BT16 Clinical Demonstration 11 – Sewing Partners Together:

Sewing Partners Together: Techniques for Moving Couples Toward Secure Functioning – Stan Tatkin, PsyD, MFT One hour video download $29.95.

Videotape Review/Commentary

I like to watch videotaped demonstrations of therapy any time I can, to see what I can learn. Very few therapists are willing to make complete sessions available, and usually I find them disappointing — despite very low expectations. Often my response to viewing a demonstration is to think of what I would have done differently, and sometimes this helps me develop more clarity about what does and doesn’t work to elicit personal change. Much more rarely I find a session that demonstrates a high degree of exceptional skill, sometimes mixed with gross incompetence.

What is most striking about this clinical demonstration is Stan’s ego-free, complete and gentle and warm nonverbal engagement with the couple. He is present, caring, spontaneous, and appropriately humorous. The speed of his acknowledging responses clearly indicate all the above — you can’t fake that kind of speed consciously. I wish he could “bottle” his mode of being and provide it to others, because most therapists desperately need it, and without this solid foundation of rapport, even the most appropriate interventions won’t be very effective. Most therapists give lip service to “entering the client’s world,” but few are able to actually do it well. Stan is right up there with Erving Polster in this regard.

 

What needs to be done?

I understand this couple’s needs to be twofold:

  1. They need to resolve the immediate distressing problem, which is their shock and grief over their foster grandson’s violent suicide, which they learned about at noon on the day before the session with Stan. Judy says, “It’s heartbreaking, very, very, and we thought he was going to make it. He came so far; he had some wonderful years. We gave him a life that he never could have had, that was hard to sustain when he became an adult. We bought him a car; he wrecked the car. We do things for him — maybe that doesn’t work — setting clearer boundaries. So he went back to his family of origin, who had abused him sexually, physically, in every way, and he got caught up in that system again, and that’s where he died.”

There are strong indications in Judy’s statement that there may be additional troublesome “unfinished business” responses that need to be clarified and resolved. There may be anger at the grandson (“How could you do this to us!”). There may be guilt (“What did we do — or not do — that caused this?”). Bruce or Judy are both therapists, so there may be shame. (“We should have been able to prevent this.”)

Bruce and Judy are also still grieving in response to the earlier murder of a young nephew 15 years ago (“We still suffer from that.”) and the earlier suicides of two other close friends of one of their sons. These old unresolved wounds may also have associated “unfinished business” aspects that need to be resolved.

  1. Judy and Bruce need to learn how to find better ways to respond to each other as a couple when dealing with this, or any other, difficult life issue — specifically, Bruce’s tendency to “close down and withdraw” in response to trouble, and Judy’s strong fear that Bruce won’t come back from this “depression.”

 

Intervening

Stan made no intervention in regard to their grief other than acknowledging it. Ideally both the grief and the relationship would be changed. I would have focused first on the couple’s shock and grief, because it is so intense and immediate. I would have used the phobia cure method on the traumatic manner of the grandson’s death, and I would have used the resolving grief method on the grief/losses, each of which usually takes only one session or less. If there are additional responses of anger, grief, shame, etc., those would also need to be resolved, using appropriate methods. Each of these interventions would have changed the structure of the memories that elicit their distress, so that they would automatically have much more resourceful responses to each other in the present.

Stan focused on the couple’s difficult interaction in response to this and other stressful issues, specifically Bruce’s tendency to withdraw in the face of difficulty, and Judy’s need to stay connected with Bruce, and her intense fear of his withdrawal into “depression.” This focus was consistent with the title of the session, “Sewing Partners Together: Techniques for Moving Couples Toward Secure Functioning.” (I have some serious reservations about the metaphor “sewn together” because if partners are sewn together, it’s very difficult to walk, much less dance.)

 

Cross questioning

Stan nicely demonstrates how to ask one member of a couple about their understanding of the other’s experience. For instance, after Judy says, “Whenever he gets depressed, I get really scared,” Stan asks Bruce. “Do you know why she gets this reaction, why she gets scared?” This method provides both verbal and nonverbal evidence of how well they understand each other, because it simultaneously elicits both Judy’s experience, and Bruce’s understanding of her experience. If there is any kind of mismatch, as there so often is when a couple is in difficulties, this provides an opportunity to clarify misunderstandings.

Understanding how a present behavior is actually in response to a distressing childhood memory, rather than the present situation, is a great way to give the partner perspective, and elicit empathy, and this is particularly useful with partners who are blaming and combative.

Rather than ask “Why?” which could elicit historical analysis, it would be better to ask, “Do you know what she experiences when you get depressed and she gets really scared?” because that would elicit a specific description of her internal experience in the present, in contrast to the past history that created it.

Their responses indicate that they understand each other quite well, and care for each other, so while this is an elegant demonstration of a very useful way of questioning, this couple doesn’t really need it. Judy and Bruce’s responses indicate that they already have this kind of understanding, probably developed in their previous therapy. They mention having therapy with well-known family therapist Frank Pittman “30 years ago,” when “she was a witch and he was a wimp,” and there are other indications that they have had additional therapy since then — perhaps quite a lot.

 

Eliciting positive resourceful memories

Stan also skillfully demonstrates how to inquire about positive memories to elicit resourceful feelings, something that Virginia Satir was so good at. He spends over eight minutes asking how they met, what attracted them to each other, what they liked about each other, etc. This is an intervention that is particularly useful with combative or distant couples, and it was clearly enjoyable for both Judy and Bruce. But since they already had ready access to these memories, it wasn’t any kind of “breakthrough” for either of them. So again it was an elegant demonstration of a very useful skill, but one that this couple didn’t really need.

 

Eliciting how responses in the present relate to personal history

Stan asks both Judy and Bruce if their current responses are related to childhood experiences, and they both agree. For example, when Judy was a little girl her father would “get depressed, seriously depressed, withdraw for weeks, and there wasn’t much anybody could do. He would close down and just go about doing things on the farm; he wouldn’t talk. And then he’d come back one day.” At these times Judy’s mother would weep and tell Judy, “I don’t know what’s wrong with your father; he won’t talk to me.” Bruce had parallel experiences that elicited withdrawal from conflict.

While it is likely that Judy has troubling images of her childhood in response to Bruce’s “going away” that elicit her fear (and most therapists would assume that) it isn’t the only possibility. Judy’s response might be anxiety about a future image of being alone and helpless, rather than a past image. Or she might be fearful in response to a panicked internal voice predicting disaster, such as, “I’ll never be able to survive alone!” Or her experience might be a combination of these possibilities, or something else altogether.

Each of these responses would be the result of her childhood experiences, but each would have a different structure in the present, and require a different kind of intervention. For instance, if Judy is experiencing anxiety about the future (rather than a past memory) an intervention called “spinning feelings” will be more appropriate.

Rather than making assumptions, it would be simpler to ask Judy, “When you see Bruce “depressed,” what goes on in your mind that makes you afraid?” That would provide specific detail about what her internal experience is, and indicate what kind of intervention might be most useful.

Judy says, in regard to Bruce, “We’re joined at the hip!” suggesting “enmeshment” that would make Bruce’s absence or death particularly difficult for her to cope with. Perhaps they are already “sewn together,” contributing to the intensity of Judy’s fear. If so, that would indicate another important issue to explore in more detail and resolve.

 

Understanding dynamics vs. making changes

Understanding that Judy’s present fear is more in response to her history than to the current situation relieves Bruce of at least some of the responsibility for Judy’s present distress, and Judy’s understanding of Bruce’s childhood will do the same for her. Unfortunately, eliciting historical reasons for present behavior also implies that the present behavior will be hard to change. Fortunately, there is a flip side to that same implication, namely that if you change their experience of their history, that will automatically change their responses in the present.

It’s very important to make a clear distinction between understanding how something happens and intervening in order to change what happens. Many therapists make the mistake of thinking that understanding or “insight” alone is curative, but it isn’t. At best, understanding provides good information that can be used to select an appropriate change intervention. In medicine, knowledge that a fever is a result of a virus or bacterial infection may be very useful in selecting an effective treatment, but the knowledge is not a substitute for the treatment, and knowledge without treatment is of no use.

None of Stan’s many skillful interventions were directed at changing the implicit procedural memories that are the basis for this couple’s automatic and unconscious troublesome responses in the present. (Daniel Kahneman’s “system 1.”) Stan presupposed that Bruce and Judy would continue to respond with withdrawal and fear; his interventions were directed at how they could cope with each other’s troublesome responses.

To summarize, this couple’s childhood memories elicit problematic responses. Rather than attempt to change the memories that cause their difficulties, Stan attempted to change how they dealt with the troublesome symptomatic responses that resulted from the causes. Treating a symptom is only appropriate when there is no way to treat the cause.

In all fairness, treating the symptom rather than the cause is very widespread in therapy. For instance, the symptoms of anxiety (hyperarousal, tingling, fast breathing, etc.), are generally (perhaps always) caused by an internal voice predicting some kind of disaster, such as a plane crash, or being abandoned and helpless. Most therapies, and most therapists, focus on trying to change these symptoms using relaxation, deep breathing, repeated exposure, paradoxical intention, etc. At most, they try to change the content of what the internal voice says, by arguing with the voice, which is counterproductive.

However, the main cause of anxiety is not the content of the internal voice, but the fast tempo, loud volume, high pitch and strident sound of the voice. You can easily verify this in your own experience by saying an innocuous sentence like “I’m going downstairs” in a loud strident, “anxious” voice. Slowing the tempo of such a voice automatically lowers the volume, pitch and strident quality, and these changes elicit feelings of security instead of anxiety. Another way to change the nonverbal aspects of an internal voice that elicits anxiety is demonstrated in this short video.

 

Changing past memories in order to change present responses

There are a number of different ways to change troublesome implicit memories. Most therapists try to eliminate them with some kind of amnesia, distraction, or replacement, but it is much easier and more effective to modify them so that they are no longer troublesome. As Milton Erickson said of therapy, “Your task is that of altering, not abolishing.” Furthermore, altering always involves adding to the memory in some way, rather than subtracting. For instance, eliciting the positive intention behind someone’s harsh criticism changes its emotional impact by adding to your experience of it.

One of the most straightforward ways to change a troublesome childhood memory is to have a vivid dialogue with the younger self, in which the client imagines being with the younger self at the time of the troubling memory, and uses all their adult skills to advise and comfort the younger self in whatever way is appropriate, both verbally and nonverbally, using nonverbal visual, auditory, and kinesthetic feedback to verify when the younger self has, in fact, been comforted and reassured. One particularly useful piece is to point out that, “I am from your future, and I know you survived this,” because it is so incontrovertibly true.

In doing this, it is crucially important that the client take the active empowering role in comforting and reassuring the younger self. In contrast, in some “inner child” work the client is asked to take the role of the younger self, who is reassured by someone else. This is disempowering, since the “other” has the power, not the client, so it is ineffective at best, and infantilizing at worst. There is much more detail about this method of changing troublesome memories in this article.

A second method is somewhat more detailed and complex, and also more elegant. In this process the client is asked, “What experience could you have had earlier than that troubling event, that would have prepared you for that problem experience and made it easier to deal with?” Then the client is instructed how to create this experience in a way that is vivid and powerful in preparing them for the traumatic event. Finally the client is guided in carrying this new memory with them as they come up through time through the troublesome event — again transforming it by adding to it, in contrast to subtracting.

This new memory is carefully designed so that it changes the client’s internal responses. The choice of this experience, and the details of it, is content that emerges entirely from the client, so no content is introduced from a therapist, role-player, or other outside source. It makes no attempt to magically change the external events that happened in the traumatic memory, which would leave the power in the magic, another disempowering mistake that some therapists make. Again, there is much more detail about this method of changing troublesome memories in the article mentioned above.

Either of these two methods can transform the implicit procedural memory that used to elicit problematic behavior in the present into a response that is more resourceful and useful. When each member of a couple has more resourceful responses, the difficult symptoms no longer occur, so there is no need to develop ways to cope with them.

 

Eliciting responses to cope with symptoms

In contrast, Stan asks the couple to move closer and look into each other’s eyes, “for a minute,” which I think is deceptive, since he then insists that they continue to do this for the next twenty minutes or so of the session. He elicits how the couple can respond to their own, and their partner’s symptomatic behaviors, to “reach across the chasm” between them when Bruce withdraws and Judy gets scared. Stan gets mutual agreement and commitment to maintain their connection. Bruce agrees to move forward instead of withdrawing, and Judy agrees to be more active in insisting on contact if Bruce withdraws.

Although heartfelt, congruent and sincere, these are conscious-mind agreements (Kahneman’s “system 2”) that are slower, require effort, and presuppose that each partner will continue to unconsciously respond in the ways that were programmed into them by their childhood experiences. Stan’s interventions are directed at helping Judy and Bruce cope with their troublesome responses rather than changing their causes. The unconsciously generated “system 1” grief and the unresourceful coping behaviors that each of them learned in childhood haven’t been altered, and they will be much more automatic, faster and stronger, and will easily overwhelm the conscious strategies that they agreed to.

Bruce and Judy began the session with fresh, raw gaping wounds of grief, as well as several major older festering losses. They were also burdened with the problematic coping behaviors they learned as children when faced with insurmountable difficulties. All these responses — grief, withdrawal, fear, etc. — are elicited by unconscious procedural memories over which they have no conscious control — they can’t just consciously decide to respond differently. They left the session with the same injuries and limitations, poorly prepared for the task of dealing with the real life aftermath of their foster grandson’s suicide — the funeral, the others involved, and all that that entails.

Empathy and mutual understanding is a great foundation, but it is no substitute for effective interventions to change the causes of difficulties. This couple volunteered for a demonstration of how to “sew partners together,” but despite all of Stan’s many extraordinary skills, all they got was a band-aid with a smiley face on it.

 

Stan Tatkin’s Response

Tuesday, November 14, 2017

I was most impressed with Steve Andreas’ write-up and critique of my live demonstration at last Brief Psychotherapy Conference. I found it comprehensive, informative, loving, and more than a bit flattering. However, within the critique I suspected a possible misunderstanding.

The title of my demo was Sewing Partners Together: Techniques for Moving Couples Toward Secure Functioning. The title’s puzzling message may have implied something profoundly in-depth such as working through trauma, facilitating grief work, or otherwise modifying unconscious implicit memory patterns that maintained partner distance and misunderstanding. Alas, the purpose of the demonstration was infinitely more boring though the couple was anything but. I endeavored to show four techniques for quickly gaining information when interviewing a couple: cross-tracking, cross-questioning, cross-commenting/interpreting, and going down the middle. It just so happened that the volunteering couple, the lovely Bruce and Judy, received news of their foster grandson’s suicide the day prior to our demo. The “session” with them was raw and intensely moving for both myself and the audience.

When doing live demonstrations, one must adapt to the needs of the couple and work with the constraints of the agreed upon demonstration elements. In this case, it was to remain within the scope of crossing techniques, which is what I would likely use regardless at the beginning of working with this or most any couple. Why? Because gaining accurate information is key to understanding precisely who and what sits before me. I have often said that real time is too fast due to subcortical, memory, and implicit recognition patterns found in all interactions. Therefore, the therapist, before doing anything, must find out what is going on and who are the people sitting in front of him/her, determine what they really want, and what might they be up to in this moment or the next. Narratives often lie or are distorted for a variety of reasons and so the clinician, understanding the inherent challenges in getting accurate information, must endeavor to glean information through multiple streams of data, such as somatic feedback mechanisms as observed by monitoring microexpressions and micromovements, vocal or prosody shifts and changes, color changes in the face, changes in pupil size, response timing, and changes in striated muscle areas of the face and limbs. In other words, the main task for any clinician is first the discovery of “what is this” before attempting to do anything “about it.” That’s where crossing techniques come in.

Cross-tracking is a visual means of observing the face and body of the person who is not talking and then sweeping the eyes back and forth, up and down, to survey each partner’s somatic reactions. Because the talking partner is using up resources for language and speech, their face is best observed just after they finish talking, a time when resources are freed up and the face is more likely to show emotion and signs of stress previously hidden. Cross-tracking is a extraordinary method for catching partners in the act of being themselves.

Cross-questioning (based on the Milan Group’s circular questioning method) is yet another powerful technique for gaining information quickly and effectively from partners by asking one partner about the other. Again, the therapist is using this method to observe tiny shifts and changes in the face, voice, body, and timing as compared to narrative. The non-speaking partner is observed first and then the eyes travel back and forth, up and down. All the while, the therapist is also using their own somatic responses, thoughts, fantasies, and impulses as yet another data stream for discovery and understanding. Cross-commenting/interpreting, in a similar fashion, allows the therapist to gain both explicit and implicit information for later use in the session.

Going down the middle is a method of interpreting or confront the couple down the center so as to address the couple system without implicating either individual.

Having partners sit across from each other at a relatively close distance so as to activate the near vision system (ventral visual stream and the fusiform facial area), helps facilitate interactive regulation and attention to one another’s face and eyes, is a precondition for informal trance induction. Given the constraints of the demonstration, trance induction and deeper work in the implicit realm was not the focus of this exercise. Therefore, I had no intention to do concentrated work with the partners’ grief, trauma histories, or longstanding relationship issues.

The demonstration with Bruce and Judy satisfied both the advertised intent of showing crossing techniques and at the same time, only lightly addressing the grief and trauma of their recent loss as well as their history of interpersonal misappraisals and mismanagement. If this were a real PACT session, the methods Steve so eloquently described would most certainly be used, albeit, with methods familiar to PACT therapists. Each of these techniques – not demonstrated at the event – focus on implicit, procedural memory systems and make use of induction methods to facilitate co-created alternate states of consciousness (usually parasympathetic) to promote modification of deeply held childhood beliefs and patterning. We use movement, poses (holding positions) staging, and a particularly powerful, lengthy psychodramatic procedure called Lovers Pose in which partners are put into a trance. Thereafter, we continue to explore, discover, and heal unresolved loss and trauma through “bottom-up”, strategic techniques.

I had the delightful opportunity to speak with Steve Andreas for the first time long after the conference. I believe I found a kindred spirit, someone with whom I had previously been unfamiliar. I have some catching up to do regarding his extensive work with NLP and trauma. I look forward to learning more from him.