Couples in Distress: Working With Bottom-up Interventions

Despite our conscious narratives, which are formed in the brain’s left hemisphere, much of what we do is driven by fast-acting processes and affect-regulating capacities encoded in the right hemisphere as part of procedural memory. Our early repeated relationship experiences not only create a psychological blueprint for how we view ourselves and others, but also determine how we will operate in future relationships. They also influence the development of brain structures responsible for affect regulation later in life. These memories (when manifest in psychobiological reflexive behaviors\micromovements in the body and face) can either refute or support our conscious narratives. They also influence how we move toward and away from people and how we get people to move toward and away from us, particularly in times of threat. This is one way that the past can be seen as taking place in the present.

Accessing these processes and capacities in real time can provide clues about the subpsychological issues related to attachment organization and arousal regulation that underlie high and chronic levels of distress in couples. Armed with this information, a PACT therapist does not rely on verbal report alone while assessing what is really going on when a couple present in therapy. This is where bottom-up interventions are particularly potent because they are designed to access processes encoded in procedural memory. The PACT therapeutic stance is focused on moving couples toward secure functioning and uses both top-down as well as bottom-up interventions to do so. In attachment terms, secure functioning is characterized by qualities such as attentiveness, true mutuality, attunement, and sensitivity. These qualities are considered optimal for psychological and neurological development, as well as for social-emotional functioning.

In PACT, using bottom-up interventions (e.g., asking questions to elicit psychobiological responses; staging specific interactional events; and tracking moment-to-moment shifts in internal states, as registered on the face and in the body, and bringing them into awareness) can lead to powerful revelations about what is really going on with a couple in chronic distress. Subsequently, this positions the couple to move in the direction of repair and development, and toward safety and security.

Sarah and Erik are in their mid-30s and have been together for 8 years. They present complaining of exhaustion, miscommunication, and frequent arguments that leave them feeling little other than frustrated. In session, they appear to exhibit frequent moments of misattunement, and attentiveness and mutual sensitivity are lacking in their interactions. This is reinforced by their respective attachment histories, which appear to be characterized by insecure parenting.

In session, as Sarah begins to express feelings of hopelessness about things ever getting better, I notice her voice volume begin to increase, her speech become pressured, and her tone become sharp. As I cross track between Sarah and Erik, I notice that Erik several times breathes in as if to speak but does not. As Sarah continues to speak, Erik grows increasingly silent and still. His face is flushed, and his breathing shallow.

I use a bottom-up intervention to ask Sarah to notice what is happening to Erik. “He’s doing what he always does. Just sitting there.” she says.

To validate how she might experience him in this moment, I then wonder out loud if she’s aware of how she sounds and how that might affect Erik. As we examine together the moment-to-moment shifts in this real-time interaction, Sarah recognizes that her harsh tone and voice volume, more than her words themselves, trigger on a psychobiological level Erik’s early experiences with intrusive caregivers, leading him to grow more silent and still, as he did when he was a child. Erik sees that his self-protective and reflexive behaviors trigger Sarah’s childhood experience of inconsistent caregiver availability and neglect, and as such, only serve to escalate her distress.

Further moment-to-moment tracking in session reveals that Sarah is negativistic when Erik attempts to reach out to her in real time with the comfort she reportedly longs for. In the wake of this awareness, Sarah’s face turns flat, her eyes dart, and her body freezes. I point this out and ask each of them to notice what is happening.

Sarah is able to report that she sees her partner reaching out, but that she can’t go to him. Erik becomes aware that he feels conflicted—both wanting to reach out but not being certain how to, or only doing so in small ways, and fearing rejection. This new information reframes the couple’s difficulties as issues related to giving and receiving comfort—issues that are rooted in early experience and are now being expressed on a psychobiological level.

At one point, I roll my chair closer to Sarah to provide support through proximity, while directing a cross comment to Erik: “Remember when Sarah told the story about falling down the stairs and hurting herself, and no one came for a long time... and when they did come, they didn’t really help her ? I wonder if that happened to her more than once, and if that is part of what is happening to her when she hurts in some way and needs you to help? Maybe she can’t receive it now, just as she didn’t receive it then.”

Erik nods. From the way he leans forward and the gentle look he gives Sarah, I sense that this cross comment both brings him out of his shell and also helps him feel closer to Sarah, while allowing Sarah, the space to explore her feelings.

As I help Erik and Sarah explore what is happening within and between them, she is able to have a somatoaffective experience that links some of her present difficulties in her relationship to her experiences of neglect and abandonment in childhood. She is able to get in touch with her grief as it felt in her body when she was a child, as well as give words to it now. This is something she was denied at critical junctures in her childhood. In turn, her husband, who so often felt frozen and unable to respond to her complaints, begins to feel he can have a meaningful impact on his partner.

It is interesting to note that Sarah’s prosody toward her husband changes in subsequent sessions, as her voice takes on a softer, more modulated tone. And Erik, although still less talkative than Sarah, is now willing to risk sharing more with her. Individually and together, they are positioned to move toward greater collective safety and security in their relationship, which in turn can foster mutual resilience, growth, and development.

ⓒInga Gentile, as originally posted on https://www.thepactinstitute.com/blog/couples-in-distress-working-with-bottom-up-interventions , February 16, 2015.