When we begin a new romantic relationship, the electricity, magic, and euphoria can lead us to make decisions quickly – meet the parents, move in together, get a pet, have children, buy a house, and so on. We rarely take an objective look at our partner’s personality patterns, how they manage stress, how they handle daily responsibilities, and their ability to share and negotiate. If we do, we sometimes gloss over their questionable traits thanks to the “halo effect”– a favorable overall impression causing us to believe that some things don’t really matter or that they’ll somehow get better.
Getting real
As a couple therapist, I’ve noticed that things get real when lives merge and joint responsibilities become apparent at a very mundane level. Who will:
- Arrange for meals (whether restaurant reservations, take-out, or cooking)
- Make social arrangements with friends and family
- Plan weekend activities and vacations
- Walk the dog, clean the house, pay bills, etc.
These responsibilities can break down according to traditional gender roles, although this is becoming increasingly rare. Often partners will choose tasks they’re accustomed to and like doing, while some important things fall by the wayside or are done inadequately, much to the chagrin of one or both partners. It’s rare when joint responsibilities are thoughtfully and amiably discussed, and each person upholds his or her part of the agreement. Why does such a common, simple aspect of coupled life become complicated and so often result in visits to a therapist’s office? Is it a core problem or a symptom of something more basic? Let’s look at what happens when sharing is inequitable and problems develop.
The pitfalls of inequitable sharing
Kate and Ahmed are a couple in their mid-30s who grew up in families that followed traditional gender roles: dad worked full-time as the major breadwinner, while mom was a homemaker and occasionally worked part-time. When the couple met eight years ago, they both worked at high-pressure jobs. After moving in together, they ate out, ordered take-out, and outsourced everything from housecleaning to pet walking.
After five years of marriage and two children, Kate continues to work full-time while Ahmed is a stay-at-home dad. Now there are also school meetings, play dates, aftercare, and school vacation activities to plan. Neither has much time for their own pursuits, and Ahmed is getting tired of their usual Sunday dinners with Kate’s family. He also feels resentful that Kate offers to “help,” but rarely anticipates their family’s needs or steps forward to plan with him. They’ve become distant and resentful of each other for not prioritizing their connection as a couple. Sex is infrequent and monthly date nights are mostly spent planning for the kids and often end up in an argument.
Finding a more equitable solution
Kate and Ahmed’s situation is not unusual. In fact, it’s one of the main reasons couples seek therapy. Some may view it as part of a normal stage couples go through – the “seven-year itch.” They’ve fallen into a pattern of just assuming that the other will do what’s needed without negotiating who is better to take on certain responsibilities and what help is required.
Through a series of guided communication exercises, Ahmed and Kate worked in therapy by listening to each other and understanding the impact that their current arrangement was having on them. As a homework assignment, they made a list of all the tasks that were necessary to accomplish for their family to function and what each was currently doing. The therapist then helped them negotiate what each preferred to do and was able to do. Without their lists being entirely equal, they each felt comfortable with what they had agreed to in light of their roles in the workplace and at home.
Family-of-origin cultural patterns came to light during this negotiation. Kate came from a large, tight-knit Irish-Catholic family that gathered every Sunday for dinner. During therapy, Kate was able to see that her staunch adherence to her family’s expectations was detrimental to her marriage. Kate and Ahmed reached a compromise, deciding to have dinner with her family once a month.
Sharing doesn’t have to mean everything is always shared evenly
Equitable sharing usually doesn’t mean everything is always shared evenly. A partner who works at a high-pressure job may be able to devote less time to family matters, but the other partner needs to agree that he or she is both capable and willing to carry the extra burden. In the case of a full-time graduate student, for example, a partner may shoulder much more than the student, who might be fully occupied with teaching duties and dissertation writing. But the agreement needs to be that it’s short-term, and that the balance will be more equitable in the future.
Also, culture – in its many aspects – can play a major role in couples’ decisions about what works best for them. For example, many African American, Latino/a, Native American, and Asian cultures may be either more patriarchal or matriarchal. While the actual amount of time spent on tasks may be uneven, it’s understood that either the father or mother or extended family members exert a major role in family functioning and a 75–25 percent pattern of sharing may be acceptable. On the other hand, research by the psychologist Charlotte Patterson on lesbian couples indicates that role-sharing is much closer to 50-50 than for heterosexual couples (Patterson 1995).
Making it work
From the start, sharing in coupled relationships depends on clear communication and negotiation. While these are the vehicles through which good relationships grow and develop, basic issues such as trust, acceptance of each other, and a commitment to working things out are the foundations for preventing resentment and alienation, and to establishing and maintaining the satisfying connections that couples experienced in the first days of romance.
SELECTED READINGS
Arcidiacono, F., & Pontecorvo, C. (2008). An exploratory study of the everyday lives of Italian families: household activities and children’s responsibilities. Cahiers de Psychologie, 43.
Klein, W. Izquierdo, C., & Bradbury, T.N. (2013) The Difference Between a Happy Marriage and Miserable One: The Atlantic, March 1, 2013.
Klein, W., Izquierdo, C., & Bradbury, T. N. (2007). Working relationships: Communicative patterns and strategies among couples in everyday life. Qualitative Research in Psychology, 4(1-2), 29-47.
Moore, MR. Gendered power relations among women: A study of household decision making in Black, lesbian stepfamilies. American Sociological Review. 2008; 73:335–356.
Parker, K, & Wang, W. (2013). Roles of Moms and Dads Converge as They Balance Work and Family. The Atlantic, March 13, 2013.
Patterson, Charlotte, 1995. Families of the lesbian Baby Boom: Parents’ Division of Labor and Children’s Adjustment.” Developmental Psychology 31(1):115–23.
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ABOUT THE AUTHOR
Dr. Terry Patterson is a licensed psychologist in San Francisco with decades of experience as a therapist, professor, and clinical trainer and supervisor. He is board-certified as a Couple & Family Psychologist and also treats depression, anxiety, and transitional issues in adults and adolescents.
I sat quietly while the client in front of me closed her eyes and recounted in vivid detail the sexual assault she had experienced many years before. The pain of the memory was evident on her face and in her voice. The details were shocking and sad, yet I felt truly honored to bear witness to her healing process. It was my first experience with prolonged exposure (PE) for PTSD.
I was excited to be practicing PE for the first time. Though many of my colleagues found it uncomfortable to ask a client to experience such distress, I’d been doing other forms of exposure therapy with most of my anxious clients for a few years and found it one of the most rewarding things I could do in my practice.
Exposure is a therapeutic procedure in which a client repeatedly approaches and contacts something they fear, whether a place, situation, thought, memory, or physical sensation. It’s one of the most powerful tools we have in mental health care. What seemed so scary to both my clients and me in the beginning – getting dirty on purpose in OCD, boldly embracing social interactions in social anxiety disorder, or intentionally self-inducing panic symptoms in panic disorder – quickly became empowering. Clients feel emboldened and enlivened as the situations they have desperately avoided lose the power to control their lives. And it’s a thrill to be part of it.
Exposure therapy for PTSD
PE involves first constructing a hierarchy of situations that the client fears approaching and beginning to approach them one by one. These situations usually have some association with the traumatic event, yet they’re no more dangerous than other everyday situations. Examples might include going out in public, being in crowds, talking to new people, walking near the area (if safe) where the traumatic event happened. This is called “in vivo” exposure.
The next part of the process involves describing the traumatic memory in great detail while being recorded, then listening to that recording in the session and as homework, repeatedly, until the memory begins to lose its power. This is called “imaginal” exposure.
Fear reduction – necessary or not?
Something funny happened that first time I practiced PE. We were doing the imaginal exposure part of the treatment, and the protocol called for the client to recount her traumatic memory repeatedly, hopefully until her subjective units of distress (SUDs) reduced by 50 percent. The ninety-minute session was nearly over, and her SUDs had hardly budged. She had started at 90 on a 100-point scale, and we were down to about 80. Something similar happened every time she practiced exposures, whether imaginal or in vivo, over the course of therapy.
Yet I wasn’t really worried. I was armed with a key piece of information from the science of exposure therapy. UCLA researcher, Michelle Craske, and her colleagues had recently published a review that observed that fear reduction in exposure does not predict outcome. In other words, you don’t have to feel less scared or distressed to get the desired benefit of exposure. The PE protocol, published prior this review, didn’t incorporate that knowledge, though it didn’t completely rule out the possibility of improvement with limited reductions in SUDs.
Wanting to be the best scientist-practitioner I could be, I prepped the client during the education phase of the treatment by saying that though we would look for her SUDs to go down, new research suggested she would improve even if they didn’t. So when those numbers barely budged week after week, we just observed it, and made note.
Something did change in a big way, however. Despite her intense discomfort, she told me she could feel the experience shifting, becoming less powerful, less all-encompassing. The memory began to have less impact, even if she still felt lots of distress. Her PTSD symptoms began to diminish, and when we conducted an assessment using a standardized measure of PTSD symptoms at the end of about 12 weeks, she was in the subclinical range.
What’s going on in exposure therapy?
Historically, researchers and practitioners assumed that what made exposure work was the habituation that usually occurred. This makes sense: in most situations, the more time we spend with something uncomfortable, the less uncomfortable it makes us. In other words, we become habituated to it.
However, the evolving science of exposure, including the data that shows fear reduction doesn’t predict outcome, suggests that what is more essential to the process is something called inhibitory learning, in which the fear-inducing stimulus begins to also be associated with safety instead of danger. The association with danger doesn’t necessarily go away, but it now competes with the safety association. And the stronger the safety association becomes, the more it inhibits the influence of the danger association.
How did this work with my client? Over time, situations and memories that once evoked typical PTSD symptoms – fear, hypervigilance, and an urge to escape – gradually began to evoke other responses, such as a sense of renewed safety, a feeling that the traumatic event was in the past, and a feeling of compassion towards herself and others who had experienced similar traumas. The fear response didn’t completely go away, but she now experienced it in the context of other, more helpful responses.
Maximizing the Impact of Exposure Therapy
This evolving science is reviewed by Michelle Craske and her colleagues here, along with ways we can make exposure as effective as possible. I’ve summarized some of it below with the help of brief catchphrases I recently encountered in a chapter on exposure by Carolyn Davies and Craske in a new book called Process-Based CBT, which is part of an effort to direct the field of cognitive behavioral therapy away from focusing inordinately on techniques and towards processes of change. If you’re new to exposure therapy, I suggest you take these suggestions, which probably fit best in later stages of therapy, lightly. It’s still important to maintain the client’s buy-in by starting small and giving them opportunities to succeed early on.
Expectancy violation (“test it out”)
If inhibitory learning is behind the effectiveness of exposure, then the more your client encounters learning experiences that violate his or her expectations, the better. Structure your exposures for maximum expectancy violation. You could encourage your client with panic attacks to do multiple hyperventilation trials, far more than seems “safe,” in order to discover that one can hyperventilate for long periods of time, even more than 30 minutes, with no adverse consequences. You could encourage your client with OCD to get as dirty as possible or even eat a piece of candy off a toilet seat to really show that life doesn’t fall apart when you expose yourself to potential contaminants.
Deepened extinction (“combine it”)
Combine exposure modalities. For example, have your client with PTSD work up to purposely hyperventilating while doing in vivo exposure in crowds. Or encourage your client with social anxiety to imagine the worst-case scenario happening (i.e., perform imaginal exposure) at the same time he or she interacts with people in a fully engaged way in a social setting.
Occasional reinforced extinction (“face your fear”)
Many therapists (myself included) practice exposure hoping that their client only has positive experiences. We certainly don’t want clients with social phobia to have a truly embarrassing moment in a social situation. But this might actually provide additional benefit. Because embarrassment, rejection, and other feared but ultimately safe outcomes are a part of life, your client, with your support, can discover that these experiences are survivable – and can even be a source of growth.
Removal of safety signals (“throw it out”)
It’s tempting not to discourage your clients from holding on to some safety signals – having a safe person nearby, carrying hand sanitizer, carrying a beta-blocker or benzodiazepine “just in case.” However, when clients continue using safety signals, they continue to give themselves the message that without their magical assistance they’re not capable of handling anxiety (or the situations that evoke it). This is contrary to the new learning that we hope they’ll gain.
Affect labeling (“talk it out”)
In a well-constructed study with four comparison groups, subjects went through an extensive spider phobia protocol. Those who distracted themselves, reappraised their thoughts (e.g., “I can handle this; this isn’t so bad.”), or completed exposure without doing anything additional, performed less well than those who simply named their feelings as they were arising (e.g., “I’m feeling really anxious in the presence of this ugly spider.”) Presumably, this brought them closer to the experience itself, allowing them to be fully present to benefit. So the next time you’re helping a client go through exposure, encourage them to mindfully track their experience as it arises: “I’m noticing my heart begin to race. My hands are getting clammy.”
Variability (“vary it up”)
When habituation was considered the primary mechanism driving exposure, it made sense to create a hierarchy and go up the hierarchy from least to most distressing. As you habituate to one level of distress, it seems logical that you’re better prepared to move on to the next level of distress. But new research suggests that you get more traction jumping around the hierarchy a bit. So don’t be reluctant to encourage your clients to play around with the order of exposures. You may have already noticed this in your practice: sometimes clients suddenly become eager to try something higher up the ladder than you had anticipated. Go with their willingness.
A final note: be bold
Exposure therapy can be hard for the therapist to do. A recent study suggests that therapists who score high in experiential avoidance, the tendency to try to suppress or minimize uncomfortable thoughts and avoid the situations that evoke them, may spend less time on exposure with clients who need it. Think of conducting exposure with your clients as your own inhibitory learning experience. The more you do it willingly, in multiple contexts, with multiple people, the more the experience will seem safe – and perhaps even exciting, as it is for me – and the more you’ll see how it can transform the lives of your clients.
CONTACT US
If you need support, Lyra can connect you to a behavioral health solution. You can get started today if Lyra is offered by your employer. Sign up now.
And check in frequently here or follow us on Facebook, LinkedIn, and Twitter for more insights into optimal well-being.
DISCLAIMER: The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.