Neuroscience and Clinical Practice

Dr. Robert J. MacFadden

Insights from a new book that uses neuroscience findings to understand and intervene with couples. Love and War in Intimate Relationship: Connection, Disconnection and Mutual Regulation in Couple Therapy. Marion Solomon and Stan Tatkin. W.W. Norton, 2011. These are excerpts and notes taken directly from the above text with page numbers attached to many of the notes.

In the dyad, the well-being of each rests in devotion to the well-being of the other. It is in the best interest of each person holding the office of “primary attachment figure” to ensure the other’s comfort, safety and security at all times. P. 45 Secure partners demonstrate knowledge and understanding of the vulnerabilities encoded within the implicit memory system of the other during early attachment formation and reinforced later in childhood via trauma or loss. 45 These vulnerabilities are available to both attack or repair, and each partner knows how and when he or she becomes activated by external events and how to regulate them quickly and effectively in public or private. 45 Couples need to know this so they can work toward secure attachment and interactive regulation by placing emphasis on real empathic understanding and protection of one another as a two person psychological system. 45 Where true mutuality exists, each person serves as witness, minister, cheerleader, and facilitator of each other’s life journey. 46 Mental and emotional states more manageable under secure partnership conditions.

Bowlby (1988) said that our deep wish is to be able to hold hands with our important others while in heaven and in hell, in high states and in low states, in positive emotion and negative emotion and to do this without fear of dismissal, abandonment or punishment. Partner’s are responsible for one another’s care and must be experts in the care and treatment of the other. 47. Focus on the couple’s collective nervous system 47. In therapy focus is shifted away from content and towards implicit processes, encouraging moment to moment awareness of each other’s faces, voices, bodies, and so on. It is the rapid misattunement-error-correction process that, if faulty, leads the couple down the path of misappraisals, mutual dysregulation, biological threat, system avoidance and eventual dissolution. 47-48 Focus on attachment and arousal. Secure couples are skillful at interactive regulation whereas insecure couples manifest regulatory deficits. Because implicit systems are extremely fast-acting survival oriented, and non-verbal biological mechanisms, a psychobiological approach to couple therapy centres on experience via therapeutic provocations and conflict enactments, social cues, movement exercises and other psychodramatic techniques. Therapist must maintain focus on moment-by-moment shifts in partner arousal and affect and seize upon the awareness of these shifts above all other matters. In the initial phase, therapist often serves as the external regulator for both partners, establishing conditions of safety and security. Must help move clients up and down the arousal scale, towards sympathetic and parasympathetic arousal as needed. May have to help a client hold an unregulated state in awareness long enough to develop tolerance. Therapist eventually becomes more of a coach to help couples with new experiences. 49 Psychobiological tools include top-down and bottom-up, left-right and right left interventions. 50. Top down are processes that begin with high left and right hemispheres and move downward toward the body. Usually involves cognitive approach first, rather than beginning with body sensations. Left-right refers to processes that begin with more explicit, verbal and linear left hemisphere and cross to the more implicit non-verbal and non-linear right hemisphere. As an example, can you see your partners pained face. Bottom-up begin as body memory and sensation and move upward towards the brain, evoking emotional experiences, awareness, integration and perhaps interpretive cognition. Secure partners are master co-regulators of each other’s nervous systems. High mutually amplified positives, low mutually attenuated negatives, and evidence of repair. 69

Owner’s manual: What are 3 or 4 things that he or she needs to hear or have reinforced to make him or her feel good? What are 3 or 4 things to which he/she has remained vulnerable? What is the quickest way to calm him or her? What is the quickest way to excite or stimulate him or her? What are some surefire ways to bring on tears? In secure attachment relationships, partners are able to perform these tasks and quickly minister to one another in ways others cannot. 70 Bottom up approaches go first for experience and then for insight or change. These experience driven tools directly address fast, primitive and fundamentally reliable sensorimotor, subcortical operations, using this approach bypasses slower, more confabulatory and unreliable verbal/cognitive functions. Implicit systems continually influence and drive the behavioural detail that form our perceptions of safety and security, verbal and cognitive intervention alone will have no appreciable effect on the actual, state-dependent problems all couples encounter in real time. 83 Looking at couple problems from an attachment perspective- between the inner subjective experiences of two or more individuals. It depathologizes. 90 Secure individuals reside within a world of true mutuality, a two-person psychological system in which the well-being of both is an ongoing priority. 91

Regulation. As infants, we move from an automatic, inflexible, nonconscious level to a purposeful, flexible conscious system of self-regulation. We begin to incorporate rudimentary self-regulatory functions at around 10-12 months of age, when our OFC (orbitofrontal cortex) comes online (Schore, 1994). Impulse control and frustration tolerance are orbitofrontal, self-regulatory functions that are not fully completed until the frontal lobe matures in early adulthood. We learn to self-regulate with the help of our first external regulators, our primary caregivers. Our young self-regulatory system is a duplicate of theirs. Besides some constitutional and genetic factors, we are only as good at arousal regulation as our external regulators. If our primary caregiver was an effective modulator of his/her own feelings of anxiety, fear, anger and excitement, we tend to be effective in turn. 100 Parents may avoid or actively dismiss, discourage or devalue certain bodily states so children must avoid or regulate these states on their own. This can lead to poorly managed internal experience which can produce later negative social consequences. In couples, one person may avoid high states and approach low states and the other may be the reverse. Together they form a biphasic couple. Therapy can help each partner to regulate or tolerate higher states and lower states. 101

Autoregulation is the earliest and simplest level of arousal regulation. It is insular and automatic. Gaze aversion in an infant is an example, preventing over stimulation. Helps to calm down. Looking at eyes very stimulating, baby may need to calm down. If parent persists, may dissociate. Blankie and sucking thumb are further examples. Not just calming down, but also the other way- being stimulated: tv, drugs, fantasy, reading. We regulate our up and down (I’m bored…). 102 These are individual, personal. For avoidant persons (attachment style), reliance creates a 1 person psychological system of non-mutuality. It confers a pleasantly dissociative state. For angry-resistant style, extended periods of noninteraction with primary figures leads to intensely dysregulated states. For them, autoregulation demands high energy expenditure. 101 Interactive regulation is the process where two individuals co-manage and dynamically balance ANS (autonomic nervous system) arousal in real time. If not available (e.g., neglect), turn to self-regulation which is lonely. Autoregulation is self-absorbed, internally focused, pro-self, and interactive regulation is interpersonal, externally focused, and pro-relational. Attunement is being on the same page, in alignment, in synchrony. Produces a sense of safety, security, attraction and is sustained by a couple’s capacity to remain predictable and friendly on a micromoment basis. 103 Misattunement is unpleasant. Negative reactions need to be repaired. Skillful couples will repair without much awareness of what they have done. Discomfort arises if the couple takes longer than usual to repair. Too much time without repair breeds insecurity and threat. Time is of the essence. 104

Further Insights

Here are some further insights into how neuroscience lets us look at couples differently:

1. Couples are unconsciously changing each others’ brain structures and processes. Emotional exchanges create a flow of neurotransmitters that help to restructure the brain. In a negative scenario, with chronic conflict, the hippocampus of each partner may shrink and impede the ability to retrieve memory and to form new memories. Chronic fight or flight can cause situations of constant arousal which makes problem-solving difficult or impossible. This is also associated with other health problems such as depression and anxiety.

2. Couples with secure attachments who attune well can help each other regulate their emotions. This can help out with problem-solving and lead to deeper attachment bonds. Attachment is deep knowledge at the implicit level and can’t be consciously regulated. The EFT experience can change attachment at the implicit level.

3. Therapy requires positive emotions and relaxed attention for optimal learning. Acknowledge problems early on and move to maximum positive emotional experiencing through things such as solution-talk, strengths-based conversations, positive imaging, relaxation training, homework that promote positive experience, positive relationship history reviews.

4. Work to help the couple to rewrite thin stories to thick positive versions. Reverse negative sentiment override and move to positive sentiment override. Remember Gottman’s positivity finding.

5. Where implicit knowledge has a strong negative impact, work to interrogate the beliefs explicitly and to challenge them. You can’t change original knowledge, but new learning that is positive and constantly reinforced can inhibit this earlier knowledge. Use other family members, friends to create a heavy exposure to these new realities. Overwhelm the old with new knowledge that eventually itself becomes implicit.

6. When stress elevates, old knowledge, beliefs and biases can return. Expect regression and continue to build on new positive beliefs.