CSAR

The Untreatable Couple?
Misfires and Arousal Dysregulation in Couple Therapy

by Stan Tatkin, PsyD, MFT

Perhaps the most important area of co-regulation is a couple’s ability to relieve distress. Couples who are unable to quickly attenuate and foreshorten distress states are in danger of amplifying threats. Threat states can come about when partners have sustained and repeated bouts of misattuned moments, wherein they are unable to error correct or repair breaches in the intersubjective field. Partners who are poor at catching attunement errors will find themselves caught in a rapid succession of multiple errors that, if not corrected in a timely manner, will likely amplify between the partners in a manner that is equivalent to a biological threat state. The longer the delay in error correction or repair, the more threatening partners will appear to each other.

In addition, the more intense the dysregulation and the longer the duration of dysregulation between partners, the more likely the experience will go into long-term memory and influence all future similar moments. Because real time is too fast and because energy-conserving memory systems are also extremely fast at protecting the self from harm, partners caught in this vortex of dysregulation will likely mistake each other’s reflexes as purposeful and meaningful behavior. This is the confabulatory nature of the narrative-prone left hemisphere, which must fill in the gaps left by nonconscious subcortical processes.

Those of us who have worked with couples who have amassed a long history of unresolved and unrepaired threat experiences know full well how difficult it can be to intervene in the rapid psychobiological reflexes that characterize these couples. The psychobiological trajectory of chronically dysregulated couples, over time, almost ensures a highly kindled hypothalamic process that takes on a life of its own.

Such is the challenge for the psychobiologically oriented couple therapist, who, in my opinion, is better suited than are many other therapists for working with arousal issues.

Having said that, we have to consider the unique problem of the newly formed couple who presents similarly to veteran couples with a long history of chronic dysregulation, accumulated through years of acute misattunements and ongoing disrepair. Mind you, these are not disorganized couples, and they do not meet the full criteria for an axis II diagnosis.

How do we, as psychobiologists, make sense of such couples? Do we simply write them off as having two nervous systems that don’t get along? Is there such a thing? Are there couples who lack psychiatric evidence of pathology, yet who cannot co-regulate properly? And if so, what do we do with them? What might we say to them?

My work with high-arousal couples—partnerships that include two individuals with sympathetically biased arousal systems—has shown that these couples, while hypothalamically driven to fight for long durations, eventually run out of steam and do not seem to be negatively affected by their history of fighting. For these couples, therapist-led mindfulness or breathing exercises seem to work well at slowing partner acceleration, because these exercises tend to increase parasympathetic tone. However, these couples tend to remain highly resistant to doing the exercises outside therapy, and therefore render these interventions of little clinical use. Additionally, high-arousal partners are typically resistant to taking medication.

On rare occasions, when I’ve shared my concern with massively dysregulated couples that their nervous systems simply do not seem to get along, something very interesting has happened. After a period of depression and then acceptance, they returned to therapy and simply tried harder. It may be that the clinician in this situation is spared, for the time being, of having to solve the problem for a couple. It may be that grasping the grim reality of something that is seemingly unsolvable and has nothing to do with partner pathology, wrongdoing, or fault has a particularly sobering effect on partners. Given that couple therapy is a collaboration between the therapist and the couple, it may be that when the therapist is out of ideas to solve what seems an unsolvable matter, the couple step up their game to prove us wrong.

 

Stan Tatkin, PsyD, MFT, is a clinician, author, PACT (Psychobiological Approach to Couple Therapy) developer, and co-founder of the PACT Institute. Dr. Tatkin teaches at UCLA, maintains a private practice in Southern California, and leads PACT programs in the US and internationally. He is the author of Wired for Dating, Wired for Love, and Your Brain on Love, and co-author with Marion Solomon of Love and War in Intimate Relationships.

 

 

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