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If Therapy Is Medicine, How Do We Prevent Overdose?

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” (, 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?

Competency Cards




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Healing Trauma Relationally Through PACT

Healing Trauma Relationally Through PACT

By Jeff Cohen, MFT

PACT Level III Therapist, PACT Ambassador

When Gayle and Paul came to see me, it was clear that Gayle felt Paul was the problem. Paul was taciturn to an unusual degree and could be quick to anger. For her part, Gayle presented as highly verbal, competent, and overtly friendly; adept at managing the tasks of their family and her career.

Though I didn’t know of Paul’s trauma when we first met — he lived in terror of upsetting a threatening stepmother and a physically punishing older brother — his manner and speech suggested that he moved through the world in a very protected stance.

It might have been easy to view Paul as the one who needed help. He was extremely literal, arguing about the minutia of his upset with Gayle, and for a long time was unable to understand the concept of providing relief first in an argument. From a PACT perspective, when a willing partner is able to help settle the distressed partner, it helps them both feel more settled and available to hear each other.

Looking in Both Directions

As PACT therapists, we look in both directions to assess a couple’s dynamic. Invariably, the couple alerts us to mirroring sensitivities and areas of injury. We see how primary partners are familiar to each other in recognizable and sometimes unconscious ways stemming from their own family histories.

As it turned out, Gayle had lived through her own family trauma. Her father was physically violent toward her mother and self-destructive. As the eldest child, Gayle become highly functional and competent in taking care of others. Indeed, her self worth was linked to that and to a belief that she needed to be perfect to be loved. Though Paul didn’t have a lot of ground to stand on from his angry and defensive stance, he was correct in pointing to a lack of openness and feeling he received from Gayle.

Initially we had to address Paul’s anger. To do so meant understanding the triggers which set him off so quickly. He was terrified of Gayle leaving him, so any comment along the lines of, “I can’t take this anymore,” would elicit that fear. Gayle’s comments were understandable in the context of their conflicts. As a PACT therapist, I also wanted to help her see how her comments threatened their relationship, so we experimented with other ways she could respond in those moments.

Practicing Neurobiological Responses

Gayle learned to set clear limits and be reassuring at the same time: “Stop! I’m scared when you yell. I’m right here. I’m not going anywhere, but I need you to talk more softly.” When this didn’t work, I asked her to simply sit down on the floor, to make herself small, which we experimented with first in the office.

PACT therapists will have couples act out situations to elicit the neurobiology of their actual responses. In this instance, to the surprise of them both, when Gayle sat down, Paul instantly settled down. Her sitting evoked his shame and guilt for how he was treating her. 

We also worked with the internal wall which kept Paul safe and protected but also isolated. As he learned to identify when his wall was going up, I validated how well that wall had served him. “Your five-year-old self didn’t have anything else he could do. Thank goodness you found some way to protect yourself.”

Comments along these lines helped Paul feel compassion for what he had experienced. The acknowledgment allowed his softer side to emerge which, in turn, helped Gayle feel empathic toward him. This is the value of working with one person’s trauma in front of their partner.

Healing Trauma, Seeing Tenderness

“Can you look at her now?” I asked in one session when Paul felt his wall going up.

Since he was accustomed to seeing threat, I deliberately slowed the process down so he could take in what was happening. PACT therapists help couples see and read each other more accurately.

“Notice her eyes, what do you see?”


“Warmth, yeah, that’s right. And what does that warmth convey to you?”

“Caring,” he said. “Tenderness.”

“As you continue to look at her,” I instructed, “notice what happens inside of you as you feel her warmth and caring and tenderness.”

“It’s really hard,” he said, “I want to turn away and shut down.”

We had previously identified the shame he carried about being inadequate, how his anger and shame were intertwined, and how his defensiveness was partly a way to keep himself from having to feel that shame.

So now I reminded him, “Of course you want to turn away. It’s what you learned to do, but it also keeps you feeling alone. Young Paul didn’t have another option, but your adult self does. Let’s see if that younger you can watch as the grown-up you tries something different.”

Integrating the Experience

PACT therapists have couples face each other as a means of coregulating each other; doing so also helps keep them in present time, rather than fixating on negative memories. As Paul continued to look at Gayle and speak about his experience, I narrated what was happening, to help him integrate the experience.

“Notice what you’re doing,” I said. “You’re talking about how frightened you are without reacting to the fear by shutting down. You’re tracking your own experience while staying present with her, all at the same time.”

By slowing my pace and speaking gently, I was also eliciting his own mindfulness, which I knew would be settling and help promote new neural pathways to form around this experience of safety and connection.

“As you’re allowing yourself to be vulnerable now,” I asked, “do you think she likes this?”

This was not a hard question to answer. Gayle was doing her best to hold back tears, but I wanted Paul to register the impact he was having.

He nodded. “Yes, I think she’s very happy.”

Gayle reached out to hold his hands. “I feel so close to you when you let me see this part of you.”

“It’s new to me, too,” he joked.

“Yes, it is,” I affirmed before turning to Gayle. “Can you notice a difference in him?”

Changing the Couple Legacy

PACT therapists often ask questions of people about their partners to encourage them to track each other more carefully and to reveal both what they know and what they misread about each other.

In this case Gayle was right on. “He seems much more open.”

“I feel that, too,” Paul replied. “I feel more open and relaxed inside.”

Paul looked visibly different. “Because you’re more connected to yourself,” I said, “you’re able to feel more connected with Gayle. Can you feel how that is true?”

He nodded.

PACT is an experiential-based model of couples therapy, and I kept directing Paul back into his experience so he could verify for himself what I was observing.

“You’re also changing your legacy,” I said, wanting to underscore the importance of what was happening. “It wasn’t safe for you to go to anyone when you were young, but notice how available Gayle is when you allow yourself to be more open and vulnerable. Connection may not have been available to you then, but it is now.”

Seeing Paul take up his work made it safe for Gayle to do so as well. “I want more connection but I’m not sure I’m capable,” she admitted, beginning her own process of healing. Gayle was able to recognize that she also carried shame — remember, people are drawn to what is familiar — though she expressed it differently than Paul did.

As they learned to manage each other more effectively, in part by being more responsive to each other’s sensitivities, Paul also started thinking relationally, which was a paradigm shift for him. “I’m safer to her,” he observed one afternoon, “which allows her to show up more.”

Indeed. Partners do this for each other, and PACT is an approach which can teach them how.

Working with Families – PACT Style

By Stan Tatkin, PsyD, MFT
PACT Co-Founder

Two main issues face the PACT family therapy process: Structure and Attendance.


A challenge within typical family therapy is the structure that holds some family members to their particular family roles. While viewing members within the system frame is valuable, especially when it comes to various roles different members play, it can also restrict the flow of information as some members expand and express while others contract and remain in the background. 

Using the PACT method to do family therapy may be more effective and convenient for both therapist and family. By dividing family members into pairs, the therapist can do “couple therapy” with various dyadic combinations, thereby freeing members from default role constraints and constrictions encountered when faced with the entire family system.

As long as invited members are of an appropriate age and maturity to participate in a couple-oriented approach, this structure:

  • allows pairings to speak more freely about thoughts and feelings.
  • breaks up alliances or substructures that exacerbate family conflict.
  • increases intimacy between family members.
  • opens more time and space for good work to be done.

Consider holding one or two sessions for at least two to three hours each per configuration to accomplish focused goals. The longer session serves a goal-driven purpose and can lead to satisfactory results for all involved.


Family therapy is typically organized by getting most or all family members in for at least one meeting, if not several subsequent sessions. The challenge facing therapists who use this format is legendary: how to get the same people to show up each time. Dyads solve the attendance problem as only two family members meet with the therapist at any given time – father and son, mother and daughter, sister and brother. Again, the only requirement is that children be mature enough to do “couple therapy” with an adult parent.


The dyad sit on moveable chairs and will spend a majority of session time face to face and eye to eye. However, the first-seating orientation is likely a V-formation with both individuals facing the therapist. This initial PACT session interview structure allows for a back-and-forth interaction between individual and therapist with cross-tracking, cross-questioning, and cross-interpreting. Specifying seating positions allows the therapist to get the lay of the land, so to speak, before putting the couple into the face-to-face position.

When the therapist obtains enough information to move into face-to-face positioning, individuals will then sit closely across from one another. The therapist will begin additional cross-questioning to test and retest early hunches, earlier flagged behaviors, responses, and interactions for further examination.

During this configuration, the therapist may choose to draw partners into an informal trance, the purpose of which is to slow partners down, focus their attention. Cultivating attention and presence ensures that partners keep eyes on each other while the therapist has them sit in silence for about ten minutes. This focusing exercise helps partners build vagal tone, an alert but relaxed state. Focusing and grounding partners in this way also builds a safe container, allowing more emotional “headroom” to tolerate difficult topics and painful admonitions.

Following the initial focusing phase, the therapist can move to difficult questions, bring up historical injuries for clarification and reconciliation, and help partners confront matters of deception, withholding of information, wrongdoing, and other unresolved issues in a safe container. Emphasis should be on truthfulness, clarity, and repair.


Mother and daughter come in after years of estrangement. The session length is four hours, sufficient time to reach the stated purpose for the session. Without unforeseen complications, and if done properly, they should not need a second session.

Mother has not been forthcoming about husband’s disappearance from their family home a decade ago. After 10-15 minutes of focusing the partners on each other’s eyes and tracking the moment-to-moment changes on each other’s faces, I ask my first question.

Therapist [to Mother]: As you look into your daughter’s eyes, tell her the truth about you and her father.

Daughter: (starts to cry)

Mother: (reaches out for Daughter’s hands) You were away at college. Your father was having an affair, or so I believed, and I kicked him out of the house. It turned out I was wrong this time, but only for this one instance. He cheated on me several times during our marriage. I couldn’t trust him.

Daughter: Why did you lie to me? Why didn’t you tell me the truth? You told me he left us for another family. He died a month later, and I never had a chance to speak with him again. How could you continue the lie even after his death? I thought he abandoned us. You turned me against him.

Mother: I know. (lowers her head)

Therapist [to both]: Just hold for a moment. Go back to staying in each other’s eyes. [Moments pass, then to Mother] Tell her why you lied to her and continued to lie.

Mother: I hated him, what he was doing to me and our marriage. I was terrified to tell you the truth.

Therapist: “Terrified.” Why terrified?

Mother: One or two of the affairs were with underage girls. (starts sobbing) Daughter: (face goes white, starts to say something)

Therapist [to Daughter]: Hold for just a moment. Just stay with your mother.

Several minutes go by before the mother recovers enough to speak.

Mother: I felt so ashamed. You knew one of the girls. I couldn’t tell you that your father was a sexual predator. I couldn’t. I know I hurt you. I lied to you and made you think that your father just abandoned you. I was confused. I was afraid maybe that he… maybe he…

Therapist: …molested your daughter?

Mother: Yes.

Daughter: (with a soft voice) He did. Twice when I was about 12. I never told you. I never thought you would believe me.

Later in this session and in this face-to-face configuration, the therapist might install secure-functioning principles in order to midwife a reparative trajectory or pathway for moving the dyad forward into the future. Moving the couple into the future is also a device to fulfill their agreed upon therapeutic goals.

Therapist [to Mother]: Now as you realize the consequences of withholding the truth from each other, do you believe you both made the right decisions?

Mother: No. The secrets I kept led you away from me. You lost your father and then you lost me. I was wrong to keep this from you. And, I am so very sorry that I didn’t check with you earlier when I found out what your father was doing with underage children. That was horrible. I should have protected you. I should have made it okay for you to come to me.

Daughter: I blamed you for Dad leaving us. All that time I thought it was you. I didn’t tell you about what Dad did to me. I never thought I would. I wanted to think he was my only ally.

Therapist: Neither of you have been honest or forthcoming with the other. You both have been feeling alone, isolated, bound by secrecy and shame. Isn’t it about time for that to end? Your husband, your father, is no longer here. It’s just the two of you now. What will be the future of this relationship? What should the future be? What do you want it to be?

With partners still face to face in close proximity, the therapist can, and should, facilitate a process whereby both partners can forge a new relationship based on what they learn and want going forward. In this particular form of family therapy – though this example might seem complex for one session – the therapist acts as a consultant and facilitator with an agreed upon purpose and goal.


Each family dyadic combination requires a unique clarification of purpose, procedure, and goal for the session. Many variables exist. Suffice to say, each dyad has distinctive issues and concerns relating to history, age, and family role.

Dyadic sessions require a minimum of two to three hours. In general, I book three to four hours to get the job done. It’s not that future sessions are off the table. Rather, when using this modality, the therapist should be highly focused and time efficient so the “couple” finds clarity and relief as quickly as possible. If appropriate, the couple therapist should encourage ongoing individual therapy for both people.

As in all PACT therapy, the therapist is tasked with getting accurate detailed information from both individuals. Among methods for obtaining truthful information:

  • disciplined testing and retesting of hunches
  • corroboration
  • finely-tuned monitoring of somatic reactions
  • monitoring of collaborative and coherent speech

Only with accurate, detailed data that arises from each individual’s narratives, implicit and explicit behaviors, and partner reactions, can the therapist adequately formulate interventions and a treatment pathway for the dyad. Leading the session by following each partner step by step – remaining present to the interpersonal field and alert to the actual interactive sequence – helps mitigate therapist overreach, false assumptions, misappraisals, and personal bias.

Next time you are tasked with seeing a family or family members, consider forming various dyadic combinations instead of working with the family in its entirety. I think you will find this PACT approach more rewarding, more enlightening, and more effective.

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How Secure-Functioning Principles Help Parents Who Are Divorcing

By Edna Avraham, LMFT
PACT Ambassador, Level III Therapist

The Psychobiological Approach to Couple Therapy (PACT) focuses on helping and coaching couples to “secure” each other in order to reduce threat, thrive, and grow closer. While they are designed for couples who want to deepen their connection, PACT principles can also apply to uncoupling or divorcing parents.

Some of the secure-functioning principles are:

  • Thinking in terms of WE, the two people in the couple
  • Making the relationship a priority over other relationships in your life
  • Being sensitive and considerate of each other’s known vulnerabilities, and being able to predict how the other member of the couple may perceive your actions
  • Being transparent and turning to each other for support and comfort.

Following these principles creates a secure foundation for each member of the couple to feel cared for, prioritized, loved, and considered.

Divorcing couples are often in a constant state of threat: flooded with fears, uncertainty, anger, sadness, and guilt. Whether the leaver or the left, each partner is experiencing a huge loss of the family they know and expected to keep. Now they are facing an uncertain future relationally and financially. For divorcing couples with children, applying certain secure-functioning guidelines can help create a sense of safety and security for the children.

Tina and Tom were married 13 years and together 15 years. They have two children ages 12 and 8. Tom is a businessman who traveled 70 percent of the time, while Tina is a full-time mother. Tom announced his decision to divorce and move in with his new love, whom he met at work.

Tina was devastated, shocked, and angry. The most difficult issue for her was Tom’s decision to significantly reduce his travel time so he can share custody with the kids fifty-fifty. Tina felt that Tom had not been emotionally available to the children, that she was the go-to parent all these years, and that she had earned her right to be the parent with whom the kids remain most of the time.

Tom had his own version of justifying his demands. He had traveled to provide for the family and sacrificed time with his children, and now he did not want to lose more time with them. He blamed her for not being there for him when he was home and not understanding how hard he worked.

She blamed him for “living his single lifestyle while traveling” and focusing on his needs first when home. Clearly, they had not achieved secure functioning during their marriage. Could they make it happen in the divorce?

As they ceased to be a couple, Tina and Tom began transforming their relationship into a partnership of co-parenting. Within that framework, it was clear that collaboration, mutual care, and respect for the other in each of their roles as parents would create a secure co-parenting relationship as well as secure relationships with their children. The challenges of developing this capacity, however, were significant.

The major challenge of divorce is, of course, the end of coupling and the building of a new life without a partner. Doing that in the face of rejection, emotional injury, anxiety, uncertainty, guilt, shame, and increased stress should not be underestimated. Part of the work in a collaborative divorce is to have deep empathy for the pain of the loss of the marriage.

The PACT therapist understands that the feelings of anger, blame, attack, shame, and general sense of threat and insecurity need to be handled with care. For the majority of people, divorce is a traumatic experience. The therapist must balance the internal dynamics of each partner and at the same time weave in secure-functioning principles that will be most useful for each parent and for the entire family.

Divorce is an earth-shattering experience for families. The uncoupling process has a different speed for the two partners. Usually the person who initiates the divorce is more ready to move on because they have been thinking, contemplating and planning it for a while. The person who is being left tends to take longer to adjust and accept the new reality and deal with the loss.

As their therapist/coach, I first needed to support each of them with empathy for their subjective experience. In order to help them understand and empathize with each other’s intentions and investments in the family, we used communication tools that, with practice in the office, enabled them to acknowledge the hurt and disappointment they each felt. They also benefited from additional individual support. They each had their own therapists and, over time, were able to separate their own emotional war with each other from their children’s needs and suffering.

In our joint sessions, we spoke about what they want their children to remember about their divorce. I asked them to:

  • think about what is most important for each child to suffer the least damage.
  • redefine their future relationship as parenting partners.
  • discuss their vision of what their relationship will become now that they are uncoupled.

We identified their common link: the attachment and precious relationship they each had with their children. This created leverage and an incentive they could both focus on. We discussed what each honors about the other as a parent, and how they want their relationship to be with each other in the future as well as with their children. Which of the secure-functioning principles could apply to them as parents outside of the couple relationship?

They agreed to:

  • make each other a priority as the other parent. That even when they are with other partners, they will always be present as parents for their children, making decisions together and being each other’s go-to person regarding the children’s concerns.
  • respect each other’s role as a parent and never disparage each other in front of their children, family, or community.
  • think as “WE, the parents,” and be sensitive to ensure each other’s secure place with the children and each other.
  • remember each other’s vulnerabilities and protect each other from feeling excluded or isolated as parents.

The therapist must carefully weave in secure-functioning principles, paying attention to the client’s emotional readiness to make the shift into a secure co-parenting relationship. They are no longer a couple, but they can still be great parents to their treasured children – and perhaps even good friends. Throughout this difficult journey, these principles benefit all members of the family.

Techniques to Help Distressed Couples Slow Down and Reconnect

By Debra Campbell, MS, LMFT
PACT Ambassador, Level 3

When a couple comes to our office, they bring a dynamic in the relationship that pains them.  Neither partner sees the issue in the same way, and they don’t know how to solve it.  Often, they’ve argued about it repeatedly. Talking about it just starts the argument again.

The rate at which the disagreement escalates is an indicator of how many times they’ve argued the same issue.  We know they’re not dealing with anything new because the brain deals with novelty much more slowly than something we have habituated.  How, as therapists, can we help the couple slow down and experience something new?

In PACT Couples Therapy, we use proximity, micro-expression, and body language to achieve more constructive outcomes that have a lasting effect outside of session. Here’s a familiar scenario:

Last fall, Rebecca and Bob were running late to their therapy session. They had struck a patch of bad weather, both literally and figuratively. These well-educated professionals have been married for about a year.  By the time they arrive, Rebecca is in tears. Bob is red in the face.

I can cut the tension between them with a knife as we walk down the hall to my office. They each sit in a rolling chair. Bob crosses his arms and pushes away. Rebecca looks at me, grits her jaw, and fights tears. She declares, “This Kavanaugh trial is going to destroy our marriage!”

The U.S. Senate Judiciary Committee hearing had stirred up some old hurts as well as a historical style of arguing for them. My job is to slow them down so they can experience the argument differently. By doing this, they build new beliefs and gain skills that they can immediately implement outside the office to create safety in the relationship.


Prior to learning PACT, this situation would have been stressful as the therapist.  Couples often come to session wanting the therapist to play referee or give solutions. With PACT, the direction is clear – they’re in each other’s care.

I instruct them to face each other, adjust their rolling chairs to eye level, and scoot into each other. They reluctantly agree and slowly move toward each other. Knee to knee, they’re two to three feet away from each other’s face. At this distance, the visual system has the highest acuity for every minute detail and movement on each other’s face.

Suddenly, the couple attunes to the present. Now we are dealing in real time with what is actually happening between them, not historical data or a pre-rehearsed argument. They are able to incorporate new information. When the micro-expression of their partner matches what is being said, a new reality sets in. The couple falls in love in each other’s eyes.


Couples misread each other. Instead, they tend to see what they have experienced in past relationships, generally with their family of origin. This contributes to overall misunderstandings and myths in the relationship.  Rebecca and Bob are face to face, eye to eye, as I ask the following questions and check that they accurately read each other’s facial expressions:

Me: What do you seen on her face?

Bob: She is sad, but it is a manipulation.  She always gets upset if I disagree with her. [He sighs.]

Me:  Is he right?

Rebecca: I’m sad, but it isn’t because he disagrees with me, it’s because I was date raped in college and the trial has been very difficult to watch.  Obviously, Kavanaugh is guilty, but he will likely get approved anyway because it is so hard to prove what happened, just like what happened to me in college. [more tears]

Me:  What do you see on his face?

Rebecca: He looked angry, but less so now…something else, I can’t place it.

Me:  Is she right?

Bob: Yes and no… I was angry before, but now I’m more hurt.  I know that happened to her and I feel terrible about it.  I would kill that guy if I ran into him.  At the same time, I feel scared for all men if the judicial system can find someone guilty without proof.  I want to protect her and myself at the same time but it seems impossible…

Me:  Do you believe him?

Rebecca: [slowly] Usually not, but right now, yes.

Me: Where do you see it?

Rebecca: In his eyes. I can see he is scared but also that he cares about me. His shoulders are more relaxed, too. His arms aren’t crossed.

Couples often make the mistake of communicating without looking at each other – especially when things start to go sideways.  The lack of facial cuing contributes to their misunderstandings.

Me:  Do you guys usually have these conversations face to face?

Bob and Rebecca: [Both shake heads, indicating no.]

Rebecca:  This argument just went down in the car.

Bob:  We talk about this kind of stuff side by side while watching the news . . .

Rebecca:  . . . or cleaning the house or cooking in the kitchen. . .

I suspect that they are misreading each other based upon their experiences from their families of origin. I want to expose that by testing their expertise on each other’s history.

Me:  Did Bob have manipulative parents?

Rebecca:  His father and mother are so manipulative to this day.  I can completely understand why that would bother him, if he thought I were manipulating.

Me:  Is she right?

Bob:  Yes, my parents are manipulative. My relationship with them is strained.

Me:  Does Rebecca manipulate you?

Bob:  No . . . she really doesn’t. [His face relaxes.] She protects me.

Me:  Did her parents protect her growing up?

Bob:  Financially, they took care of her. She always had what she needed . . . went to a private school, etc.

Me:  What about emotionally?

Bob:  Well . . . no, I guess not. Her family doesn’t talk about personal stuff at all. I can understand how she might want that from me. I told you, honey, I would kill the guy who raped you if I could.

Body Language

Rebecca leaves her chair to sit on Bob’s lap, curls into him, and cries as he holds her and rubs her back. When the crying calms, she resumes her seat.  A spark renews in their eyes and a tangible feeling of connection.

Physical touch generally calms the nervous system faster and better than any other method of soothing. When couples can rely on each other for soothing, they become each other’s safe place. Couples that function securely can calm each other down using eye contact, proximity, tone of voice, body language, and physical touch. They act as an emotional resource to each other, a soft landing. Instead of relying on themselves to calm down or someone outside the partnership to soothe them, they rely upon each other. This interactive regulation is generally very healing when they have not received such emotional support in their families of origin.

PACT therapists assess a couple’s ability to accurately read each other’s facial expressions and body language. We do this by going granular. We ask questions about what their partner is feeling, where they see it, and checking with the partner to make sure they got it right. This is often where we expose new data:

  • They don’t read each other’s faces accurately.
  • They mistakenly apply historical data from their childhood relationships to their current relationship.
  • They have never learned that you can tell when someone is telling the truth by their facial expression, tone, body language, and timing.

Instinctually, as therapists, we are trained to reflect whatever we see back to our clients.  However, reflecting back that they have clearly had this argument before and that this is not new material does little in and of itself to change the dynamic. By putting them face to face, eye to eye, going slowly, and checking, we force them to address the reality in front of them.  This present focus attunes them to live, novel data that creates an immediate shift in their affect and understanding. The truth lies in their facial expression, body language, tone of voice, and timing.

Do You Have Your Partner’s “Owner Manual”?

By Lisa Rabinowitz, LCPC
PACT Level II Therapist 

In your romantic relationship, paying attention to your partner’s responses and attitudes is especially prudent. Observing impressions and reactions can help you become more in tune with a partner’s likes and dislikes. I refer to this practice as “obtaining your partner’s ‘owner manual.’”

For example, if I say the word rollercoaster, most people have a strong response, whether positive or negative. If I then plan a trip to an amusement park with my partner – and I love amusement parks – that’s great for me, but did I think about my partner and his reaction?

What if my partner hates amusement parks? The above example could be a win-lose situation if one of us likes rollercoasters and one of us does not. Pro-relationship couples promote win-win situations. Therefore, I need to know more detailed information about my partner to increase my chances of win-win opportunities with him.

Inevitably, your lives get busy. Time marches on. However, if you want your partner to feel important and loved, you must continue to update your knowledge and understanding of this person on a monthly, weekly, and daily basis. You need to be observant, like Sherlock Holmes. What makes her smile? What makes her feel sad? What triggers and irritates him? What brings him joy and happiness?

I’m not suggesting that you stalk your partner and start looking in his phone or following her when she leaves the house, but do you know what matters most to this person? In case you’re asking yourself, “Why does all this detail matter?” it does matter. When you know and understand your partner, then you can predict what may be perceived as threatening, which then creates insecurities.

In addition, you can learn the fastest ways to soothe and comfort your partner whenever he or she becomes hurt, which inevitably happens. I suggest when you notice X about your partner, you should be cautious and check in with a question, such as, “I think I noticed your face change to a sad expression. Did that just upset you?” Nonverbal cues, such as a change in facial expression, can help you better understand your partner and add new information to your partner’s “owner manual.” Here are a few scenarios to help illustrate why gathering this type of information about your partner is important.

Angie and Steve have been dating for a little over a year. Last week Steve stopped to buy her a hydrangea plant. Angie felt letdown as she wondered, “Why is he giving me blue hydrangeas when he knows I love yellow roses?” You might say, “It’s just flowers, so what? Why does that matter?” The reason it matters is because Angie wants to know she matters, just as your partner wants to know you are paying attention and noticing her likes and dislikes, interests, triggers, sensitivities, and what makes her tick.

Another example of paying attention to details happened to me last month. My husband said he really liked the chicken dish I made. How did I respond? I proceeded to make the same chicken dish every weekend that month! He had to politely let me know that, while it was delicious, he likes variety and asked if I could make a different chicken dish.

After our conversation, I realized that I should have known my husband likes variety. Even though I have eaten oatmeal for breakfast every day for the past 10 years (OK, a little exaggeration), he has a different type of breakfast almost every day. And, he regularly comments on my singular breakfast choice. How did I miss that?

Of course, you need to realize that you and your partner will make mistakes and overlook things that seem inconsequential. I share this example of paying attention to what my spouse said because as a committed partner, I want my husband to know I care about him, just as he shows me that he cares about me. Each of us can practice paying attention on a daily basis so we become more attuned to what matters to our spouses and more connected as couples.

In one of my sessions, Elizabeth and Rafael were discussing a conversation they had about going out of town so they could spend time together. Their lives were exceptionally busy, and Elizabeth kept saying, “Yes, we should go out of town, but now is not a good time.” Rafael was trying to reach out to his wife, but Elizabeth was not understanding his needs. In our conversation, I brought up information he had shared in a previous session. As a child, his parents were unavailable to him and would constantly cancel plans. As a result, he was sensitive to Elizabeth’s lack of commitment to spending time together.

Whether dating or married, every couple gets busy and caught up in their own lives. At times, one partner may even feel stuck doing all the listening without the equal opportunity of being heard. However, couples who understand and listen to each other’s needs and counter with solutions stay connected.

Elizabeth shared her concerns about the relationship, too. In the end, the couple worked out that, when Rafael asks her to spend time with him, Elizabeth could say, “I’d love to spend the weekend with you. Would X date work for you?” By giving her husband a specific date, he felt that she was making him and the relationship a priority, healing old hurts and pain from his childhood. The couple made a date – just the two of them – for 3 months from our appointment. We discussed how to be understanding of individual schedules and, on balance, the need to make time for each other.

  • Slow down and focus on your partner’s feelings and reactions to situations.
  • Take note: if you are talking about X and your partner turns away or looks down, check to see if he is upset or if something is bothering him.
  • Create win-win situations by thinking about your partner.

As partners, it’s essential for us to have our partner’s owner manual. When we don’t, we risk being seen as threatening or not loving our spouse. Frequently, partners end relationships because one partner didn’t know what really mattered to the other. If you begin to hear statements such as, “You just don’t know me,” “You don’t get me,” “You don’t seem to really care about me,” take action. Find a reputable PACT therapist in your area to help you “know each other,” reduce insecurities and increase your connection. When you take the time to obtain your partner’s owner manual, you begin communicating “I want to understand you,” which will improve the likelihood of a secure relationship.


Tatkin, Stan. (2016). Wired for dating: How understanding neurobiology and attachment style   

can help you find your ideal mate (p. 31). Oakland, CA: New Harbinger Publications, Inc.

Tatkin, Stan. (2018). We do: Saying yes to a relationship of depth, true connection, and enduring

love. Boulder, CO: Sounds True.

Attunement + Evidence: Using What You Experience to Help Your Clients

By Lindsey Walker, LMFT
PACT Ambassador and Level II Therapist

Couples therapists often struggle with how to sort through the many feelings and complicated relational dynamics that arise in couple therapy sessions. You have two people, both hurt. Each come with a different perspective, combined with years of history and unresolved conflicts, and they are looking to you to figure it all out.

By walking into your office, they invite you into their relationship. As a therapist, you join them through attunement. As a PACT therapist, you combine your attunement with identifying the couple’s observable behavior, which enables you to determine what they have not yet integrated into a secure-functioning relationship.

When you mind your own experience with couples, while simultaneously observing how they interact with each other, they provide you with real-time information about who they are and how they handle their relationship. As you gain this information, you can feed it back to them. This helps them build an understanding of how they are functioning. It also creates opportunities for them to move away from destructive dynamics.

In one session, Rochelle and Brandon sit as far back in their seats as possible, leaning away from one another without trying to be obvious. A line of tension runs through their bodies, which tells me they are not fully relaxed.

I look at one member of the couple and see her folding in on herself, hands tucked under her legs, which are crossed. She bites her lower lip. Her partner’s body twists toward her. However, his neck cranes to look at me whenever discussing his feelings or experience.

I take these observations in and then turn my focus inward to take note of my own senses. Am I feeling something strongly? Seeing any notable pictures in my mind’s eye? How’s my body handling the stress of the situation? What ideas are coming to mind? Is there something I’m moved to say here? How pressing is it? My breath is shallow. I feel tension in the room and also inside of me. Most notably, I feel stuck — if someone asked me to speak, it would seem impossible.

As therapists, through our attunement, we experience the relational wounds that our couples bring to us. This body-to-body exchange of information is communicated so quickly. Couples often miss it, which is why they end up in therapy, stuck in repetitive cycles.

In the example of Rochelle and Brandon, when I look inward, I get information about what it feels like to be with them, which the couple needs for themselves. Closeness is difficult for them. Internally, I interpret their body postures combined with historical information I have gathered about them: they deal with the tension of intimacy by either turning inward (Rochelle), or toward something or someone else (Brandon). Speaking openly about their more vulnerable experiences is not something they know how to do.

From the neck down, Brandon shows me that he wants to be with his partner. From the neck up, however, his eyes plead with me, asking to know whether or not he’s safe to turn all the way toward Rochelle. I feel a great sadness well up in me.

I feel that these two are mourning the loss of closeness in their relationship, and they don’t yet know how to connect over it. When they are not in the therapy room, they resort to old patterns of attack/defend in the face of vulnerability. As a result of not knowing how to express his more vulnerable self safely, Brandon gives his sadness to me, instead of to Rochelle. Though she is facing him, Rochelle does not signal to him (or to me) that she is ready for what he has to offer. She is too preoccupied with managing her own anxiety.

My purpose in their relationship in this moment is to contain the experiences that they are not yet equipped to handle within themselves or their relationship. I recognize this via my own felt experience, what I see in them, and how Brandon is interacting with me.  I prepare to help move them toward each other.

Brandon starts to talk to me. I want him to know that what he is saying is valuable, so I focus my attention on him. This kind of affirmation can serve as a bridge for him to contain his own experience within their relationship. Yet, the goal of couple’s work is to help them find affirmation and support within the couple system. Knowing this, I want to turn them back toward one another to see how they handle each other in this vulnerable moment.

Now a therapist can take many directions, all lead to the same essential thing. Here are several possibilities, including the PACT methods of cross-questioning, cross-commenting, or going down the middle:

  1. To her: “Does he always look away from you when he’s feeling vulnerable?”
  2. To her: “He’s about to tell me something important, and I don’t want you to miss it. What happens when you ask him to look at you?”
  3. To him: “There’s something you want to tell her, but you feel more comfortable telling me. Why?”
  4. To him: “Experiment with turning your head to face her. Look her in the eye, and tell her what you just told me.”
  5. To both of them: “You want to be close, but it’s hard for you to fully let go.”
  6. To both of them: “It’s hard to speak about how you feel with one another.”
  7. To both of them: “You guys are so sad together, but you don’t know how to share it.”

With these interventions, you’ve taken what you discovered about them and used it to highlight how they operate with one another. This helps them:

  1. Identify a feeling they have so they can begin to integrate it into their couple system.
  2. Increase awareness of how they react to one another in tense situations.
  3. Own the idea that there is something they want together (though in some cases, not) and for which they are both responsible.

Couples therapy moves fast. Your couples signal to you all the time about their distresses, their hopes, their worries, the ghosts from the past that they struggle with. Your ability to be pulled into their system, and yet retain the sense of your own experience and observational abilities while in it, is one of the best tools you can use to help them heal their relationship.

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Self-Regulation and the PACT Therapist

By Carolyn Sharp, LICSW
PACT Level III Therapist

After laughing with Marty about the wonderful date they had, Peter adds, “Of course we had to go to the restaurant you wanted.” With that slight emphasis on going to Marty’s restaurant pick, they go from shared laughter to bulging eyes and hostile voices, following each other out of connection and into attack. All it takes is one wrong comment to spin into the dynamic this high-arousal and high-conflict couple came to address. My heart rate increases and my throat tightens as my mind imagines the session going out of control. With my own arousal rising, I’m in danger of losing my capacity to be helpful.

Christina and Sam stare listlessly at the floor during extended pauses after my questions and comments. Their passivity and disconnection are in charge here, and neither partner makes a move toward closeness or engagement. I feel a yawn forming and can hear every sound outside my window, as boredom threatens my effectiveness. This couple will continue to do what they always do if I don’t activate the energy in the room.

In both these cases, the couple’s work together depends on my ability to self-regulate—to calm myself in the former and to self-activate in the latter. With PACT’s embodied approach (whereby the therapist uses the live felt-experiences of a couple to help them learn new ways of being with one another), my job is to help the couple learn to co-regulate each other’s nervous systems so they can find connection and safety. Their ability to do this is central to forming a secure-functioning relationship.

As a PACT therapist, self-regulation allows me to set the tone for the sessions and to create the frame and expectations for partners’ behavior. Additionally, when I am self-regulated, I have the capacity to marshal all my resources to respond helpfully with any interventions needed. I can’t fall outside my own window of tolerance or allow myself to react from emotion. Central to the skill of self-regulation is awareness of the strengths, challenges, and triggers within my own arousal system. The volume and speed of a couple’s speech can be irritating to my system, but tone and emotion are what cause my heart rate to spike. In the other direction, the slowness of their responses can be lulling, but disengagement between partners is the cause of a drop in my attention and attunement. Being aware of these triggers is the key to my ability to notice and take action.

The use of deliberate practice and repetitive skill-building exercises to automate responses to calm or activate myself when stressed has been enormously helpful to my self-regulation (Rousmaniere, 2016). I practice resetting my system when excited or bored so I can do so in session, without pause. Developing the emotional muscle memory to calm or excite myself makes it more likely that I can do the same in times of stress or in overwhelming situations.

Two of the simplest and most reliable means of self-regulation are exhalation and simple grounding (i.e., the ability to return my attention to my body and the room quickly). Using these has proven invaluable, and I often invite couples to practice them with each other when the room goes “high temperature” or “frozen” (the vernacular I share with couples). Lastly, the PACT serenity prayer serves as a powerful grounding in my role and responsibilities as a therapist. Through self-regulation, I am present with the couple before me and I allow them to practice being in each other’s care. The skills of self-regulation were useful in sessions with the two couples I described.

Peter and Marty came to PACT to learn to head off their explosive conflicts, as well as to help each other get through those conflicts safely. Through attunement and better co-regulation they are learning to do this. My self-regulation is integral to their process as I stay present and tuned in, while fully in my own window of tolerance. With a long, slow whistle on my exhale (indicating a nonverbal “wow” to Peter’s comment about the restaurant), I catch their attention. They are immediately connected through their mutual irritation at my interruption, followed quickly by amusement as they realize I just distracted them from their escalating fight. Being tuned into the energy in the room and its impact on me allows me to use a distraction to help regulate this couple and move them back within their window of tolerance and into each other’s care. Following a repair to one another, we talk about the things they have been practicing at home to get out of these scenarios, and then they practice regulating each other.

Christina and Sam came to therapy for help reigniting the passion and connection they lost over time as they focused all their energy on things outside their connection. Helping them requires me to activate the energy in the room, so I stand up and have them join me and take each other’s hands. Sam follows my request and begins to describe Christina’s face. Tears come as Christina feels Sam’s presence. Describing him, in turn, elicits a big smile, the first he has shown today. I watch them squeeze each other’s hands and then move into a hug. I vocalize the shift made when moving to each other. The listlessness I felt when I paid attention to my own response alerted me to the direction I needed to take to help them move toward each other.

Couple therapy can vacillate between high and low energy, between conflict and disengagement. Unregulated, therapists can quickly follow clients down any number of unproductive paths. Remaining grounded and regulated is our most powerful tool in maintaining our focus on facilitating secure-functioning couples.



Rousmaniere, T. (2016). Deliberate practice for early career psychotherapists. Psychotherapy Bulletin, 51(3), 25–29.