Stan Tatkin on a Psychobiological Approach to Couples Therapy

Stan Tatkin: Right. It's actually a psychobiological approach to couples therapy.

ST: When we're talking about psychobiology, we're talking, really, about the brain and the body. And we're looking at five domains—the first being attachment. And by attachment I mean infant attachment as well as adult attachment.

The second domain is arousal regulation. We focus on preparatory, or anticipatory, systems that work alongside the attachment system, and that are embedded in procedural memory. These anticipatory systems prepare us for moving toward and away from others, based on history and experience. And this is read through the body —through the face, the eyes, the pupils, the voice or prosody of the voice, skin color, temperature, movement, posture, and so on.

The third domain is neurobiological development. We take a deficit-based approach, not a conflict-based approach, meaning that we don't really focus on conflict. We don't focus on what most people —couples, at least —bring into therapy as a presenting problem: money, sex, mess, kids, and time. That is what most everybody complains about. Rather, we look at the couple's ability to be a co-regulatory team--to be able to manage each other, particularly during distress. How good are they during stress? Everybody has conflicts, as John Gottman says. Every couple has conflict. We're looking to see how a couple handles conflict and whether they handle it in a secure functioning manner or in an insecure functioning manner.

The fourth domain is therapeutic enactment. We work with procedural memory. We work with the body, with a bottom-up approach. In other words, rather than use interpretation, we stage experiences so that couples have an enactment, or certain state of mind, state of body, online to work with. So it's really experience before interpretation.

ST: It's using a lot of psychodrama —going back to Moreno, but also Gestalt, pulling from Satir. By basically moving people into experience, using a bottom-up approach rather than a top-down approach, we avoid tapping into higher cortical areas first, which are really good at error correcting, really good at processing, but can also mislead the therapist.

In other words, higher level cognitive processing is not as reliable as the body. So we want to get at the body first.

And then the fifth domain is therapeutic narrative. This is the therapist's own stance about why couples should be together. It has to be a coherent narrative that, along with theory, explains where the couple has been, what their trajectory is, why they are where they are, and where they're going. The narrative is grounded in secure functioning relationship, as opposed to an insecure functioning relationship. So it's very much as it is when you're working with personality disorders: the therapeutic stance is very important.

ST: Yeah, very.

ST: It depends on which domain we're focusing on. With the people in my training, we focus on all five domains, each having its own set of principles and goals. But I would say one of the first ideas for therapists to grasp is: what is a secure functioning relationship, and what is insecure functioning relationship? I would say probably the easiest way to parse this is that an insecure functioning relationship is fundamentally based in a system that is unjust, insensitive, and unfair.

ST: Yes.

ST: Well, that's a big question, and that's more about therapy for themselves. We're talking here about theory. There are therapists who might have an insecure attachment if they were tested, say, in a proper AAI [Adult Attachment Inventory] with a reliable coder. But they could still be effective therapists and understand what a secure functioning relationship is, and follow those principles.

Here's the difference between therapist self-awareness and education, adherence, and understanding of theory. I think the very first thing is, talking professionally —and again, this is also true for couples —it is entirely possible for two individuals to be insecure but to form a secure functioning relationship. That is, their model of relationship, the principles they follow, would be considered secure functioning. What we're comparing is a two-person psychological system based on true mutuality (good for me and good for you), versus a one-person psychological system with too much emphasis on self-values or -interests, rather than on relational interest.

But there are other factors —not just a two-person psychological system —that add up to secure function. The other, in terms of a primary attachment relationship, is a mutual protection of the safety and security system for the couple.

This means that both partners agree that the relationship comes first, and that the safety and security of the relationship come first. And the reason it comes first is because, without that agreement, neither can really thrive.

Looking at the mother/infant attachment system and what we know about that system, in terms of security, a secure relationship is based on attraction, not fear or threat. Insecure models base their relational glue around fear or threat. So protection of that safety and security system is a key feature of a secure functioning relationship.

Yet another factor is a lot of mutually positive, amplified moments between the two, which are usually face to face, eye to eye, sometimes skin to skin. That is actually called primary intersubjectivity —when two people are in close physical proximity and using each other's eyes and communication to amplify positive moments, which, by the way, have neurochemical parallels to them.

And then, secondarily to that, is joint attention, wherein partners focus on a third thing to amplify the relationship. That's another quality of secure functioning. Namely, first, a lot of mutually positive amplified moments between the two people, and then —this is really important —second, that the negative experiences that partners encounter individually and collectively are mutually attenuated and foreshortened by the couples' skill at metabolizing and managing distress.

So I would say those two are extremely important for secure functioning relationships: high positives that are mutually amplified, and negatives that are quickly repaired and corrected. Distress is relieved quickly, not dismissed. When you asked the question, "How does a therapist apply this or understand this," I think we first must understand what it is, and then adhere to that idea when looking at couples. And then, of course, it's very hard, if you're working in this way, not to grow yourself, and look for it yourself in relationship.

ST: Well, it becomes everywhere, because that's where your focus is.

ST: That's right.

ST: We're looking for couples to be able to rely more on interactive regulation, coregulation. People who are insecurely attached —that is, basically the avoidant and what I call the angry-resistant on the other side —have different styles that are wired in from childhood, in terms of how they regulate. For example, the avoidant, who comes from dismissive and derogating parenting, relies on autoregulation, which is a form of self-stimulation, self-soothing. It's not just simply a defense: it is an adaptation from very, very early, and it's wired in. So this is a default position.

ST: Or masturbating, or reading. Or singing, like you said, or performing, writing. Anything that doesn't involve another person —although there are things that involve another person, with which the avoidant person could autoregulate. In Kohutian terms, that would be using that person as a self-object. So autoregulation is normal--everyone does it--but the avoidant over-relies on autoregulation. And that's a sign of a one-person psychological system. The thing with autoregulation is that it's a very energy-conserved state, almost dissociative. And the problem with the avoidant is his or her inability to shift from being alone to interacting. Avoidants can shift from interacting to being alone, but not in the other direction very easily.

The angry-resistant, by contrast, focuses and over-relies on external regulation. Angry-resistants require another person to help calm them down or stimulate them. They, in contrast, have a hard time shifting from interaction to being alone, not from being alone to interacting. So you have two one-person systems that avoid relying on interactive or mutual regulation, which is what we're trying to move couples toward.

The angry-resistant will feel some fear about separations and reunions, particularly about being dropped. But both partners have a responsibility to repair these reflexes with each other, regardless of whether they are avoidant or angry-resistant. So we have a lot of emphasis on getting the couple, especially during distress, to coregulate —eye to eye, face to face —and to make quick repair, make things right as soon as injuries or distress arises. This way there's no memory of the event.

ST: Sometimes I do. But, basically, I suggest to my students that we push the therapeutic narrative forward by expecting a secure functioning relationship, not just teaching it. We expect one. So when people are not operating in this way, we wonder why. Don't forget, it's not simply the avoidant who can create a tone that is threatening, and who starts a fight. Let me just say this: [quote:the reason most couples enter into conflicts that are problematic is because of their inability to know how to manage one another. They don't know how the other person really works.

ST: Yes. Much of the therapy is really active and experiential. I do very long sessions —two to four hours, sometimes six hours, and they're all videotaped. And the reason for this is to be able to move the couple through a variety of states, which are very much like real life. Instead of talking about events, we try to enact them and try to make the corrections in real time, while they're in that state of mind. So this becomes a part of procedural memory, which is actually why they get in trouble in the first place.

ST: There's a lot of coaching, yes.

ST: The idea here is that each partner is in the other's care. They're not in the therapist's care. So we want to point to each partner: "Did you see that on her face? Did you notice that?" I don't want to be the only person noticing things. I want them to be able to see things. I should say that the room is set up in a particular way, like a staging area. Everyone is on chairs with wheels. So I can see body movement. I can turn to them. They can turn to each other, and I can see them turning away, as well. [quote:So the emphasis is to get them to read each other. They have to be experts on each other.

ST: On the attachment level, we want to educate both partners in terms of their attachment orientation. This isn't to say that we're going to give them jargon, but we want them to understand from where they came and how that has wired psychobiologically into their nervous system and every cell of their body, to normalize it. This is not a pathological view of human nature. This is a very natural view of human nature in terms of attachment, adaptation. We all adapt. And the nice thing about looking at developmental theory is we can get a picture, a sense, of how someone has to adapt to certain situations. And that gives us a sense of what the person is going to do in the future.

We want people to understand who they are, really, and to take responsibility for that. For example, if the avoidant is dismissive or derogating or gets angry when his or her partner approaches, then he or she must quickly fix that and make it right. But also, we want each partner to understand the other and to know how to manage the other in the best way. When we look at attachment, we know that it isn't so much about personality; rather, it's about the sense of competence and agency that two people in a dyad feel they have over the other. In other words, I know that I can manage you. I can shift your state if I need to. I can move you around if I want to, without the use of threat. I can do this in the best way.

And that's what we want. We want couples to learn who they are. They didn't get married to be different people. They got married to be just who they are. But they want to feel that they know how to manage the other person. So the emphasis here is very different. We're not teaching people how to manage themselves. We're teaching the proper way, which is how to manage each other. And this, again, is borrowed from developmental theory.

ST: It's both/and, but too many therapies focus on self-regulation.

ST: Right. The way that this works is that, in a primary attached relationship, it is much more efficient for me to manage your state than it is for me to manage my own. And one of the reasons it's more effective is that, the way we're wired, at close distances you can see what's going on in my internal state, my nervous system, before I know. I can see what's going on in yours before you know. This gives us an advantage. There's a reason this is built in at close distances. At far distances, we're interested in whether we're attracted or we're dangerous. But in close distances, we're able to see into each other's nervous system and to be able to respond in this dance of mutual regulation.

So that's what we want to encourage, on the attachment level. On the arousal level, we want to make sure that couples can talk about anything, do anything, without fear of dysregulation. One of the reasons therapy sessions are very long is I like to set fires and put them out, or make messes and clean them up —however you want to look at it. But we want to get into areas of difficulty so that partners are not afraid, so that they know how to co-manage these situations by tensing and letting go, and never getting into a situation in which they dysregulate one another. They must know how to stay in a play zone, even when they're fighting. This is a very, very important part.

ST: It is. Couples should not be afraid of anything when it comes to each other, and they certainly should not be afraid of the relationship breaking simply because they're in conflict. So we take off the table any fear having to do with the relationship breaking or falling apart on either side of the partnership.

ST: Well, in the very beginning, if that is really a very strong message and one partner, at least, is drifting or pushing in that direction, this is where it gets kind of tricky.

I will go in that direction and push it all out. In other words, I call it "bending metal" —going in one direction or the other fully. I'm not in the business of breaking people up. But if there is resistance and there's one person saying, "I don't know if I want to do this," then I will go full bore into breaking them up, for the purpose of getting pushback or blowback. In other words, I want to find out what they're really made of, and I think one of the jobs for all therapists is to clarify what's going on.

ST: Right. One of the reasons this approach goes fast is the therapist is very active and evocative, and even a bit of a clown-at-the-bullfight kind of person. I was trained psychoanalytically; this is very different because we want to push the boundaries and see what people are made of. So if somebody thinks he or she wants out of the relationship, then we have a session on "Let's divorce," and we'll go all out. And then I will look for pushback. Now, much of the time, people are using this as a way to threaten the partner to get him or her to comply. But once it's exposed that they really aren't going to leave, they don't want to leave, they can't leave, then it gets taken off the table. Because we've already proven that the person is not being truthful. They're using this as a maneuver to threaten the partner. So we want to get that off the table as soon as possible, and we do that by getting them to throw down, basically.

You can see this is taking a little bit from strategic family systems, too, in that we're being a little tricky, but always in the interest of clarification. So that's how that's handled.

ST: Oh, that's our bread and butter.

ST: A lot of people end up coming in because either they are having an affair or they're hiding one. And in this model, we think of affairs not as attraction to a third, but an aversion toward the primary. So when two people assume the office —and I think of it as an office —of primary attachment figure, it's almost like the office of Presidency. The office of Presidency has a certain valence to it. Forget who's sitting in it. And then there's the person with his or her personality, which either adds to, amplifies, or whatever, the office.

So when two people assume the office of primary, this is a very intense relationship that resembles no current relationship, only past relationships. And, as such, people become deep family when in these positions. That is why a lot of problems arise. I call it the marriage monster. As soon as people get married or they enter into the relationship with a sense of permanence, all these attachment fears coming from procedural memory and experience begin to arise. So movements away and toward each partner we see as part of the predictable trajectory, and not just as happenstance or an accident.

So, most affairs, depending on who's having them, reflect the insecurity of the primary attachment relationship, not so much the attraction to the outside third person. Ironically, many people pick, as their affair, somebody who's almost identical to themselves. And one of the common things I'll hear, and I'm sure you hear too, is "Why aren't I like this with that person? Why do I feel this way with my sister or my brother and not with you? Why my friends don't do this to me?" My thought about that is, "Well, marry your friend and then see what happens." Because it is a phenomenon of marriage or commitment that this material starts to come up.

ST: Move towards security and to understand who each person is and how to manage him or her.

ST: Yes, we're promoting interactive regulation, which is a close monitoring of each other's face, voice, eyes, and body. And by the way, interactive regulation in this close proximity, and mutual gaze, are how we fall in love, most of us. So it's simply going back to the way we originally began anyway. But also, the goal is to learn how to do this so that you and I, as partners, can talk about anything. We can enter into any area of importance without fear of threat or dysregulation. And that's a major, major goal.

On the developmental level, the therapist really has to discover what deficits do arise —and we all have deficits, and especially they come up in relationship —to clarify those and to hopefully help move them along developmentally. Partners need each other to do that.

If I am with you, and I discover that you've never been able to read my face, you've never been able to read anybody's face, that is going to be one of the reasons we have trouble. And I may have thought you were doing this purposely, when actually you weren't. This is a deficit. This is something you've never been able to do. That changes the game in a lot of ways. And sometimes people will never get very good at something. Other times they can get better with the help of the partner.

ST: In general, we're moving people towards a secure functioning relationship. And that includes, like I said, true mutuality. In other words, everything we do is based on a social contract, borrowing a bit from attachment theory and John Rawls here —a social contract that's based in fairness and justice and sensitivity. So, if the relationship comes first —not us as people, but the relationship —and it becomes the air we breathe, the water we drink, our basic fundamental engine of energy to go through the day and to brave the world, then there are things that we have to do with each other to keep each other feeling attractive and attracted to the relationship. And one of those is making sure that every decision we make is one you're good with and one I'm good with. There is no dragging you along because it's good for me, but it doesn't have to be good for you.

So we're changing really from a monarchy, or dictatorship, to a system that is fair between these two generals, who are both in charge and they have to please other.

ST: Neither one of us is happy. And everyone who lives below us and around us will be unhappy, too. I kind of think of this as king and queen. If the king and queen are in disorder, everyone in the land is in disorder.

So that goes with kids and that goes with everybody we interact with socially.

There's one more part here: the management of thirds. By this I mean third things, third people, third objects, third tasks. This could be drugs, alcohol, work, in-laws, friends, children, dogs, pets, and so on.

ST: A secure functioning couple has a kind of couple bubble around it, wherein the dyad comes first, and thirds are secondary. What this means is that the couple is aware that in public and in private they protect each other at all times. They don't allow either of them to be the third wheel for very long, at least not without repair. In this way, everybody actually fares much better. So the management of thirds is a huge deal. As therapists, we can find out right away if a couple is mishandling this by the way they address us.

One of the reasons I have them on chairs with wheels is that I can see how they're moving and who they're talking to and who they're addressing. If I notice the partner is talking to me, ignoring the other, or saying something about the other without checking with him or her, then I know both of them handle thirds poorly. And not just in the therapy session, but everywhere. So, another big goal is the management of thirds, in public and in private.

It's great fun.

ST: First of all, I would recommend that someone who wants to get into being a couple therapist do it wholeheartedly, because it is very different than working with individuals and families. It's a specialty. And I think, as such, it deserves a lot of attention and a lot of focus. Having said that, I think that it is next to impossible to see a couple, particularly in the beginning, for an hour. I think the therapy sessions must be long, to give therapists enough time to relax and not be pressured. Otherwise, the therapist, him- or herself, can become dysregulated, and pressured. More mistakes are made that way.

So longer sessions to watch the couple cycle through different states, to give therapists time to think and formulate. Begin to play very, very close attention, not to content, but to micro-expressions, micro-movements. I think therapists today should be trained —whether it's Paul Ekman's material or other places to get this training —to work with the body and be able to pick up very subtle but very significant cues on the face and the voice that reveal shifting states and emotions. This is very key to working with the body. I think it's important to try to avoid getting caught up in the content of what a couple's talking about and start watching, basically, these two nervous system interacting.

One thing I do want to say before ending here is that this is a maxim that I always use and say: people do not know what they're doing. This goes for us therapists, as well. We do not know what we're doing most of the time, and we don't know why we do what we do most of the time. And there's a reason for this. When we are interacting with another person, we're using very fast-acting subcortical processes that never see the light of day in terms of higher cortical areas. We're simply acting and reacting very quickly, as we should. And then, when asked why we did what we did, we really don't know. But because we're human beings and because we don't like to not know, we make it up.

I could say that this is a function of the left hemisphere that confabulates, because it doesn't know what the right hemisphere and subcortical areas are doing. But this is the flow of data through the body and the brain. We act and react much faster than our cognition, and certainly our words.

So the therapist would do well to understand neurobiology and how the brain actually works and what people are really doing. A lot of things that are happening between two individuals —and this includes individual therapy —are sub-psychological. In other words, it's biological. It doesn't even get to the higher levels that we consider psychological or theory of mind. This is our most basic nature. Our number one imperative as human beings is to not get killed. It comes before love. It comes before everything else. And we have some very, very well developed —in terms of evolution —primitive areas of our brain that are very good at looking out for our survival. They don't give a damn about relationships or anything else. If it comes down to feeling threatened, we do war instead of love. That's what I'd say.

ST: That's right. Love and War in Intimate Relationships: Connection, Disconnection, and Mutual Regulation in Couple Therapy. It is available through Norton in the Interpersonal Neuroscience Division. The official publishing date is February of this year.

ST: Thank you.

ST: We do trainings in Los Angeles; San Francisco; Seattle; Austin, Texas; Boulder, Colorado. Maybe soon to be in New Jersey. We also have an international group that we do training with, as well. So it's spreading like wildfire right now. And if people want to get involved in the training, which is a great deal of fun, they'd have to go to this web address: www.ahealthymind.org, and the click on the city that's nearest to them.

ST:

Applications for Individual Therapy

We didn't really get a chance to talk about how this translates into individual work, but it does, because we're dyadic creatures. Individual therapy is a dyad. I will say that, as a cautionary note, being an individual therapist for so many years, I now view primary attachment relationships as sacrosanct. And if an individual does come to me and is in a primary attachment relationship, I will work my darnedest to get that partner in, to turn it into couple therapy. And the reason I do that is because when we're working with the primary attachment relationship currently, we're dealing with proxies: people who represent the past. And there's no more powerful system than that system. The therapeutic relationship tries to approximate that, but really can never do that for a variety of reasons. For one, the therapeutic relationship is asymmetric. So, when we have that capacity and that exists, I think we should shift to couples therapy. If the couple or the individual is unwilling to do that, I think it's incumbent upon the individual therapist to act as an adjunct —to move that relationship forward rather than try to compete with it.

So I think there are mistakes being made now with individual therapists who are competing with primary attachment relationships. And that would be a nice thing, I think, for people to start to learn not to do.

ST: Right. Instead of trying to compete with it, we try to promote the one that already exists. Unfortunately, when we see one individual who's in a relationship, we will never, ever know the truth. One person is not a reliable reporter of the relationship.

ST: After a while doing this, you understand again the principle that people don't know what they're doing. That's true for everybody. So, in this work, working psychobiologically, we want proof. We want to see it. We don't want to hear about it. We want to see it.

ST: That's right.

ST: I only promote divorce as a trick. I only promote divorce to test the mettle of at least one person who is drifting in that direction.

ST: Well, if the metal yields, then no harm, no foul, because clarity is the most important thing. People aren't going to do anything because you tell them to, not really. I have stopped being the arbiter of who should be together and who shouldn't. I assume that partners will no longer be together when they are no longer together. Until that time, they're a couple, and I'm their couple therapist. And I continue to assume that my job is not to decide whether they're right or wrong for each other, but to move them toward a secure functioning relationship. That's my job. If they do not make it, they'll be better the next time for therapy. But I don't decide anymore. Now, when I have strong feelings about the couple not being together, it's always countertransference that passes momentarily. There are a lot of therapists who've tried to break up couples, and I think this is actually morally wrong.

I think nature has its own path. Primary attached relationships are very complex and very strong. We don't understand them fully. I think people are quite capable of ending things when they're really, really done. And they'll prove it. Otherwise, you're the couple therapist until that time. That's my belief.

ST: Thank you.