed his experiences and feelings related to early sexual childhood abuse by an athletic coach. His wife in turn disclosed physical abuse that she had experienced from her father for being obese. The very next session, they came in highly agitated and distressed. The husband reported that the wife had used the content of his sharing against him in an argument and called him a “faggot.” For good reason, the husband felt treatment was a potentially an unsafe environ. Though the wife was ashamed and apologetic for her behavior, she was also enraged by his physical abuse that he inflicted on her. At that point, it was necessary for me to rejoin with the couple, and create safety through the introduction of mindfulness practice and speaker/listener exercises. It generally is not until end stages of treatment that I gradually introduce the exploration of the core affect through the structure of these skill-building exercises. And when each has demonstrated the ability to be respectful and compassionate, I delve deeply into the core emotions that are being activated in their relationship.
While I am interested in exploring in the middle stage of treatment the feelings that occur in the “here and now” as each partner speaks and listens to the other, in this third phase we often explore what feelings from past traumas are being activated by their relationship. Metaprocessing of these feelings helps each partner observe their feelings without necessarily becoming reactive. I too will share my feelings that have occurred during the exercise and then, following AEDP protocol, will ask each of them what it felt like to hear my responses. As an example, in the prior case of the husband who was traumatized when his wife called him a faggot, following speaker/listener exercises in following sessions, he tearfully shared his shame for so destructively expressing his insecurities in domestic violence episodes with his wife. I thanked him for “teaching me what it means to be a man.” Several waves of deeply expressed mourning followed, as he took in my response.
Although I see myself as the catalyst for both setting the structure and creating the conditions for this healing experience to occur for the couple, the goal of treatment ultimately is for the couple system to experience compassion, love and acceptance for one another as each integrates these previously hidden aspects of self. As the couple become more adept at mindfulness practice and successfully use the speaker/listener exercises both in session and at home, I now encourage each to explore what feelings may have informed their defensive responses. As I gently urge each person to scan their body to see what they are physically and emotionally feeling, I also have them use a 1-10 scale to identify their stress levels. Learning to take a break, or to focus on one’s breath before being activated, is an important step for couples accustomed to cycles of violence.
This resiliency model for working with high conflict couples that I am presenting here is not a linear one. If a couple has demonstrated early on an ability to observe and modulate their affect, I begin to explore core affect with each person by exploring if they ever have had similar feelings in earlier relationships. The timing of this vulnerable work is a clinical judgment that each therapist will determine for himself (i.e., if and when the couple system is receptive for a deeper exploration of the roots of traumatic feelings that are being activated by the dynamics of the current relationship).
Tunnell (2012) has written about the necessity of exploring and metaprocessing earlier traumas for couple therapy to be effective. If the work that I have been doing with the couple during mindfulness practice and communication skill-building has gone well, we will be able to metaprocess feelings and identify the core affect that is being activated to create “fight/flight/freeze” behaviors. For highly defended couples, they need to have some practice at building confidence in their ability to speak and listen, and regulate their affect. Once that happens, it is usually safe to go back in time to unpack and identify what traumas have created the defensive behaviors that inhibit intimacy in their relationship.
Case Study: Free To Be Seen
We have all acquired defenses to hide parts of our emotional selves that we experience as shameful. Although adaptive at the time, defenses that obscure these unacceptable parts often create distance and are a barrier to intimacy in our adult lives. The following case of Linda and Stanley illustrates how to listen for the subtext that is informing the couple’s presenting problem. This couple came in for treatment with the wife literally choked up with feelings because her husband had left the kitchen a mess the previous evening. Her voice sounded as if someone was strangling her. Her constricted voice alerted me to the possibility that a traumatic shamed part of her may have been driving the feelings. The task for me is to see how we can slow down the couple system so that each partner feels safe to explore and reveal these defended-against feelings of helplessness that may be obscuring core feelings such as sadness and anger.
Linda and Stanley are in their mid-thirties, each with demanding careers. She is a professor up for tenure at a local university and he had recently finished a residency and passed his boards in orthopedics. They have two young children. They were referred to me for treatment by their individual therapists.
The presenting problem as stated by Linda is Stanley’s self-involvement and his inability to be present for her in co-parenting. From Stanley’s point of view, though he allowed that at times he was overly anxious and though his individual treatment focused on these episodes, he was unable to interrupt the cycles. In his words, “it’s just who I am; you need to get over it.”
Stanley was readily able to identify feelings of being overwhelmed with anxiety dating back to his childhood. Although he felt his parents were caring and loving, he believed that his father had suffered from being obsessive compulsive and he felt that he never could succeed in his father’s eyes. When he went to his mother for comfort, she minimized his feelings, telling him that he was overly sensitive. He also felt badgered by his mother if he didn’t excel in school. Essentially, he had no internalized model of how to self-soothe when he felt anxious.
Linda, on the other hand, reported growing up in the Pacific Northwest, in a carefree childhood. However, when I explored her current feelings of loneliness that she experienced in her marriage, she immediately teared up. When I said, “This stirs up some deep emotions, can we slow down and make space for them?” she seemed both relieved but apprehensive about exploring their origins. She pushed me away as she said, “No one has the perfect childhood.” At this early stage of treatment, I wanted her to feel safe. “Until proven otherwise,” I said, “I think all parents want the best for their children.” She nodded in agreement.
Over the next several sessions, I introduced them to mindfulness practice. Both reported feeling calmer after these sessions but given the hectic quality of their lives, they had little time for practice, or for one another. Making time for meditation at home seemed out of their scheduling abilities.
In this session, they came in with long faces, she looking angry and he appearing white and scared. They sat silent. I asked them, “How have things gone this past week?” Linda immediately launched into a tirade about Stanley’s once again lack of consideration and thoughtlessness. When I asked for a specific incident, she reported getting up that morning and finding mustard on the kitchen counters and the remnants of hot dogs on the stove grill. “I’m not his mother! He never thinks about me. He thinks I’m there to pick up after him. It’s like I have three kids!” Stanley jumped in, “That’s it! You speak to me as if I am your child. You sound just like my mother and it makes me want to run the other way!” The session was off and running and I needed to slow them down before the proverbial car wreck occurred.
The pull for therapists when this scenario occurs is to address the concrete presenting problem, i.e., Stanley’s sloppiness in the preparation of his snack. I find that even if they came to some acceptable agreement for his picking up in the future, the underlying dynamics of Linda’s feeling alone and Stanley feeling badgered would not have been addressed. At this point, I had worked with them for several sessions and I felt well joined with them. I thought they might be ready to go deeper into what core issues were represented in these behaviors.
I asked Linda if it would be alright with her if we worked with these feelings of anger that she was experiencing. She agreed. I then asked Stanley to actively listen during this time to see what he could learn about his wife. He concurred.
“Linda, can you place a hand where you are physically experiencing this anger?” She hesitated and then placed one hand on her chest and the other on her throat. I was surprised, expecting that she would have placed her hands on her stomach. I then said, “Can you tell me more about the feelings in your throat?” She immediately teared up and said, “It’s like I’m choking. I can’t get the feelings out.” I said, “Is it OK if we just make some space for those feelings now.” She nodded in agreement.
I then said, “How old are these feelings? If they could come out, what sound or words would they make?” With little more prompting, Linda began to talk, in a choked voice. “It’s like when I was 12. My mother would never pick up the kitchen. She would cook a meal and leave everything out and go to bed. My father and I always had to clean up after her.”
I simply nodded and made some soothing sounds. Then I said, “Tell me more.” What unfolded was a painful history of sexually abuse that Linda’s mother had experienced when she was a child. When Linda was twelve, her mother was just beginning to emotionally acknowledge this abuse by a close relative. Linda’s mother had been overwhelmed by the recollections and had become unable to function at home. Linda, just entering her teens, was all alone with these feelings of helplessness and the abandonment that she experienced. Her father took over both parenting roles, taking up the slack as his wife stayed in bed, unable to cope.
When I asked whom she had to talk with about this trauma, she said, “No one.” Her family created a wall of silence around the abuse. “What a lonely, confusing time this must have been for you.” She nodded in agreement. When I asked Stanley if he knew about this trauma, he said that he did but that he never had understood the profundity of her aloneness. “I wish I could have been there for you.”
That was my cue to connect the dots — to make the journey of healing become interpersonal and interconnected for them. These moments are the “magic” of being able to do family systems therapy. “But Stanley, you can be there for her now. What can you do so Linda doesn’t feel so all alone?” On cue he said, “Well, I could be more neat and pick up after myself more.” I said, “What do we do with your ‘badgering mother’?” “Oh, that won’t be a problem,” he said, “because I know that I’m cleaning up to help Linda heal.” It was so interesting how Stanley, who had been brought in by Linda to be fixed, had become the healer in his marriage.
In the next session, as I always do, I asked the couple how the past week had gone and how the last session influenced their week. What Stanley related is what makes family therapy so rewarding: “I cooked dinner twice this past week and cleaned up the kitchen afterwards. And, I prepared the children for bedtime on the days that Linda taught late.” Wanting to reinforce this behavior and pleased to see his excitement, I inquired what that was like for him. Stanley replied as if he had read the textbook, “It’s so good not to feel like the ‘patient’ in this marriage and to know that I can help Linda heal, just as she has done for me.”
I looked over at Linda whose eyes were filled with tears, and asked if she would share with Stanley what she was feeling. She in turn said how good it felt for him to respond to her needs and to know that she has him as a partner, “To know that I’m not all alone parenting.”
This was not a miracle cure but a giant step towards co-parenting and responding in a supportive healing way to each other’s needs. In the best of circumstances, family therapy has the ability to help heal earlier trauma: Linda’s profound feelings of loneliness when she lost her mother’s emotional support, and Stanley’s shame for feeling so inept as communicated to him by his parents. It would take more sessions for these new behaviors to become second nature as new neuronal pathways became hard wired in their brains.
From the Therapist-Patient Dyad to the Systemic:
Opportunities for a Couple to Heal One Another’s Attachment Traumas
The transformative healing power of introducing AEDP into couple therapy treatment occurs in three stages: (1) the patient initially being free to explore psychological defenses that inhibit the expression of shamed parts of self in the presence of their partner, (2) getting beneath the defenses to explore core affects also in the partner’s presence, and (3) the final stage when the couple, with the help of the therapist, metaprocesses what it was like for each of them to experience these feelings together. As in the individual AEDP model, this metaprocessing is an essential ingredient in the transformative power of the couple therapy treatment. In resiliency-focused couple work, ideally I want the couple to metaprocess the core feelings with one another as I observe, or step in only when the process gets derailed. What follows is a core state where the couple can talk openly and undefended about their painful experiences of attachment loss that activates the wounded parts of themselves in relation to one another. The processing of feelings which often includes mourning for what may never be leads the couple to a calmness and ability to accept themselves with a newfound compassion.
To reiterate, the metaprocessing that binds the core affective state experience to left brain learning occurs optimally between the couple. The family therapist intervenes with the couple only when a misattunement occurs between them, usually due to an inability for one partner to have empathy for the other. The therapist must gauge when it is safe for them to do this work, using his interactions and assessment of each partner.
Another Example
Recently I was working with a heterosexual couple where the presenting issue in the session was a “white lie” the husband had told his wife over the weekend. He was supposed to be having lunch with a friend, but the friend had stood him up. The husband, feeling ashamed of his friend’s carelessness, decided to withhold the cancelled meeting from his wife and ended up having lunch alone. As life would have it, the wife ran into the friend the next day and asked how lunch had been for them. When she discovered the lie, she had a strong physical reaction she described as feeling as if she had been kicked in the stomach.
In the session following this incident, she was withdrawn and difficult to engage. I began with a mindfulness guided meditation. I noticed after the exercise that she looked sad. I asked her what she was feeling. Initially she hesitated, and then teared up as she said, “I feel like there’s a weight on my chest.” Though I had been working with this couple for only a few sessions, I felt that they were ready to do deeper work. Bypassing the skill building phase of treatment, I asked them both if it would be alright if we made time to work with this feeling. When they both agreed, I prepared the husband for his task and said, “As you listen, first notice how you’re feeling and then see what you can learn about your wife.” To the wife I said, “Tell me more about the feelings you’re having.” She said that she felt all her emotions were caught in her chest. I simply nodded and said, “Tell me more.” She said when she had discovered her husband’s lie, she had a sinking feeling that she didn’t really know him. If he could lie so easily about this lunch date cancellation, what else might he be lying to her about?”
I knew enough about them to realize that trust was a sensitive issue and that a vague sense of mistrust had been a theme for both of them throughout their relationship. By her extreme reaction, I assumed that a very young part of her had been activated by this breach of trust. I reflected how painful it felt for her to be to be lied to. I was taking a risk at this stage, not knowing how the husband would receive this information, as I encouraged her to go deeper. I wondered if she had ever experienced similar physical feelings earlier in her life. I kept one eye on the husband to see if he would be able to listen with compassion during this exploration.
At this phase in treatment, I’m interested in creating an environ where each partner can feel safe to explore younger parts of the self (Schwartz, 2009) that are being activated by the couple’s interactions.
What the wife shared was a childhood of broken trust as she described what it was like growing up in an alcoholic home. Her father was a binge drinker and she never knew when he would come home inebriated. Her mother, in an attempt to protect him, constantly made up excuses for his bouts of drunkenness. When family plans would be disrupted, she shared how angry she felt as her mother lied to protect the father. When she tried to confront her mother with the truth, she was physically punished for being disrespectful, “a mouthy kid.” She quickly learned to keep her anger, fears and disappointments to herself so as not to alienate her parents.
I encouraged her to fully express the feelings that seemed to be suffocating her. How old were the feelings? If they had a voice, what would they say? With little coaching, she vomited out a life time of sadness and repressed anger. “How could her mother not protect her? Why had she lied to her? How could she ever trust her to tell the truth?”
Now in her second marriage, she found herself once again wanting to run away from a husband for fear that he too was mistrustful and unwilling to listen to her pain. This recent breach of trust felt like a tipping point for her. She knew she could survive with her son on her own. She wasn’t sure she had the strength to stay with her husband, given his deceitfulness.
There were many courses that I could take at this juncture of treatment. I chose to focus on her current feelings of betrayal and asked her to imagine that this younger little girl was here with her, right now. “Can you see her? How old is she?” She nodded as she said, “8”. “Ask her what she needs. Does she need to be comforted?” She hesitated and shrugged her shoulders. To encourage her I said, “Perhaps you can use the experiences that you have had comforting your son, that adult competent you, to comfort this little girl right now?” She responded, “I think she needs to be held.”
After she talked in a deeply moving way to this young abandoned part of herself, we metaprocessed what this experience had been like for her. Her voice was no longer constricted and she appeared deeply calm as she spoke of her sense of relief in not feeling that she would suffocate. She also wept with compassion and sorrow for this little girl who had never felt safe. Next, I wanted the couple to jointly metaprocess this experience. Before that could happen, though, I needed to see where the husband was emotionally. I turned to him to assess if he was able to take up a role other than that of the listener.
To gauge where the husband was emotionally, I first explored the feelings he might be having as he listened to his wife share. If he was in a defensive state, he could easily have dismissed or shamed her for revealing these feelings. I said to him, “What was that like for you to hear her? What are you feeling?” As is often, but by no means always the case in this early phase of treatment, he felt both moved and relieved to hear about this side of her that she had never shared with him. He said that he was so moved to see her sadness and tears, emotions that she rarely if ever had let him see in their marriage. He reported that she had always been the “doer” and the “rock” with him. He then, without prompting, shared his own shameful experiences of childhood that explained why he often lied or withheld information. The story he told was one of learning to lie out of fear, originating during his childhood. He began lying to protect himself from his father and peers’ ridicule. He had a learning disability, difficulty focusing in school, and was severely ridiculed by his father for his low grades. As he concluded his story, he then turned to his wife and in a tearful voice said, “Please forgive me. I didn’t intend or mean to hurt you. I would never want to do that. You are my life.” At that point in the session, all three of us were in tears.
This is ‘a best case’ scenario. If he hadn’t responded in this empathic manner, I could have proceeded in one or more other directions. I might have chosen to model my empathic feelings and reflect the courage that it took for her to do this work. And then I could turn to the husband to see if my feedback resonated with him. If the husband’s defensiveness was intractable, time permitting, I then would work with him. “What feelings were you experiencing as you listened to your wife share?” If he expresses anger, I would explore how he somatically experienced those feelings. Following that, I might explore with him when else in his life had he experienced similar feelings. Inevitably, this questioning will lead us to some trauma that the partner has experienced. When one partner feels manipulated and defended by the other’s sharing, generally there will be a history of trauma related to this block. Even if the couple cannot metaprocess the wife’s current emotional state, we will have a better understanding of the terrain and emotional obstacles that prevent them from having empathy for one another. This would then become a map for further treatment.
But in this instance, the husband had been able to respond to his wife’s core affect with love and compassion. Together, after he had shared his feelings of sadness for her and identified his own defensive patterns, they were able to mourn their lost childhoods where neither felt loved or accepted. These are the sessions that inspire family therapists to want to do this work. The feelings at the end of such a session, no matter how emotionally intense, are often those of calmness. Processing core affect inevitably leads both the couple and therapist to core state.
Conclusion and Implications for Future Work
Helping couples to experience a core affective state is a three-step process. Initially, it is necessary for the therapist to explore with each partner what core emotions inform the defensive behaviors, then the therapist metaprocesses with the partner who has done that work what it was like to experience and share these feelings with the therapist, and finally, the therapist invites each partner to share with one another their feelings in response to the other’s revelations. This work usually needs to be repeated many times for both partners to trust the other and to become comfortable expressing core affect. Couple sessions have the potential to create a new intimacy as a trust develops that neither will be rejected for these previously disowned hidden parts of the self. This deep emotional work not only helps each partner heal but achieves the goal of therapy as the couple strengthens their attachment to one another and deepens their intimacy.
The fulfillment of doing this work comes as we witness and experience the profound healing that occurs when a couple is able to discontinue their learned defensive cycles and experience that they trust and accept one another. We all have a need to be seen and connected to others. When we begin to trust in our essential goodness and when we are able to lower our defenses so that the other can experience our whole being, no matter how painful the process, we experience a sense of peacefulness.
Couple and family treatment do not tend to be long term. Usually in 8 to 12 sessions, once a couple experiences a new more intimate way of relating, they express a need to go back to their busy lives of careers and family. This creates a dilemma for me: I know that profound changes can occur quickly but we also are structured to revert back to the more familiar defensive behaviors when threatened. And for this new, less defended way of relating to become ingrained, the couple must repeatedly practice their new ways of being intimate – over a period longer than 8-12 weeks.
The question that I continue to explore, both in my supervision of doctoral students at Teachers College and in my work with families in private practice is: Can couples accustomed to high conflict defensive behaviors, continue to do this work on their own after only a relatively short term exposure of treatment (i.e., 12 sessions)? If treatment, for whatever reason, has not provided the opportunity for the therapist to do this attachment work with each partner, can the couple continue to do this healing work outside of therapy so that each person in the family has the experience of being seen and affirmed? If one person has the experience of core state and the opportunity to metaprocess that experience with his or her partner, will other members of the family feel invited to do similar work? Does witnessing one’s partner in a core state and perhaps having an opportunity to mirror back this state have a transformative effect on the traumatic wounds of the observer-participant too?
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Acknowledgements
Dr Greenan is deeply appreciative of his work with Ben Lipton and the other senior faculty of AEDP, his Friday AEDP Peer Family Support Group, and his collaborative relationship with Gil Tunnell. He would like to thank Sal Minuchin, Sakyong Mipham Rinpoche and Diana Fosha for their teachings and generous support that have informed and become the cornerstones of this resiliency-based couple treatment model. And, he is deeply grateful to his doctoral students who inspire him and were the catalyst for him to write this article.pd
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