Abstract

Most couple therapy models (Declaire & Gottman, 2001; Beck, 1967; Bader & Pearson, 1988; Greenberg & Johnson, 1988; Johnson, 1996) do not produce effective outcomes. This is mainly because of the lack of sound theoretical constructs for most of these models. This paper shows how a model based on Imago Therapy (Hendrix & Hunt, 1988; Hendrix & Hunt, 2003; Hendrix & Hunt, 2005) and Voice Dialogue Facilitation (Stone and Stone, 1989; Stone & Stone, 1993; Stone & Stone, 2000) can be based on sound neuroscience evidence: Chan (2015); (Pare & Duvarci, 2012); Lewis, Fari & Lannon (2000); Harlow’s (1958); (Brehony, 2003; Farrow & Woodruff, 2007; Schore, 2003) and can help couples in distress not only heal and reestablish their initimacy, but also prevent experiences of future distress in ways that the current Imago Therapy model cannot.

Why most couple therapy models failed to work for couples

Gottman couple therapy (Declaire & Gottman, 2001); CBT couple therapy (Beck, 1967); Developmental Couple Therapy (Bader, 1988); and EFT Couple Therapy (Greenberg & Johnson, 1988) have largely failed to help couples in distress because these therapies are not based on neuroscience.

Distress among couples activates their amygdala, and these models focus on trying to sooth the amygdala (i.e. extinguishing its activations) via the prefrontal cortex (PFC) processes i.e. Gottman's "time out" method; Beck's cognitive reframing; Bader's couple rational communication and Greenberg's empty chair dialogue with the non-present partner.

These models are inadequate because:

1. Couples in distress would not be able to access their PFC (Johnson et al, 2013)
2. The PFC – even when accessed – would not be able to connect to the activated amygdala in time to calm it down and help the partner in time of distress from acting out their distress i.e. trigerring their learnt conditional response (CR) (Chan, 2014).
3. The activated learnt amygdala neural connections can only be extinguised by extinguishing the conditional stimulus (CS) and pairing the CS with the unconditional stimulus (US) for those learnt connections (Pare & Duvarci, 2012); the CS in this case being the threat experienced by the partner, and the US representing the threatening emotional experiences first experienced from the early caregivers.
   Greenberg's Couple EFT is the only model here that does not attempt to bypass the amygdala and recruit the PFC. By getting the patient to focus on his/her painful primary emotion and dialoguing with an imaginary partner in the empty chair, the patient continues to stay somewhat in the activated amygdala state.
   However, because the partner is not actually present in the therapy, the empty chair technique may have limited effect; Chan (2015) argued that effective therapy needs to have physical proximity with partners in order for the couples to experience "limbic resonance" with each other, which cannot be done with the empty chair technique.

The need for both partners to have emotional dialogues during therapy

The term ‘limbic resonance’, or ‘limbic regulation’,  was coined by Lewis, Fari & Lannon (2000). They describe it as a “...symphony of mutual exchange and internal adaptation whereby two mammals become attuned to each other's inner states” (Lewis et al., 2000 p. 63). The concept is based upon Harry Harlow’s (1958) work on the importance of physical contact and affection in rhesus monkeys and has been extended by recent brain research on humans (Brehony, 2003; Farrow & Woodruff, 2007; Schore, 2003).  The basic concept is that brain chemistry and the nervous system is measurably affected by the physical proximity to others.  The way humans synchronise and regulate each other through limbic regulation has profound implications for personality development and lifelong emotional health (Lewis et al., 2000). Lewis and colleagues go on to argue that limbic regulation between client and therapist is a fundamental aspect of psychotherapy and that the client’s maladaptive patterns of relating can be modified through the therapeutic experience.

To what extent is this deep form of non-verbal and empathic connection dependent upon the close physical proximity of the therapist and client, and between couples in therapy? Cash (2001) stated that based on research and her personal clinical experience, online therapy does not appear to stimulate limbic resonance to the degree necessary for fundamental therapeutic change. She argued that the multisensory stimulation of sitting close to the therapist cannot be replicated through screen-screen mediated interaction. Human bodies and minds are not designed for the online experience. She likens the online experience to feeding pure sugar to a person who needs food – it will provide an immediate high, some nourishment, but ultimately starve the recipient. This argument supports the recent research (Happiness Research Institute, 2015) showing the increase of depression linked with social media use support this view, i.e. Cash (2001).

Chan (2015) has extended this argument to include much of psychotherapy models which do not utilise both individuals as a couple in therapy together; these models, he argued, would also fail to achieve the necessary therapeutic effect due to the same lack of limbic resonance found in Greenberg's empty chair and other models such as Beck's couple CBT (Beck, 1967) and Gottman couple therapy (Declaire & Gottman, 2001). These therapies, despite having both partners in "therapy", does not involve couples interacting or dialoguing at an emotional "limbic" level, which would stimulate the activations of learnt connections in response to stress experienced in relationship with early care givers: ie, the US.

Johnson (1996) has developed Greenberg's couple EFT model to include both partners in therapy and to focus on their primary distressing emotions – initially anyway. However, the model then gets couples to deescalate their distress thereby deactivating their amygdala.

The problem with this model is that it is the therapist who is deescalating the couple, and not each other. Because of this, the amygdalae of couples are not able to get the extinction from the learnt activation of the distress experienced by couples in conflict. Limbic resonance and limbic regulation will not be achieved.

The source of the learnt activation of the couples' amygdalae i.e. the US, is the experienced threatening behaviour of early care givers (Hendrix & Hunt, 1988; Hendrix, 2003; Hendrix & Hunt, 2005) and the conditioned stimulus (CS) is the experienced threatening behaviour of the partner, hence the Imago (Ibid). The therapist, in this case, has not taken on the role of the CS (unlikely possibly for therapists in psychodynamic or psychoanalytical therapy) because there is no available facility for transference especially since both partners are present in therapy.

Pare et al (2004) has shown that the amygdala is able to get extinct within itself in terms of the learnt activated neural connections, without connections to the PFC. This will be done when the CS is no longer experienced as a threat, e.g. the hostile partner is no longer hostile but has become nurturing instead. Hence, the amygdala's learnt activated connections – in response to the CS – is extinguised and therapeutic healing is achieved.

Imago Therapy as a NeuroScience-based model

The Imago model (Hendrix & Hunt, 1988; Hendrix, 2003; Hendrix & Hunt, 2005) has theoretically been set up to achieve this very goal: partners using the couple dialog are taught to nurture and heal one another when they are in distress.

Inadequacy of Imago Therapy

It is difficult, however, for couples in distress to do the couple dialogue, especially among themselves at home without the therapist. Couples continue to experience each other as the CS and this results in their CR. This I term Couples Negative Imago dynamics - their acting out behaviour, CR1, which in turn evokes CR2 in the other partner, and subsequently gets them to experience the CS i.e. threatening experience with the other partner, where this triggers their own CR - CR3 - which would result in their partner experiencing them as the CS and continuing to trigger the CR - CR4 - from them and so forth.

Imago model therefore also cannot aid in relapse prevention of distress for couples.

NeuroScience based Voice Dialog Imago Therapy Model Effective Therapy

With the current model, we propose that instead of getting couples to dialog the topics of distress and thus evoke their distress selves and the learnt amygdala activations, we start the therapy with getting couples to dialogue with their other more nurturing selves. With the increased awareness of their more nurturing and nurtured selves, e.g. confident selves, happy selves, and pleasurable selves, couples would be able to dialog with each other's distress selves more sucessfully in later therapy sessions and provide nurturing for each other's imago developmental needs (Hendrix & Hunt, 1988; Hendrix, 1993; Hendrix & Hunt, 2005). This would extinguish and heal their learnt activated amygdalas connections (learnt during childhood by the lack of nurturing experienced with their early caregivers i.e. the US).

With this nurturing couple dialogue now implemented with the partner (we call the vulnerable partner, VP) having experienced a CS (a threatening experience with the threatening partner(TP)), he/she can choose to hold his/her vulnerable selves in balance with his/her other selves - eg confident selves - and choose not to do his/her CR, i.e. acting out behaviour, and instead choose to respond with his/her nurturing self (creative response - cr) so that their partner will no longer experience the CS with them i.e. the individual is no longer experienced as a threat by the VP and the VP's amygdala learnt activation to the CS (and eventually to the US if applicable) is thereby extinguised with the therapeutic healing outcome and healing is achived.

Relapse Prevention

With the learnt activations of their amygdalas to the CS partner and US caregivers somewhat extinguised (it would be a long term process to extinguish all these learned activations) and healed (hence a similarly long term process), and with couples having developed more awareness of their other - nurturing - selves (Stone and Stone, 1989; Stone & Stone, 1993; Stone & Stone, 2000), couples who go through NeuroScience Based Voice Dialog Imago Therapy would be able to also prevent evoking their own and their partner’s CR i.e. distress selves in their relationship with each other.

Instead, they can choose to respond creatively with nurturing responses and break the negative imago dynamic.

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