|Gender Issues Mind/Body Men in Therapy Anxiety Great Attachment Debate Mary Jo Barrett Future of Psychotherapy Couples The Future of Psychotherapy Mindfulness Ethics Etienne Wenger CE Comments Trauma Attachment Theory Challenging Cases Brain Science Alan Sroufe Clinical Excellence Clinical Mastery Attachment Symposium 2012 Couples Therapy Wendy Behary Community of Excellence Linda Bacon Narcissistic Clients Diets William Doherty David Schnarch|
|Case Study - Page 3|
Making a Commitment to Change
After Adam and Sarah had experienced applying Stop techniques, I met with them together to put these skills into practice. Adam echoed the doubts of most clients at this juncture: "I still feel that I'm going to lose it when Sarah and I really get into it. How can I remember to do all this stuff when the heat gets turned up?"
To segue into the next phase of our work, I asked them to discuss together the words and actions that had most quickly provoked anger escalation in the past. For Sarah, it was when Adam raised his voice, approached within two feet of her, and told her she was incompetent as a wife and mother (using words like lousy, lazy, and weak) and criticized her in front of the children. Adam responded strongly when Sarah raised her voice, questioned his sanity ("You're nuts!" "You need help!" "I'm going to have you put away"), refused to speak to him for hours, and threatened divorce. They were encouraged to discuss how they felt when these threatening behaviors were directed at them, while their partner listened without interruption.
I asked each to make a commitment to change, based on what they'd learned in the individual sessions and from each other. Which behaviors were they willing to alter? Which behaviors would they agree to substitute when angry? I helped them be as specific as possible, to ensure well-defined, practical, and measurable goals. Adam agreed that when conflict arose, he'd sit down and use a softer voice, tell Sarah what behaviors he wanted her to alter without resorting to name-calling, and do all this in private. As in other cases, I said that if they wanted to, they could write down and sign their commitments to each other as a contract.
We then spent two full sessions practicing "circuit breaking" to derail anger escalation. Each partner has two potential circuit breakers, warning signals that the system is getting dangerously hot. One, an inner physical feeling signaling anger arousal, originates in the self; the second, the partner's anger actions, originates in the other. The activation of these circuit breakers signifies the need to shut down the discussion and begin using the Stop method.
The self-originating circuit breaker for Adam included a tightening of his shoulders and chest or warming of his face; his other-originating circuit breaker was when Sarah's voice became significantly louder or she began criticizing him in front of the children. Sarah's self-originating circuit breakers included a tightening jaw and a flushed, warm face; her other-originating circuit breaker was when Adam got loud, stood within two arm's lengths of her, or called her a name.
These four levels of awareness (his and her self-signals and other-signals) warned that arousal was escalating and the action should be ended for as long as needed to employ the Stop techniques, calm down, and reassert control of arousal. As I encouraged them to discuss the hardest, most triggering topics that they could think of while practicing circuit breaking, they began readily to halt and derail their anger, and then redirect themselves back to calmer talking and listening about issues. I demonstrated these strategies for them, so they could practice during two sessions devoted exclusively to rehearsing together how to use circuit breaking.
As Adam and Sarah practiced using Stop with me, they not only became more proficient in derailing their anger arousal, but also less reactive to each other. Just as exposure training reduces anxiety to feared situations, these rehearsals helped them feel less threatened as they learned new ways of responding to old anger triggers. They felt more prepared for the next provocative encounter and more relaxed about how to handle each other's actions.
A Vision of Relationship
Now that their anger arousal was under control, we could begin to discuss underlying relationship issues during our couples sessions. Through conversations emphasizing I-statements and active listening, I asked each to discuss their vision of how they'd like their lives to be in a year and beyond in major life areas: love and intimacy, friendships, activities/interests, spirituality, intellectual stimulation, family/parenting, financial. Once they each better understood the other's vision and underlying needs, both could craft more-realistic expectations of their partner and a mutual vision for their relationship, reducing sources of future conflict.
During 10 additional sessions, they practiced using Stop to derail anger arousal that would emerge as they decided how to collaborate on implementing their individual visions and their common goals. For example, Adam wanted more time with his male friends, and Sarah wanted to visit her parents more frequently—something Adam had resisted in the past, which had been a source of arguments. They agreed that on the same weekend at least once a month, they'd fulfill these individual goals, removing a source of conflict. They reported using Stop and circuit breaking with much success at home. By mutually managing their arousal, they reported success in discussing and resolving differences as they worked on satisfying their needs.
This CBT based systemic approach to anger treatment acknowledges that couples inhabit an interdependent relationship, and that treating both of them, regardless of who's the "angrier," helps each identify and alter his or her contribution to the problem. Nevertheless, the approach I'm describing is no miracle cure. One partner frequently refuses to participate. When I'm forced to work with one partner alone, I employ the same methods for arousal management described above and use role-plays with me standing in for the partner to allow the client to practice circuit breaking. Safety is always the priority, and I routinely and ongoingly assess the degree of risk if violence is an issue. When the risk is too high, I refer the partners to separate therapists until they become comfortable with joint sessions.
The path to behavior change is often circuitous, and setbacks frequently occur, especially when one or both partners minimize the need to use Stop, rationalizing that "We've got this down and don't need to do all those steps," or returns to old thinking and actions when one or more of the Five S's suddenly fuels arousal. Adam began working late and missing evening meals, driving home exhausted and out of sorts—which fueled irritability and rekindled old habits. At those times, it's especially helpful to assess what exactly has taken place and recommit to new behavior. Thus, "booster" sessions are usually necessary.
Rather than becoming overfocused on the drama of anger or its roots in an individual's life, it's crucial to understand anger as part of an ongoing, interdependent system of expressed and unexpressed needs, which ultimately must be addressed in any relationship. Rather than something that must be managed by just one partner, it's important to see it as being central to the dance of need fulfillment in a couple, and to help both partners learn new steps to convert this often destructive force into fuel for lasting relationship change.