Couple Therapy

Mona D. Fishbane


doi: 10.12744/tnpt(4)126-127

Unhappy couples come to therapy beleaguered by cycles of emotional reactivity.  These cycles run hot as partners blame each other and justify their own behavior.  The habits that fuel these cycles run deep—and couple dances take on a life of their own as clients become lost in their own reactivity.  In these circumstances the therapist can feel overwhelmed.  Can a neurobiological perspective, perhaps, help therapists and their clients with these impasses?

As I explore in my recent book, Loving With the Brain in Mind: Neurobiology and Couple Therapy (Fishbane, 2013), “news from neuroscience” can be empowering to both clinicians and clients.  A large body of research shows that most of our experience runs on automatic pilot, beneath awareness.  Consequently, we humans experience a tension between habits and choice—between the reflexive nature of our automatic brains, and our prefrontal ability to make choices in keeping with our values.  Couple therapy addresses this tension by helping partners to identify their higher goals and values, and to learn ways to regulate their emotions and automatic responses.  While old habits may dictate a couple’s frustrating cycles, cultivating their ability to make more thoughtful choices can transform their cycles for the better.

The emotional brain acts and reacts quickly, before the higher brain can identify what is happening.  After a meltdown, we seek to justify our behavior—we are, after all, narrating creatures—and a part of the left prefrontal cortex (PFC), which Michael Gazzaniga calls “The Interpreter”, concocts a story that may or may not have much to do with reality.  Then couples engage in debates about “what really happened”, each spinning their own version and blaming the other.  Understanding the workings of the emotional brain can thus help clients step out of their automatic processes and become curious and reflective about their own internal and interactive dynamics.

I engage in what I call “neuroeducation” in therapy, offering clients tidbits of information about how their brain operates as I work to empower them vis-à-vis their own reactivity.  They learn that their amygdala, which may have triggered a meltdown or an escalation, is simply doing its job—that this part of the limbic system is constantly scanning for danger, trying to keep them safe.  The amygdala does not dabble in subtleties—in fact, a grumpy or critical spouse is as threatening to the amygdala as a snake in the forest.  But we also have a higher brain, the PFC, which allows us to make thoughtful choices and live according to our values.  With this neuroeducation, clients feel de-shamed, “My amygdala caused my meltdown!” and empowered, “My PFC can help me calm down and make better choices”.  I ask reactive clients to visualize their rowdy amygdala and their wise PFC intervening to calm things down, like a good parent.  Clients love this exercise because it operationalizes emotion regulation in a playful way.  The PFC can lead us to justify our behavior, or it can help us regulate it.  This is where our higher values come into play.  For this reason, I encourage couples to articulate their own relational values so that they can become co-authors of their relationship, rather than victims of each other.

Emotion regulation is key to relationship success.  I help clients tune into emotions before they escalate, and learn to read the body states associated with emotions.  Information from the viscera (gut, heart) travels up the spinal cord to the insula in the brain, where it eventually becomes conscious—and the feeling is named.  Affect labeling (naming emotions­­) ­activates the PFC and quiets the amygdala.  Another technique for emotion regulation is reappraisal, akin to the therapeutic technique of reframing, which similarly utilizes the PFC and calms the amygdala.  Other techniques include: mindfulness meditation, which leads to positive changes in brain and immune functioning, and can facilitate emotion regulation, decrease autonomic reactivity, and enhance empathy; and slow diaphragmatic breathing, which calms the sympathetic branch of the autonomic nervous system and activates the soothing parasympathetic branch.  The interplay between body and brain in emotion regulation is paramount—the brain is embodied, and understanding brain-body processes is important for the clinician.

I encourage couples to “get meta” to their own personal and interpersonal processes.  We draw the Vulnerability Cycle Diagram (Scheinkman & Fishbane, 2004), identifying each partner’s vulnerabilities and survival strategies, and exploring the family-of-origin contexts in which they emerged.  In exploring and reflecting on the cycle, prefrontal thoughtfulness is brought to bear on limbic reactivity.  Discussing the family-of-origin roots of each partner’s vulnerabilities and survival strategies tends to increase empathy—and empathy counteracts automatic reactivity in couples. Neuroscientists Jean Decety and Philip Jackson have identified four aspects of the neurobiology of empathy: automatic resonance (mirror neurons and the insula allow us to feel in our own body what the other feels); cognitive empathy (putting ourselves in the other’s shoes, a prefrontal process); boundary between self and other (so I don’t get lost in your pain); and self-regulation (so I don’t become overwhelmed in the face of your pain, which leads to personal distress rather than empathy).  The clinician can identify which aspects of empathy need work with a particular client and tailor interventions accordingly.

Why do some people become more emotionally dysregulated than others? Research shows there are individual differences in stress reactivity, and some of these differences are related to variations in the oxytocin receptor gene.  In addition to genetic vulnerability, emotional reactivity is also shaped by early childhood experience and nurturing (or lack of it).  Experience changes the brain, and early childrearing exerts a potent influence on brain structure and functioning.

How extensively can adult clients change their ingrained patterns of reactivity? One of the most exciting developments in neuroscience in the last decade is research on neuroplasticity.  We now know that neuroplasticity isn’t just for kids, and that the adult brain is still capable of change, depending on how we live our lives.  But doing same-old, same-old does not keep our brain flexible—it leads to what Lou Cozolino calls “hardening of the categories”, whereas physical exercise, paying attention, and learning new things all facilitate neuroplasticity.  I encourage my clients to stretch themselves physically and mentally, and to take charge of their own brain health even as they become more empowered in their interpersonal process.

My reading of the research in neuroscience makes me a realistic optimist when it comes to change in couple therapy.  On the one hand, we humans are creatures of habit— our networks of neurons underlie our habits, which in turn strengthen those very neuronal networks.  In couples, partners’ habits or survival strategies are highly ingrained, and client “resistance” represents neural networks simply doing what they’ve done for years.  On the other hand, we are creatures of change and adaptation—our brain is constantly changing in response to experience.  We are not doomed to be prisoners of our habits.  Choice and change are possible in adulthood; but they take work and focus.  A commitment to change, and a willingness to practice new habits over and over again so they become ingrained as the “new normal”, is necessary for both neuroplasticity and relationship plasticity.  Understanding the neurodynamics of habits and choice crucially allows the clinician to hone interventions that facilitate individual and interpersonal transformation in couple therapy.



Fishbane, M. D. (2013). Loving with the brain in mind: Neurobiology and couple therapy. NewYork: Norton.

Scheinkman, M., & Fishbane, M. D. (2004). The vulnerability cycle: Working with           impasses in couple therapy. Family Process, 43, 279–299.

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