CC15 Workshop 03 - Working with Disorganization in Couple Therapy: A PACT Perspective - Stan Tatkin, PsyD

Description:

This workshop focuses on couple therapy with highly disorganized partners and couples. Special attention will be paid to the importance of strong therapeutic frame (rules) and therapeutic stance (goals). Highly disorganized partners and couples will be viewed through the lens of attachment theory, regulation theory, and neurobiological development.

Educational Objectives:

1. Name at least five principles of secure functioning
2. Describe at least five diagnostic markers for assessing disorganized states and traits in the clinical setting

*Sessions may be edited for content and to preserve confidentiality*

Outline:

Confidentiality and Technology

• Emphasizes strict confidentiality, especially with modern recording tech.

• Warns against unauthorized recording (e.g., Google Glass) disrupting privacy and professionalism.

Advanced Material Introduction

• Workshop targets advanced content on disorganized behavior in therapy.

• Goal: Help therapists predict, manage, and respond effectively to disorganized clients and couples.

Challenges in Couple Therapy

• Miscommunication is common; worsened by distress.

• Emphasizes collaborative communication and developmental models to assess client behavior.

Developmental Models & Brain Function

• Developmental models provide predictive value but are not perfect.

• Brain overview: left hemisphere = logic, right = emotional/social processing.

• Lower brain structures (brainstem, limbic system) are central to regulation.

Attachment & Arousal Regulation

• Describes avoidant (low signal) vs. clinging (high signal) styles.

• Discusses disorganized attachment and unresolved trauma.

• Introduces the “window of tolerance” for arousal regulation; staying within it ensures better functioning.

Vitality, Immobilization & Vagal Systems

• Vitality states (sympathetic) vs. restrictive states (parasympathetic).

• Immobilization (freeze/shutdown) is linked to dorsal vagal response and trauma.

• Differentiates ventral vagal (social engagement) from dorsal vagal (shutdown).

Therapeutic Techniques

• Encourages therapists to use mindfulness, body scanning, and facial/body tracking.

• Therapists must monitor their own arousal and adapt interventions in real time.

Case Examples

• Disorganized mother-infant pair and couple session demonstrate key concepts.

• Therapists must prepare for unpredictable responses and preserve alliance.

Therapy Session with Cutting Survivor

• Woman had self-harmed in the past; therapy explores emotional impact.

• Eye contact and touch elicit strong emotional reactions, requiring careful pacing.

• Man’s apology seen as reparative, reducing shame and promoting connection.

Grooming & Regulation

• Grooming behaviors signify friendliness and regulation.

• Woman shows signs of dorsal vagal shutdown; man’s supportive gestures aid recovery.

• Observing these interactions reveals emotional states and attachment patterns.

Attachment Styles & Co-Regulation

• Avoidant vs. anxious regulation strategies explained.

• Co-dependency can stem from overreliance on external regulation.

• Therapist helps reduce negative reactions through real-time observation.

Observation Skills

• Therapists should observe clothing, posture, movement, and emotional shifts.

• Presence and attunement increase therapeutic connection.

• Introduces concept of psychotic cores and how early trauma affects development.

Brain Development & Personality Disorders

• Early danger can alter brain structure/function (e.g., amygdala, hippocampus).

• These changes affect emotional regulation and medication response.

• Therapists should be aware of medical history and physiology.

Couple Therapy Techniques

• Keep couples face-to-face for co-regulation and efficient observation.

• Avoid premature interventions; allow interaction to unfold naturally.

• Eye contact and gaze patterns offer insight into emotional states.

Managing Disorganized Couples

• Stress increases disorganization; a strong therapeutic frame is essential.

• Therapist must hold belief in client’s capacity for secure functioning.

• Secure functioning can be achieved with structure and relational support.

Q&A Highlights

• Advice for when one partner leaves the room: manage frame and follow-up.

• PACT is applicable to all couples, not just disorganized ones.

• Session length should be adapted to couple’s tolerance and needs.

• The amygdala’s role in emotional memory is central to disorders like BPD.