Allison Howe, LMHC
PACT Level 2 Therapist, PACT Ambassador
Couples come to our office in distress. They want to feel better. For me, PACT therapy provides medicine for the couple. PACT is an approach designed to alleviate the symptoms that come from an insecure, unfair, insensitive relationship that isn’t operating in a way that works for both partners.
If we define therapy as “medicine,” we need to understand its constitution. What are its active ingredients? How is dosage determined? What does an overdose look like?
Have you ever overdosed a couple? I have. I know what that looks like, and I now know to avoid it.
Therapy as Medicine
If medicine is “the science and art dealing with the maintenance of health and prevention, alleviation, or cure of disease” (Merriam-Webster.com), then to me, PACT therapy is medicine.
PACT has the potency – not as a chemical substance but as a medicinal approach – that restores and preserves the well-being of the couple relationship. PACT therapists help couples form a foundation with principles of fairness, justice, sensitivity, mutuality, and collaboration. As this process unfolds, the couple learns to depend on one another for survival, enabling both to thrive individually and collectively.
Therapist in the Medicine
If therapy is medicine for the couple, what goes into the medicine? From a psychobiological perspective, the therapist is a primary component of the medicine. My facial expressions (either under- or over-expressiveness), vocal tone, language, and body movement (either the openness or tenseness communicated via movement toward or away from one or both partners in session) impacts the couple.
Sometimes my belief in a couple’s capacity to improve is enough medicine to nudge them forward. Other times my deep concern for their future needs expression. While this therapeutic dosage can seem like a bitter pill to swallow, the communication leads them into a healthier direction. Videotaping my sessions has offered me additional information on how my facial expressions and body movements impact the couple.
If what I say and do in the session is a primary component of the medicine, I first must identify the substance to administer. (What is the intervention?) The next step is to be clear on the dosage. (How much?) In order for the medicine to be effective, the dose must have an opportunity to take effect. (How long between dosages?)
Signs of Overdose
When a couple does not respond to an intervention in a therapy session, they are saturated. That overdose risk becomes high once a therapist identifies the substance for the intervention, administers the dose, and then proceeds to introduce another intervention of some kind. The problem is that the therapist has no way of knowing which therapeutic action was effective or ineffective. I have done this, and I have seen a couple overdose as a result.
The goal is to help couples slow down from the impact of an overdose, so be aware of the signs. Speaking slowly or not at all, looking down (or up), nodding, drinking water to self-regulate all may be signs that the couple is struggling with too much stimuli. Many clients consider themselves compliant students of the process, and it can be shaming to acknowledge they feel lost.
Conversely, how do I know when the substance of an intervention is working?
- clear signs of relief
- ease of breath
- increased coregulation
- brightness in the eyes
Another positive sign is a subsequent behavior that aligns with the task – or medicine – of therapy, which is to improve the relationship.
Overdosing by Doing Too Much
More is not necessarily better when a PACT therapist is working psychobiologically. And, working slowly often works out better.
For example, doing too much can happen when we stage a conflict in the therapy session. The process of working sequentially to understand what happened and have each partner embody their part in the process takes time and attention. Couples can get diverted and introduce other issues.
As a result, I’ve learned the necessity of staying on track. Otherwise, the medicine will simply not work. “One thing at a time” is a good prescription to give couples when they are fighting at home as well.
In addition to the risk of overdosing a couple, we can’t be inspired when we are doing too much. Consider how we may be regulating our emotions through activity. The more we move and do, the less we observe.
Furthermore, we are less in touch with the interoceptive cues that can inform us of implicit content. I struggled with this issue in my development as a PACT therapist. During the session, I now scan my body for tension, focus externally, and shift my own body as a way to avoid falling into this trap.
Doing too much can also infantilize the couple. This is bad medicine. As the therapy progresses, we expect the couple will have their own ideas so they can move their relationship forward. If a therapist has a consistent stance of doing too much, the couple may not grow to believe they are capable of managing their relationship without the therapist’s support.
As a couple begins to operate securely, they will have less need for the medicine the therapist is providing. This is the implicit goal that therapists must make explicit.
Overdosing by Saying Too Much
If a therapist is doing too much, they are likely saying too much. When I’m saying too much, I’m unable to be present and focused on the couple. I miss signs of overdose along with other implicit and explicit material. Too many words can be difficult for a couple to absorb and understand, especially if they are already stressed.
A therapist can overdose a couple by saying a number of things at once, making it difficult if not impossible to know what the couple absorbed. And, if I say too much, I cannot be sure what was or wasn’t an effective therapeutic move.
What exactly did I administer in terms of substance? If I’m not able to answer that question, it sounds like an overdose.
Prescriptions and Regulations
When a couple begins therapy, the therapy can’t be the only medicine. In my experience, when couples practice what they learn in therapy (i.e., take their medicine), they become secure functioning sooner and more effectively. We can also prescribe rituals and practices designed around coregulation for couples to do at home. These practices create new neural pathways in each partner’s brain through an iterative process.
One of the reasons for longer sessions in PACT is to give the couple time to relax and prepare for reentry to their life outside of the therapy office. Have you ever asked a couple what they remember from a past session? Examining the memory system is like looking into a kaleidoscope. Take steps to reinforce the learning that occurred in the session. Have the couple briefly review key takeaways – what they learned or a new skill to practice. Keep what I call “competency cards” near their chairs so they can write their takeaways down if they choose.
You can titrate up a low dose of therapy, but a couple will have a harder time recovering from an overdose. “Wait, watch, and wonder” is an important approach we learn in PACT training. Consider waiting to gain more information before intervening. When we watch – talking less, learning more – we pay closer attention. As we wonder, we become inspired. And, to do that, we need to be focused on the couple.
Here are additional ways to avoid overdose:
- Write down what you are thinking as a way to self-regulate during the session.
- Move your body to change your own state. Make use of a rolling chair to change your perspective.
- Practice saying less.
- Still yourself. Slow down while partners absorb what is being said.
- Do not administer a medicine (intervention) unless you know the substance you are administering.
- Videotape your sessions, if possible.
- Remember your therapeutic stance: administer the medicine to the couple (a two-person intervention system), or support each partner as they administer the medicine to their partner (a cross-administration of intervention).
PACT therapy is medicine and can help couples get better and enjoy their lives. Like any other medicine, it requires thoughtful consideration throughout the process it’s being used. It’s a natural, holistic approach that couples are wired to provide to each other. Isn’t that the best medicine in the world?