Q: A year ago, I completed what I thought was successful marital therapy with a couple, but this week, here they are again in my office. How do you get marital therapy to "stick," once couples are back on their own?
A: Most therapists are highly focused on helping couples make significant progress during therapy, but don't do much to help them maintain these gains after therapy ends. Unfortunately, the assumption that couples will continue at home to employ the skills and insights they learned in their therapist's office ignores one of the most powerful of neurological principles: habituation.
Repeated neural associations become habituated, as summarized in Hebb's rule, "Neurons that fire together wire together." More recent neurological research suggests that habits never die: they merely hibernate. If cues that once triggered them recur, the habituated response returns, even after years of dormancy. In fact, under the stress and distractions of modern living, even our more successful couples are likely to revert to their pretreatment interactive habits and forget what they learned in therapy. They'll certainly have lapses that can easily turn into full-scale relapses.
How can you possibly counteract ingrained neural associations, you may rightly ask. In fact, a growing literature on relapse prevention suggests that you can help the couple retrain their brains, so to speak, by instituting new associations—which, with continual repetition (this is the critical part), can gradually encode new, more relationship-positive associations. None of this is high-tech or tremendously sophisticated, but it does what all training and regular practice is supposed to do: establish new patterns that may become stronger than old ones.
To begin to institute a new, more positive pattern of daily habits, I ask couples to make the following plan part of their everyday ritual. Doing these three things takes less than five minutes a day.
(1) Gestures. Make some brief, nonverbal acknowledgement of your partner's importance to him or her at the four major transitional times in the day: before getting out of bed in the morning, before leaving the house, the first thing when you come into the house, and the last thing at night. (Behaviors done at major transitional times tend to have more carryover throughout the day.) This should be a gesture, like a brief touch, gentle eye contact, or just reaching out your hand. You should notice within a few weeks that affirming your partner's importance first thing in the morning and last thing at night is one of the pleasanter ways to improve over-all health and well-being.
(2) Hugs. Hug your partner, in a full-body embrace, six times a day, holding each hug for at least six seconds. Hugs are usually the first thing to go when a chain of resentment binds a relationship. The less you touch, the more resentful you get. The 6 x 6 formula isn't arbitrary. You probably don't hug more than once a day now. Increasing that to at least six times a day increases the chances of raising your level of oxytocin, the bonding hormone. The six-second minimum for each hug recognizes the fact that in the beginning, some of the hugs will feel forced and awkward. It's all right if they start out that way, as long as they become genuine at about the fifth or sixth second—which is likely to happen if you're still attached. You'll eventually find that it's easier to put your heart into the embrace than to resist it.
(3) Thoughts. Set aside five seconds for a positive thought about your partner at least five times a day. How you think about your partner when you're apart largely determines how you behave when you're together. Think of assets she or he brings to your relationship and how he or she makes your life better.
The Fire-Extinguisher Effect
Fire extinguishers don't just put out fires, they prevent them: homes with fire extinguishers have fewer fires! Of course, the presence of a fire extinguisher doesn't directly prevent fires, but making the effort to get one and then seeing it in your daily environment reminds you to be careful.
Try to come up with a "fire extinguisher" that clients can keep visible in their homes to remind them of the skills and insights they've learned. I use a CD called Argument-Sulk Reminder. It's just a few minutes in which I remind them that sulking is violating their deeper values, and they really want to be compassionate in their negotiations, rather than combative and critical. According to client reports at follow-up, few of them listen to it, but most keep it visible as a reminder of what they achieved in treatment. Another option would be a page or two of the salient points of your therapy with a picture of a fire extinguisher on the cover.
Let your clients know a few sessions before termination that you'd like to e-mail them a few checklists once a month for a year. (Just knowing that the checklists are coming in their e-mail provides a kind of fire-extinguisher effect.) Collaborate on a written summary of treatment achievements, which can serve as one of the monthly checklists. These are insights or skills you want them to keep in mind under stress. Here's the form I use: "Check all that apply. On a regular basis this month, I tried my best to improve, appreciate, connect, protect, and use binocular vision—hold your partner's perspective alongside your own."
A symptom checklist can be quite useful to clients as an early-warning sign of relapse. I ask them to check any of the following that they may have experienced in the past month: envy, jealousy, restlessness, impatience, irritability, moodiness, urge to isolate, sadness, and loneliness.
A monthly checklist of occasional behaviors that portend relapse can be helpful. The one I use has warning items like "moralized, gave unsolicited solutions, psychoanalyzed, interrogated, blamed, accused, ignored, stonewalled."
Consider a checklist of physical care. A great deal of relapse occurs when clients eat or drink unwisely and are deprived of sleep and exercise.
It's a good idea to include no more than three checklists in your monthly mailing and limit each to five items. You're likely to get a higher return rate if they're shorter.
Since we can't fight the forces of habituation, it makes sense to use them to therapeutic advantage. Whatever relapse-prevention strategy you use will work best if part of it can be incorporated into the couple's daily routine. Big insights and intense emotional catharsis may have their place in therapy, but their long-term impact is limited. When it comes to day-to-day living, if you want to love big, you have to think small.
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