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Heather MacIntosh, Ph.D., CPsych - Guest
Heather MacIntosh, Ph.D., CPsych is a clinical psychologist, Associate Professor, and Director of the Couple and Family Therapy Clinic at McGill University where she is the recipient of the H. Noel Fieldhouse Award for Distinguished Teaching. Heather is author of the Developmental Couple Therapy for Complex Trauma a Manual for Therapists and Healing Broken Bonds: A Workbook for Couples with Complex Trauma. She is also the developer and host of Healing Broken Bonds, a podcast featuring couples dealing with the impacts of complex trauma in their relationships. Developmental Couple Therapy for Complex Trauma is an evidence based, psychoanalytically informed treatment approach, developed by Heather, for working with couples dealing with the impacts of complex trauma. Heather is the author of over 60 peer reviewed journal articles, book chapters, and treatment manuals. She is in demand as a speaker at international conferences and workshops as well as a resource for local and national media in the areas of trauma, couple and family relationships and issues, and queer and trans wellbeing. She leads an active funded research program having been principal researcher on over $500,000 in peer reviewed research grants and an active co-investigator on over $7,000,000 more with other internationally recognized colleagues. Heather’s research primarily examines the impact of early life trauma on the process and outcome of couple therapy. In addition, she studies the experiences of 2SLGBTQIA+ trauma survivors in therapy, in healing their sexual selves, adapting and integrating models of treatment to ensure accessibility and inclusion of Indigenous, racialized, queer, and trans, graduate student therapist trainees and clients. Heather lives and works on land of the Crawford Purchase Mohawk territory “purchased” for settlement by United Empire Loyalists at the end of the American Revolutionary War. MerryMac Farm is in Eastern Ontario, Canada, where she strives to live with the land in peace, and to bring healing through therapy offered in relation with her Icelandic horses, her retired RCMP Musical Ride Horse, three Ojibwe Spirit Ponies, and a cadre of other creatures who bring joy, hilarity, and love to life. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D.: (00:24)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using emotionally focused couples therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and oppositional and Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D.: (01:31)
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. (02:19):
Today I'll be speaking with Dr. Heather McIntosh, who is a clinical psychologist, associate professor and director of the couple and Family Therapy Clinic at McGill University, where she's a recipient of the H. Noel Fieldhouse Award for distinguished teaching.
Keith Sutton, Psy.D. (02:34):
Heather is author of Developmental Couple Therapy for Complex Trauma Manual for Therapists and Healing Broken Bonds, a workbook for couples with complex trauma. She's also the developer and host of Healing Broken Bonds, a podcast featuring couples dealing with the impacts of complex trauma in their relationships. Developmental Couples Therapy for complex trauma is an evidence-based psychoanalytically informed treatment approach developed by Heather for working with couples dealing with the impacts of complex trauma. Heather is the author of over 60 peer reviewed journal articles, book chapters, and treatment manuals. She's in demand as a speaker at international conferences and workshops, as well as a resource for local and national media in the areas of trauma, couple and family relationships and issues, and queer and trans wellbeing. She leads an active funded research program, having been principal researcher on over $500,000 in peer reviewed research grants, an active co-investigator on over $7 million more with other internationally recognized colleagues.
Keith Sutton, Psy.D. (03:35):
Heather's research primarily examines the impact of early life trauma on the process and outcome of couples therapy. In addition, she studies the experiences of two lgbtqia+ trauma survivors and therapy in healing their sexual selves, adapting and integrating models of treatment to ensure accessibility and inclusion of indigenous, racialized and trans graduate student therapists, trainees, and clients. Heather lives and works on land of the Crawford purchase Mohawk territory "purchased for settlement by United Empire loyalists at the end of the American Revolutionary War". Merrim Farm is in eastern Ontario, Canada, where she strives to live with the land and peace and to bring healing through therapy offered in relation with her Icelandic horses, her retired RCMP musical ride Horse, Bri Ojibwe spirit ponies, and a cadre of other creatures who bring joy, hilarity, and love to life. Let's listen to the interview.
Keith Sutton, Psy.D. (04:32):
Well, hi Heather. Welcome. Thanks for joining me.
Heather MacIntosh, Ph.D. (04:34):
Hi. So nice to meet you.
Keith Sutton, Psy.D. (04:37):
Yes. Well, so I'm not even sure exactly how I stumbled upon your work, but I do a lot of work with complex PTSD, also couples work, and I probably was Googling or so on and, and came upon your work, was really interested. I got to listen to a podcast interview that you had done. I'd love to hear more about your, your work and the program that you've developed for working with couples with complex PTSD. And, you know, I'm, I'm always interested in kind of, you know, how people got to what they're doing, kind of the, the, you know, evolution of their ideas that kind of got to developing this approach that, this intervention that you developed.
Heather MacIntosh, Ph.D. (05:16):
It's definitely a long road. It does not happen overnight. So there's been a lot of steps, stages, painful growing pains to get to a place where I think we're feeling pretty solid that what we're offering is helpful, safe, tolerable, useful. Productive.
Keith Sutton, Psy.D. (05:37):
Yeah. Yeah. Definitely. So, yeah, tell me about your pursuit or career or how you got to even putting this together for the com complex PTSD in couples.
Heather MacIntosh, Ph.D. (05:49):
A lot of it is by accident, as often happens. I was doing my doctoral work at Ottawa U in Canada. And I was working on family, families and trauma and parenting and trauma, and happened to take a couple therapy course with Sue Johnson, who was on faculty there, and just found myself really fascinated by the questions of what does trauma do to a person, to a couple, and then how does that affect the therapeutic process? So I sort of shifted my energies and I worked with Sue for a few years. Of course, I'm sure everybody knows Sue is associated with emotionally focused therapy, EFT So at the time, so this would've been 2000-ish, the common belief was that you should not do couple therapy with trauma impacted couples. The sense was, you know, people wouldn't be ready,
Heather MacIntosh, Ph.D. (06:53):
people were too chaotic, there would be too much trauma stuff in the room...This felt very unsatisfying to me. Yeah. you know, people are still in relationships even if we tell them we're not going to provide them with therapy And the idea that sending folks off to individual therapy would somehow magically make them ready for couple therapy or would improve the couple relationship felt wrong. The reality was the couples who were coming to see us, many or most had been in individual therapy and it had been helpful, but when you get the attachment person in the room, it just fundamentally changes everything about what's happening. So you can do all the individual therapy in the world. It may not prepare you for being in a room with a couple. So we did a study on EFT and we worked with childhood sexual abuse survivors and their partners and found some really interesting things.
Heather MacIntosh, Ph.D. (08:03):
Couples did improve in terms of the trauma part of their ways of living in the world, but the couple part didn't improve as much as we would've liked, and the process itself was very challenging. What we were seeing was a lot of, a lot of big emotions, and things feeling really flooded. And the therapy would kind of start and stop and start and stop and start and stop. And a lot of the couples didn't make progress past a certain stage--like the first stage of the therapy because there were so much there was so much stuff happening that they couldn't hold onto.
Keith Sutton, Psy.D. (08:47):
It's hard to hold onto that deescalation phase.
Heather MacIntosh, Ph.D. (08:51):
Exactly. Exactly. Folks would deescalate and then we'd be like, yes. And then, you know, two sessions later, kaboom. The kaboom would often be about something like that you'd think, "Eh, why was that a deal?" It was a deal because it was a deal. Trauma infuses life and experiences and relationships with so many different amplifiers. So I sort of sat on that for a while and wondered, well, what's this all about? And started work at McGill in a couple of family therapy programs. So the couple of family therapy program, Gil. And I thought, well, I guess the only place to start is just absorbing myself. So I went back to about 350 hours of this therapy and listened and watched and listened and watched and transcribed some more and just absorbed myself in it. And started to really identify that some of the things that were making it really hard--both for the couple and for the, the individuals in the couple-- fundamentally there were kind of two big things...
Heather MacIntosh, Ph.D. (10:07):
One was just emotion regulation. Trauma just smacks you when it comes to being able to regulate your emotions, and in individual therapy, it's not such a big deal because you're one-on-one and the therapist can help you regulate and kinda keep the process going. But in couple therapy, there's an added element that we kind of need to regulate to be able to keep the process going. So people would get dysregulated because of-- and we did a study on this looking at what, what was the therapist doing just before the moment of dysregulation? HWhat was happening during, and then what happened after? Great. And so the therapist was doing exactly what they were supposed to be doing, heightening emotion, trying to access attachment needs. They were doing all the things, but what would happen is emotions would get triggered, trauma survivors would get flooded with shame, overwhelmed. But then--so the emotion dysregulation was a big deal.
Heather MacIntosh, Ph.D. (11:11):
But then this other thing called mentalizing, which is like, how do we understand ourselves and others, how do we hold others in mind that would go offline in that moment of being super triggered and then the partners kind of left in the dirt. Maybe the partner was saying, you know, it really hurts me when, and so they're trying to hold this and the partner loses that. So they lose their capacity to regulate themselves, but they also lose the capacity to hold their partner in mind. Yes. And so this made these two factors along with others of course, but it made the therapy really hard. So again, I spent hours and hours and hours and blah, blah, blah, blah, blah as you do really soaking up well, what's getting in the way.
Heather MacIntosh, Ph.D. (12:08):
And the simplest thing came to mind. After years of thinking about this, it was such a simple thing that couple therapy, whether it's emotionally focused therapy or Gottman or cognitive behavioral--all of these therapies work really well! The outcome studies, these are good therapies. Yeah. All of them are based upon an assumption that the people doing the therapies can do the task of the therapy. So if it's EFT, the task of the therapy is to be able to access strong emotions, communicate them, hold your partner in mind, gauge with attachment. With cognitive behavioral, the tasks involve being able to be regulated enough to identify a need, a behavior, a communication style. So in essence, the therapy itself is based upon this assumption that if you can do the task, you will do well in the therapy.
Keith Sutton, Psy.D. (13:21):
Sure.
Heather MacIntosh, Ph.D. (13:22):
And for complex trauma survivors, that was maybe an ask too far. When we come out of families that are filled with 'yuck' and dysfunction and mess-- how do we come-- we don't have those self capacities going into life. We're just trying to stay above water, and the story we tell ourselves is, "I'm going to do it differently. I'm going to find a partner"... We're going to, you know, and we have this belief that somehow we're going to do it differently. And then guess what? We just, there we are and we need help, but it's almost as though those other therapies are just, they're two steps down the road. So, developmental, couple therapy for complex trauma, which is the worst name for therapy ever created...My students hate it... B-C-T-C-T in part because there's too many C's and T's. But the, the model is based on 'let's help folks walk those two steps'.
Heather MacIntosh, Ph.D. (14:29):
So that we're infusing the therapy with how do we learn how to regulate our emotions? How do we learn how to reflect and mentalize what even is attachment? And how can we start to shift that? That person, we're not expecting people to become securely attached after coming through tsunami childhoods. What we're hoping for is with that person, we can learn how to be what we call earned secure. So that person we can have an earned secure attachment with. So the therapy starts with psychoeducation, getting everybody on the same plane, getting everybody in the same place around, "okay, this is what's happening in our relationship". Some of these things are relevant, some of them aren't. And then we move into building those skills. We move into working on self-regulation and then co-regulation. In development, co-regulation comes first. If we have an attuned responsive caregiver, it's the co-regulation that grows into self-regulation. But most of us have not had that. And so we're wandering the world looking to find ways to co-regulate, but we have to do it backwards. So many things, when there's complex trauma, we have to do backwards, top-down instead of bottom-up.
Heather MacIntosh, Ph.D. (16:02):
So we help folks learn about what is emotion regulation from a cognitive perspective. Then, how do we do it from more of an embodied perspective? We do exercises, and breathing, and reflections. And then we bring to the partner, let's learn how to regulate together.
Keith Sutton, Psy.D. (16:26):
Got it.
Heather MacIntosh, Ph.D. (16:27):
Only after we've done all of that and spent a lot of time with this idea of mentalizing and how can we stay curious? What does it look like when we lose that capacity? How can we stay attuned and responsive to our partner? It's only then that we move into, "okay, so now let's look at what has the trauma done to your sexual selves? Your attachment self? How is trauma in infusing itself into the cycle of how you connect and communicate? How is trauma being recycled in your day-to-day life, where are the triggers? What are the thing?" And it's only then that we start to really take all of that apart and it's not an overnight thing. But it is certainly my couples would say that it feels more tolerable and a little safer, a little more contained. It's slower. It can feel frustrating because we're not diving into the big stuff. So we're not going there until we're ready. So that's kind of how it came to be.
Keith Sutton, Psy.D. (17:37):
That's great, yeah. Exactly like you're saying, the trauma aspect, bringing that in into the couple's dynamic does make it very difficult. And particularly too, sometimes the, the way I've thought about, sometimes people can go into individual therapy and they can talk about their trauma and intellectualize and so on and such, and almost distance a bit from it, but then you bring---
Heather MacIntosh, Ph.D. (17:59):
They become good at it.
Keith Sutton, Psy.D. (18:00):
Yeah, and then you bring the couple's therapy them into a session and it triggers all their trauma--attachment trauma-- in there, in that moment, and brings it all out. What maybe was kind of a bit more distanced in an individual therapy and so, having ways to work with that because it can be hard especially if there's the emotional flashbacks and then the person is disconnected, like, you're kind of saying-- and let me ask, so couple pieces... let me start with, how do you conceptualize complex PTSD?
Heather MacIntosh, Ph.D. (18:37):
Oh, me personally, as opposed to the international classic?
Keith Sutton, Psy.D. (18:42):
Yeah. Yeah. I'm always interested. How do you conceptualize it? How do you explain it to a client? Like what do you--
Heather MacIntosh, Ph.D. (18:47):
So I like to think about PTSD as being very much a thing that is...I hate the word symptom. But, you know, you can demarcate PTSD quite well. Are you having flashbacks? Are you having nightmares? Is your heart running a mile a minute? Are your emotions feeling all over the place? Are you feeling like a lunatic? Are you avoiding things that remind you of the trauma? There's a, it's, it's easy to demarcate and usually PTSD of the... I hate this word too, but the "simple kind," is fairly traceable to an event, and often that event is noteworthy. There's a before and an after with PTSD. So before this event happened, I felt like this in the world. After this event happened, I felt like this in the world. And there's a sort of a comfortable way of approaching that bit by bit by bit. You know, we desensitize, we explore, and expose the memories, we somatically try to work them through the body. I guess in a way it feels a little clean. It's horrible. It's awful, but complex trauma is not so clean for most of us-- there isn't a "before".
Keith Sutton, Psy.D. (20:11):
Mm-Hmm
Heather MacIntosh, Ph.D. (20:11):
And this is a false story that a lot of trauma researchers, many who are not trauma survivors, put out into the world. Because for most of us, there isn't a "before".
Keith Sutton, Psy.D. (20:26):
Yeah.
Heather MacIntosh, Ph.D. (20:26):
We're not walking around with a sense of ourselves "before bad things happened". And then how that changed after. For many, it's like early, early childhood. And for many, there are those with what would be called a "Type A Trauma," so life threatening, terrifying. Those events are often interspersed with what we would think of as normal life. But normal life in a traumatizing household is anything but normal. But the kid growing up in the house doesn't know that that's not normal. They're like, "Well, this is, this is life. My mother's drunk on the floor. I clean her up, I put her to bed, I get myself out of bed in the morning. I go to school. I don't have any lunch because there's no food in the house." That's normal, but it's not normal.
Heather MacIntosh, Ph.D. (21:33):
So complex trauma is often those big events like a sexual assault or, being physically abused by a parent. Those big events interspersed with a lot of daily events that are just, "I had to go dumpster diving because my siblings didn't have any food." And all of that creates a lack of trust in others, a lack of awareness of like, 'who am I?' a lack of sense of value in yourself: 'Who am I? Why am I, what's it all about?' There's nobody to model emotion regulation. There's no attachment figure who's safe. So maybe we need to do a lot of attachment, sort of tango: 'I go close to you because I need you, but then I run from you because you're terrifying.' So all of this sets up this perfect storm of "I want to be close to people, but I can't trust them." "I want to feel safe in my body, but everything feels wacky and weird and I don't, I don't really know what's real, what's normal."
Heather MacIntosh, Ph.D. (22:41):
And so imagine, you know, getting into a couple relationship, wanting to have kids wanting to do all these things, but no models for-- and I sometimes think it's this hilarious thing of no models for "boring"--you know, we often think about that: "I get up in the morning, I ate my breakfast, I went to work, or I went to school. I did some things. I had some lunch. I did some more things. I went home." That's just like bizarre for most of us. We're like, "what is that all about?"
Keith Sutton, Psy.D. (23:19):
Not survival mode.
Heather MacIntosh, Ph.D. (23:21):
Not survival mode. And it wasn't actually for me until I bought this farm-- I live on a farm with a lot of animals. It's like I didn't have people to model that for me, although my partner is very regulated person. Living on this farm, the animals are very like, "yo, yo, I know it's nine o'clock, It's time!"
Heather MacIntosh, Ph.D. (23:45):
Because they know. They know about, you know, 'the sun's up. I'm hungry.' 'Oh, I'm, I'm just going to go check out that tree that I was chewing on yesterday, because It was kind of yummy.' So they know all about regulation because they just, that's just what they are. They are constantly regulating creatures. But it wasn't until I lived with them and was responsible for making sure they had their breakfast, that I started to be surrounded by a sense of, "oh, okay. These creatures are very regulated. I, I guess I need--" but it's, it's anxiety provoking because when you're used to chaos or used to not eating a certain meal, because staying home is dangerous, or you're used to not connecting with other people after work because that's dangerous. Like, most of the folks who come to see me have these almost like holes in their relational system. The idea that you could turn to a partner when you were upset is just often like, "what??"
Keith Sutton, Psy.D. (24:50):
Yeah. Mind blowing.
Heather MacIntosh, Ph.D. (24:51):
No, no, no, no. That's not how this works.
Keith Sutton, Psy.D. (24:53):
Yeah. Yeah. Well, and, and I think too that, like you're talking about, I think about as like the hypervigilance, you know is there, right? And so when things are going well, it's like, "wait a second, the shoe's going to drop". Or as many folks, you know, it's hard to be happy, that's scary, to even feel at peace or happy or safe because then other shoe's going to drop.
Heather MacIntosh, Ph.D. (25:18):
And there's also this mythology that happy is the goal.
Heather MacIntosh, Ph.D. (25:23):
Because when you're living in sort of trauma land, you look over the fence and you see these imaginary non-traumatized people, not knowing that happy of them are traumatized too, but these imaginary people-- and because you can't connect with them because you're terrified, you think, "well, they're very happy, these people, and so the goal of my life is to be like them." As opposed to actually the goal is to feel quiet and content and balanced in life, to be able to connect with your partner when you need to, and for the mundane to be lovely. Like, the "what are you having for dinner?"
Heather MacIntosh, Ph.D. (26:08):
"Oh yes. Well, actually I was at the neighbors and picked up some corn"-- like, for that to be lovely. And that's what we're working for with our couples because there's often so much conflict and distress that it's all noise. And when we start to bring all of the noise down, and start to reduce the 'AAAaaaah', then there's a bit of a fear there... Now what? There's nothing to fill this space. This space, we know. How do we fill this space?
Keith Sutton, Psy.D. (26:47):
Yeah. Well, and one of the ways I've been conceptualizing complex PTSD is, you know, if the person grew up in prolonged periods of fight or flight, could be as bad as physical sexual abuse, could have been an unpredictable parent or neglect. And just essentially, you know, not feeling like you can just sit back and go along for the ride as a kid that you had to be in, keeping an eye out, making sure everything's okay that you, you were taking care of you because you couldn't just like, kind of abdicate that to your caregiver because it wasn't safe or they weren't predictable or they weren't whatever it might be. And so therefore, the nervous system gets so dysregulated, so triggered.
Keith Sutton, Psy.D. (27:27):
And I want to ask about the mentalization because-- I've been-- it's interesting, it's, it's come up at a few different places in the last few weeks, and I didn't quite know-- and I was kind of like trying to figure out, what's the difference between mentalization, cognitive diffusion, mindfulness and so on? And so I'd love to hear about how you conceptualize mentalization and, and how that plays out in the couples.
Heather MacIntosh, Ph.D. (27:54):
It's a tricky one. When I was first starting to really immerse myself in these EFT sessions to understand what's going on here, all I was really noticing was that everybody was losing each other. I didn't quite understand what was going on, but I could, you know, I could just see and feel that folks couldn't hold each other's needs, perspectives, thoughts, feelings in mind. And even some couples couldn't tolerate at all any difference. So, "if she/he/they feel differently about this thing than I do, one of us has to be wrong."
Heather MacIntosh, Ph.D. (28:41):
There can't be any complexity-- complexity's very dangerous. So when I was first starting to figure this thing out and to really look at it closely, I was reading the work of Peter Fonagy, who's like the mentalizing god. And I had to read every paper about 20 times. because It was so dense. It was like, what is this guy trying to say? But I think if we bring it down to the brass tax, mentalizing is fundamentally, how do I navigate my social world at an embodied level, at a cognitive level, at an emotional level where I can still hold myself in mind, while also being attuned to others. So in a situation like this, we are on zoom, so I can see your face, and I can see your body. So the part of me that's other-oriented in my mentalizing can notice, "well, he looks calm, he looks content, he's affirming, he's nodding his head."
Heather MacIntosh, Ph.D. (29:45):
So my brain is going to take all those signals and tell me a story about that. That "it's okay, he doesn't think you're an idiot" and then I'm going to take that in. Then I'm going to have my own experience of what's going on with me. But when we add trauma to the mix, often there's a kind of a booboo in either the self mentalizing or the other mentalizing. Now most folks have experienced trauma, are very, very good at noticing something's wrong, right?-- that hypervigilance and picking up on little cues and signals that another person is unhappy, worried, something. Where it falls apart is that that then triggers a trauma response instead of a curiosity response. So instead of being like, "oh, gee, I wonder what's going on with Joe today? He looks a little...", it's *sharp breath in*, and then instead of turning to Joe to be curious, we shut down because it's potential danger.
Heather MacIntosh, Ph.D. (30:59):
And the same can happen in ourselves if we notice some anxiety or some fearfulness about something that we can shut down our curiosity mechanisms and stop exploring our own minds, our own bodies. Like, "gee, I wonder what's going on and feel my heart, my heart's racing a little bit, and I, nothing kind of going on, but I wonder whether that is." So mentalizing is kind of a meta. It's kind of an umbrella term for all of the things you said. Mindfulness is a part of it. Empathy is a part of it. Theory of mind is a part of it. It's that social-regulating mechanism of being attuned to what's happening in the 'other' while also being able to be attuned to what's happening in yourself, even being able to tolerate difference. So whether that's a cultural difference, political difference, a you know, "I like Chinese food. You like pizza." Being able to be like, "yeah, that's cool. I don't really like", you know--- it's the pineapple on pizza phenomenon, right? "I don't like the pineapple on the pizza, but I can tolerate that you do." And I'll ask you lots of questions about it because I think it's, you know, a bit wacky, but I can tolerate all of that.
Keith Sutton, Psy.D. (32:33):
Versus being intolerant in meaning that it has some connotation about our dynamic or how that person feels about me or, or some--
Heather MacIntosh, Ph.D. (32:42):
Or that there's something wrong with them, like, super simple. Like when we're mentalizing well, we're curious, we're playful, we're interested, we're interested in what's going on in ourselves, we're interested in what's going on the other, and we can tolerate difference. We can tolerate that we can have lots of cues about what's going on in another person, but we can't ever really know, you know? There's a capacity to tolerate the fact that, we know some things, but we don't know others. When we're not mentalizing, well, when we're struggling to mentalize, our curiosity disappears, we become rigid, we start making assumptions rather than asking questions. "I know." And in couple therapy, you'll hear this a lot when people are triggered into their stuff.
Heather MacIntosh, Ph.D. (33:43):
My favorite is two people sitting next to each other, one is like, genuinely "I'm here, I care, you matter to me" looking all soft and loving. And the other who's so triggered into trauma stuff being like, "I know that they hate me" or "I know that they don't love me", or "I know that--" very, very certain. Meanwhile the partner's sitting next to them going, "but that's not how I'm feeling". And, and as we facilitate that conversation, it's like, 'nope, the walls are up, you may be saying that, but it's not true'. And I know the truth, but how do you know the truth about them? But it's safer to know that truth.
Keith Sutton, Psy.D. (34:23):
Yes.
Heather MacIntosh, Ph.D. (34:23):
And there's all sorts of reasons why that truth makes sense. And it takes a very long time to soften the edges of that truth to allow the sort of subjective experience of 'the other'. Because letting folks in is super scary.
Keith Sutton, Psy.D. (34:45):
Definitely. And I think too, that you mentioned earlier about the shame and the shame being triggered and particularly, you know-- inPete Walker and his 'Complex PTSD: Surviving to Thriving" talks about the toxic shame as the core piece or the you know, with structural dissociation, kind of models and and such--- And I oftentimes find with many of my couples that, especially with the trauma, there's the shame aspect. And there's oftentimes that black or white 'shame and blame' kind of, you know, coin. If if they're saying, "you hurt me", then it either means I'm bad or they're bad. It's their fault bad. And that, particularly the way I conceptualize it too with CPTSD, the sense of self is not developed or trusted so much because the parent, the invalidating environment--
Keith Sutton, Psy.D. (35:42):
So the parent smacks a kid, kid's crying, and said, well, "why are you crying?" And the kid begins to question their own perception of self. And that's where a lot of the codependency kind of like "my sense of self is dependent on how the other person is feeling about in that moment". And I'm curious about any thoughts on that or how that plays in, or if this is something that's taken into account in this model. because I think that is one of the hardest things, especially with the stage two piece of EFT where you're doing the re bonding work and as somebody is getting vulnerable about maybe the hurt that's happened or about the disconnect and so on. And then, you know, like, "I feel like you don't love me"-- that is then blaming, it feels like to the other person of "you're saying I'm doing it wrong", or what, again, we do a lot of work through that. So in stage two, the person's able to hear that, hold that and see. I'm just curious about any of your thoughts on that aspect within the couple dynamic.
Heather MacIntosh, Ph.D. (36:37):
It's huge. It's huge. And in our first study, none of the couples consistently made it past stage one. None of them one kind of dallied. And this is 35-40 sessions. We're not talking about 12 sessions. They kind of dallied around in stage two, one couple, but they didn't stay there. And, and shame is a huge part of that.
Heather MacIntosh, Ph.D. (37:04):
When I was tracking emotion regulation in sessions, what I was noticing was that every time someone got triggered-- didn't matter who-- it was almost as though... If we think of emotion as a complex thing, where we can feel a little anxious, a little worried, but also curious and happy... Like we can feel lots of different things at the same time-- then what was happening was that all complexity was eradicated and only one emotion was kind of allowed in the clubhouse. And 90% of time it was shame that was the only emotion. The other 10% of time it was anger.
Heather MacIntosh, Ph.D. (37:57):
But the capacity to hold complexity and to hold multiple states of emotion at the same time was just eradicated. When the triggers came, "I'm a bad person", "you don't love me", "it's all my fault". And often it would be a partner saying, you know, "I really wish that you wouldn't, you know, mark my calendar as complete before I did the task." Something like the family calendar, it was not a big thing, but it would go straight into, "I'm horrible", "I don't deserve". And two things happen here: one, the partner who's being asked a genuinely important thing can't actually acknowledge it and take responsibility for it. Because shame actually-- as much as it might seem this way-- shame works in opposition to taking responsibility for our actions, because it just squishies everything. And the other thing is the partner who made the request gets lost in the, you know, massiveness of the shame. So it's so important to start with, we do the simple thing, the workbooks that just came out, we have a really big feeling chart in it. And we start with like, "can you feel one feeling?" "can we feel two at the same time?" And we just start with the basics because shame often just like 'Pacman's, everything just eats everything else. We lose. All of, we lose hurt, we lose sadness, we lose grief, we lose all of the things when shame just like eats everything.
Keith Sutton, Psy.D. (39:55):
--takes everything up.
Heather MacIntosh, Ph.D. (39:56):
And it's just so crappy because the shame is not about today, it's not about your partner, it's about whoever Made you feel like you were just not worthy of existing in the world and, you know, eating the food and breathing the air. Someone(s) made us feel like we were all the bad things. So we have to work our way backwards, almost building up capacity to be curious, to be interested, to notice the little cues, before we go straight into the shame hole.
Keith Sutton, Psy.D. (40:51):
Yeah.
Heather MacIntosh, Ph.D. (40:53):
Because it's not a good place for anybody.
Keith Sutton, Psy.D. (40:55):
Yeah. And I'm curious about the you know, the idea of like the emotional flashback. I might do some stage two work with client where you have a really nice kind of connecting session, the person's able to be vulnerable, their partner's there, but then when that's when triggered in a future session, all that's out the window.
Heather MacIntosh, Ph.D. (41:18):
Oh, bye.
Keith Sutton, Psy.D. (41:19):
And just back to that place of not feeling, seen, feeling safe, feeling it going to that protective place. And I'm curious about that aspect in the work of the couples or if there's anything, because I think part, like you're saying that-- and I think that's the hardest part is the, you know, even realizing it's that emotional flashback to then be able to even use any of that regulation or the mentalization all those skills like out the window in those moments.
Heather MacIntosh, Ph.D. (41:53):
Yeah. Many of our couples are really like walking in the door with a lot of curiosity and take on the psychoeducation really like, you know, a buffet. Like, "We need this understanding." "This is so helpful." And starting to identify the ways that trauma, whether it's past, present, or, you know, for, for many of our folks who are Indigenous or Black or Queer or Trans, there's a lot of contemporary trauma going on. And that contemporary trauma is really triggering old trauma, and it just makes it super complex. So when we, when we take on some of the psychoeducation that's cognitive, right? We're scaffolding something. But that thing, that thing that we're trying to work our way through is an embodied state. "I have an embodied sense of myself as no good" or an embodied sense of myself as 'not being able to trust' or whatever the emotional reality might. And so an emotional flashback might be "in this situation, in my couple relationship, every time we get to a point where my partner is asking me for a need to be met, I am immediately brought back to my father asking me for sexual favor, and you know, abusing me." And so those things become twinned.
Heather MacIntosh, Ph.D. (43:28):
And the only way to move through those things is to disentangle them. Like, I like to think about those really nasty brain tumors, the glial ones that just stick onto everything. And so I'm like, okay, let's find all the tendrils of this nasty thing--where does it live? And find all the places that it's living. And yes, we have to start cognitively because if we start in the body, it's just so big and overwhelming, and confusing, and complicated. So we start with, 'okay, this makes sense'. Sexual abuse, partner request for-- ok, makes sense cognitively. Yes. And how long can we hold it? How long can we hold it? How much work do we need to do on those trauma memories, those experiences to put it in its place, to put it on the shelf to say, "Okay, you're there. I know you're there, you're a real story, bad story, but you're a historical story."
Heather MacIntosh, Ph.D. (44:33):
And then how do we have the historical story sitting quietly next to the contemporary story? That just takes all of those little brain thingies and we have to pull them out and look at them and say, "Hey, you are absolutely a real thing. You make sense. You make all the sense in the world, but the thing you're afraid of happening has already happened." So how can we just tuck that guy in? --The partners are a part of this, partners are a part of this. Partners are like coached on how to re-orient a response by being an 'other', a different, okay, I'm going to approach my partner for something that I need, but I'm really aware that this is a trigger for them, so I'm going to approach them and say, "I know that this might feel like a trigger, so let's just take a breath together. It's important to me that we have this conversation. Can you hold my hands? Can you look me in the eye? Let's just be really grounded. This is a thing I need." And then they're working together to keep that emotional, traumatic embodied reality sitting on the shelf where it belongs.
Keith Sutton, Psy.D. (46:02):
Yeah.
Heather MacIntosh, Ph.D. (46:03):
This stuff takes a long time.
Keith Sutton, Psy.D. (46:05):
Yeah. Well I was going to say that it's also gotta be a delicate dance, I imagine. As one of my couples I was working with I was asking, you know, "what happens for you as you're hearing this from your husband?" because She had, he was upset because she had hung up the phone on him and she said, "I feel so sad. I feel so sad that his mom messed him up so badly." Yes. It was like...well, you know, even though that was happening, you know, still anybody might be hurt about that, you know, but yeah. The trauma turns
Heather MacIntosh, Ph.D. (46:34):
Also don't hang up!
Keith Sutton, Psy.D. (46:35):
Yeah, exactly. Like holding all of that all at the same . Anything in the work you were doing or the reviewing of tapes and research around CPTSD/CPTSD couples when both of them have-- as you've been talking about partners kind of coaching and oftentimes it sounds like kind of, if the partner doesn't have complex trauma.
Heather MacIntosh, Ph.D. (46:59):
Well, first thing to say is it almost never happens. I thought it did when I started this research because we foolishly put together a research grant application, all the things based on the assumption that only one person in the couple would've been a trauma survivor. Well, in fact, only one person in the couple had experienced sexual abuse, but 80% of the other partners had experienced some other kind of trauma. So it doesn't actually happen that often that a couple shows up and one has had a really fabulous childhood and never had an experience of a crappy thing and the other is, you know, navigating the train wreck that is having experienced a lot of different difficult things. It happens, but it doesn't happen so often. More often what we see is that one partner might have more childhood stuff and another might have more alive-in-the-world stuff.
Heather MacIntosh, Ph.D. (48:03):
So like adult things or, or maybe experienced bullying or maybe they're dealing with some mental health stuff not related to trauma. But they had a caregiver maybe, you know, one caregiver who was pretty reliable. So when there is a little bit of a imbalance in terms of trauma Often the person with less trauma is more able to scaffold or hold onto, or, you know, help their partner do the training wheels of trying new things that are scary. When there are two trauma survivors, both dealing with lots of stuff, we kind of have to figure out ways to take turns. Okay. So how are you going to support him, her, them in this moment of this new stretchy thing? And it only gets really challenging when the perfect storm is their norm. So like the most traumatizing thing I experienced totally fits with the trigger that you have and vice versa--That's when it gets really complicated. And as we try to untangle that sometimes, sometimes it can feel like we're in that maze. It doesn't have an exit.
Keith Sutton, Psy.D. (49:24):
Yeah.
Heather MacIntosh, Ph.D. (49:25):
It just takes a long, long time.
Keith Sutton, Psy.D. (49:26):
Definitely. well this is great that it sounds amazing the research you're doing and the work you're doing. You mentioned there's a workbook that's come out.
Heather MacIntosh, Ph.D. (49:36):
Yeah. We just, we just published a workbook with Rutledge called "Healing Broken Bonds" and it goes through developmental couple therapy for complex trauma step-by-step arom a client perspective. So it has lots of handouts with educational stuff, journal reflections, lots of activities, exercises, things you can do on your own, things you can do with your partner. I find it's really helpful for my couples I'm working with so that we can be tracking how things are going, but I'm also hearing from people who are farther away, like couldn't come to see me, that have been using it on their own. I've even been hearing from people who are like, "I have not been able to have a relationship because things are just so messed up for me right now, but I'm working through it so that at some point I'll be able to". And so finding it so far it is being received well, the first book was a treatment manual for therapists. Yeah. But I just kept getting emails from people saying, do you have anything for us for the couples? Yeah. So that's where this came from. And we also have a few episodes of a podcast that kind of go with it.
Keith Sutton, Psy.D. (50:53):
Oh, great.
Heather MacIntosh, Ph.D. (50:54):
That walk folks through some of these ideas.
Keith Sutton, Psy.D. (50:58):
Definitely. Wonderful. And I realize the last piece of the question I was wondering-- it sounds like it's a lot of a primer for the couples work in the affect regulation, the mentalization engaging the cognitive, you know, kind of top-down processing to then help them stay in it to do. And is there a particular influence of when it gets into the couple's work, is it an EFT attachment based? Is it more of like a skills based? Is it, what is the influence in the--
Heather MacIntosh, Ph.D. (51:33):
That's a really good question. I would say, so in stage three, that's where we start to really dive deep. And it's primarily an attachment emotion focused type frame. So we're trying to help the couples practice being able to really be tuned into each other to build secure attachment with each other. But I wouldn't say that it's not all the things, you know, some of it is pretty cognitive. Okay, this is a moment when-- if we think about secure enhancing behaviors or earn secure enhancing behaviors-- so think about the four steps in an attachment cycle. So one partner expresses a need, the other partner receives that expression, and then responds. And then the first partner also then has to receive the support. So there's those four steps and it's really helpful for couples to be like, "Oh, step three, that's where we really fall apart" and to practice that over and over again. "Okay. I'm, I'm going to make a bid for support right now and it's going to be something small, something that's not going to, you know, rock our world and then we're going to try it". But what we're trying to do is change something so deeply, not conscious, so deeply in our bones. But if we just sort of say, well, we're not conscious of it, therefore there's not much we can do about it, that's no fun.
Keith Sutton, Psy.D. (53:20):
Yes. Yes.
Heather MacIntosh, Ph.D. (53:21):
So we just try these. Okay, let's try a new sequence. Yeah. Let's see what happens if when my favorite one and it's an off-- a frequent one-- where they do great. Step one, "I tell you that I have a need." "Oh, I hear the need, I respond", but then either 'I can't receive the response because somehow it's not right or I didn't even hear it'. Or, you know, there's so many different ways that that third and fourth step can kind of fall apart-- that we have to be conscious of the thing, but trying to be conscious of it does give us access to the part that's not conscious based on how we feel, what we think, what we do. So if my trauma has taught me that I should never tell people how I'm feeling, and I'm trying to practice asking my partner for what I need, I'm first going to go through telling them in kind of vague ways.
Heather MacIntosh, Ph.D. (54:34):
And feeling hurt that they don't pick up on it, or "I'm going to be crying in my bedroom with the door closed" and feeling hurt that they're not picking up on it. So I'm going to notice when I'm trying to set a clear specific request, 'oh it's not clear,' 'it's not specific'-- the partner couldn't possibly know what I need-- that it's only through that process that I become aware of all of the anxiety, all of the fear, all of the dread, all of the embodied yuckiness of what it means to ask for something specifically and clearly.
Keith Sutton, Psy.D. (55:15):
Well, this has been wonderful. You're doing great work and it's really great to hear about it and definitely going to check out that workbook. I've got some couples that, that would definitely benefit from that. Thank you so much for taking the time, I really appreciate it. This is great.
Heather MacIntosh, Ph.D. (55:30):
Oh, it's great to talk to you.
Keith Sutton, Psy.D. (55:31):
Great. Thanks a lot. Take care. Bye-Bye.
Heather MacIntosh, Ph.D. (55:34):
Bye-Bye.
Keith Sutton, Psy.D. (55:35):
Thank you for joining us today. If you'd like to receive continuing education credit for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists and evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults with our licensed experienced therapists, in-person in the Bay Area, or throughout California online, and our employment opportunities, go to SFIAP.com. To learn more about our associateships and psych assistantships in low fee treatment through our nonprofit Bay Area Community Counseling and Family Institute of Berkeley, go to sfbacc.org and family institute of berkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACCs website sf-bacc.org. BACC is a 501(c)3 nonprofit, so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using emotionally focused couples therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and oppositional and Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D.: (01:31)
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. (02:19):
Today I'll be speaking with Dr. Heather McIntosh, who is a clinical psychologist, associate professor and director of the couple and Family Therapy Clinic at McGill University, where she's a recipient of the H. Noel Fieldhouse Award for distinguished teaching.
Keith Sutton, Psy.D. (02:34):
Heather is author of Developmental Couple Therapy for Complex Trauma Manual for Therapists and Healing Broken Bonds, a workbook for couples with complex trauma. She's also the developer and host of Healing Broken Bonds, a podcast featuring couples dealing with the impacts of complex trauma in their relationships. Developmental Couples Therapy for complex trauma is an evidence-based psychoanalytically informed treatment approach developed by Heather for working with couples dealing with the impacts of complex trauma. Heather is the author of over 60 peer reviewed journal articles, book chapters, and treatment manuals. She's in demand as a speaker at international conferences and workshops, as well as a resource for local and national media in the areas of trauma, couple and family relationships and issues, and queer and trans wellbeing. She leads an active funded research program, having been principal researcher on over $500,000 in peer reviewed research grants, an active co-investigator on over $7 million more with other internationally recognized colleagues.
Keith Sutton, Psy.D. (03:35):
Heather's research primarily examines the impact of early life trauma on the process and outcome of couples therapy. In addition, she studies the experiences of two lgbtqia+ trauma survivors and therapy in healing their sexual selves, adapting and integrating models of treatment to ensure accessibility and inclusion of indigenous, racialized and trans graduate student therapists, trainees, and clients. Heather lives and works on land of the Crawford purchase Mohawk territory "purchased for settlement by United Empire loyalists at the end of the American Revolutionary War". Merrim Farm is in eastern Ontario, Canada, where she strives to live with the land and peace and to bring healing through therapy offered in relation with her Icelandic horses, her retired RCMP musical ride Horse, Bri Ojibwe spirit ponies, and a cadre of other creatures who bring joy, hilarity, and love to life. Let's listen to the interview.
Keith Sutton, Psy.D. (04:32):
Well, hi Heather. Welcome. Thanks for joining me.
Heather MacIntosh, Ph.D. (04:34):
Hi. So nice to meet you.
Keith Sutton, Psy.D. (04:37):
Yes. Well, so I'm not even sure exactly how I stumbled upon your work, but I do a lot of work with complex PTSD, also couples work, and I probably was Googling or so on and, and came upon your work, was really interested. I got to listen to a podcast interview that you had done. I'd love to hear more about your, your work and the program that you've developed for working with couples with complex PTSD. And, you know, I'm, I'm always interested in kind of, you know, how people got to what they're doing, kind of the, the, you know, evolution of their ideas that kind of got to developing this approach that, this intervention that you developed.
Heather MacIntosh, Ph.D. (05:16):
It's definitely a long road. It does not happen overnight. So there's been a lot of steps, stages, painful growing pains to get to a place where I think we're feeling pretty solid that what we're offering is helpful, safe, tolerable, useful. Productive.
Keith Sutton, Psy.D. (05:37):
Yeah. Yeah. Definitely. So, yeah, tell me about your pursuit or career or how you got to even putting this together for the com complex PTSD in couples.
Heather MacIntosh, Ph.D. (05:49):
A lot of it is by accident, as often happens. I was doing my doctoral work at Ottawa U in Canada. And I was working on family, families and trauma and parenting and trauma, and happened to take a couple therapy course with Sue Johnson, who was on faculty there, and just found myself really fascinated by the questions of what does trauma do to a person, to a couple, and then how does that affect the therapeutic process? So I sort of shifted my energies and I worked with Sue for a few years. Of course, I'm sure everybody knows Sue is associated with emotionally focused therapy, EFT So at the time, so this would've been 2000-ish, the common belief was that you should not do couple therapy with trauma impacted couples. The sense was, you know, people wouldn't be ready,
Heather MacIntosh, Ph.D. (06:53):
people were too chaotic, there would be too much trauma stuff in the room...This felt very unsatisfying to me. Yeah. you know, people are still in relationships even if we tell them we're not going to provide them with therapy And the idea that sending folks off to individual therapy would somehow magically make them ready for couple therapy or would improve the couple relationship felt wrong. The reality was the couples who were coming to see us, many or most had been in individual therapy and it had been helpful, but when you get the attachment person in the room, it just fundamentally changes everything about what's happening. So you can do all the individual therapy in the world. It may not prepare you for being in a room with a couple. So we did a study on EFT and we worked with childhood sexual abuse survivors and their partners and found some really interesting things.
Heather MacIntosh, Ph.D. (08:03):
Couples did improve in terms of the trauma part of their ways of living in the world, but the couple part didn't improve as much as we would've liked, and the process itself was very challenging. What we were seeing was a lot of, a lot of big emotions, and things feeling really flooded. And the therapy would kind of start and stop and start and stop and start and stop. And a lot of the couples didn't make progress past a certain stage--like the first stage of the therapy because there were so much there was so much stuff happening that they couldn't hold onto.
Keith Sutton, Psy.D. (08:47):
It's hard to hold onto that deescalation phase.
Heather MacIntosh, Ph.D. (08:51):
Exactly. Exactly. Folks would deescalate and then we'd be like, yes. And then, you know, two sessions later, kaboom. The kaboom would often be about something like that you'd think, "Eh, why was that a deal?" It was a deal because it was a deal. Trauma infuses life and experiences and relationships with so many different amplifiers. So I sort of sat on that for a while and wondered, well, what's this all about? And started work at McGill in a couple of family therapy programs. So the couple of family therapy program, Gil. And I thought, well, I guess the only place to start is just absorbing myself. So I went back to about 350 hours of this therapy and listened and watched and listened and watched and transcribed some more and just absorbed myself in it. And started to really identify that some of the things that were making it really hard--both for the couple and for the, the individuals in the couple-- fundamentally there were kind of two big things...
Heather MacIntosh, Ph.D. (10:07):
One was just emotion regulation. Trauma just smacks you when it comes to being able to regulate your emotions, and in individual therapy, it's not such a big deal because you're one-on-one and the therapist can help you regulate and kinda keep the process going. But in couple therapy, there's an added element that we kind of need to regulate to be able to keep the process going. So people would get dysregulated because of-- and we did a study on this looking at what, what was the therapist doing just before the moment of dysregulation? HWhat was happening during, and then what happened after? Great. And so the therapist was doing exactly what they were supposed to be doing, heightening emotion, trying to access attachment needs. They were doing all the things, but what would happen is emotions would get triggered, trauma survivors would get flooded with shame, overwhelmed. But then--so the emotion dysregulation was a big deal.
Heather MacIntosh, Ph.D. (11:11):
But then this other thing called mentalizing, which is like, how do we understand ourselves and others, how do we hold others in mind that would go offline in that moment of being super triggered and then the partners kind of left in the dirt. Maybe the partner was saying, you know, it really hurts me when, and so they're trying to hold this and the partner loses that. So they lose their capacity to regulate themselves, but they also lose the capacity to hold their partner in mind. Yes. And so this made these two factors along with others of course, but it made the therapy really hard. So again, I spent hours and hours and hours and blah, blah, blah, blah, blah as you do really soaking up well, what's getting in the way.
Heather MacIntosh, Ph.D. (12:08):
And the simplest thing came to mind. After years of thinking about this, it was such a simple thing that couple therapy, whether it's emotionally focused therapy or Gottman or cognitive behavioral--all of these therapies work really well! The outcome studies, these are good therapies. Yeah. All of them are based upon an assumption that the people doing the therapies can do the task of the therapy. So if it's EFT, the task of the therapy is to be able to access strong emotions, communicate them, hold your partner in mind, gauge with attachment. With cognitive behavioral, the tasks involve being able to be regulated enough to identify a need, a behavior, a communication style. So in essence, the therapy itself is based upon this assumption that if you can do the task, you will do well in the therapy.
Keith Sutton, Psy.D. (13:21):
Sure.
Heather MacIntosh, Ph.D. (13:22):
And for complex trauma survivors, that was maybe an ask too far. When we come out of families that are filled with 'yuck' and dysfunction and mess-- how do we come-- we don't have those self capacities going into life. We're just trying to stay above water, and the story we tell ourselves is, "I'm going to do it differently. I'm going to find a partner"... We're going to, you know, and we have this belief that somehow we're going to do it differently. And then guess what? We just, there we are and we need help, but it's almost as though those other therapies are just, they're two steps down the road. So, developmental, couple therapy for complex trauma, which is the worst name for therapy ever created...My students hate it... B-C-T-C-T in part because there's too many C's and T's. But the, the model is based on 'let's help folks walk those two steps'.
Heather MacIntosh, Ph.D. (14:29):
So that we're infusing the therapy with how do we learn how to regulate our emotions? How do we learn how to reflect and mentalize what even is attachment? And how can we start to shift that? That person, we're not expecting people to become securely attached after coming through tsunami childhoods. What we're hoping for is with that person, we can learn how to be what we call earned secure. So that person we can have an earned secure attachment with. So the therapy starts with psychoeducation, getting everybody on the same plane, getting everybody in the same place around, "okay, this is what's happening in our relationship". Some of these things are relevant, some of them aren't. And then we move into building those skills. We move into working on self-regulation and then co-regulation. In development, co-regulation comes first. If we have an attuned responsive caregiver, it's the co-regulation that grows into self-regulation. But most of us have not had that. And so we're wandering the world looking to find ways to co-regulate, but we have to do it backwards. So many things, when there's complex trauma, we have to do backwards, top-down instead of bottom-up.
Heather MacIntosh, Ph.D. (16:02):
So we help folks learn about what is emotion regulation from a cognitive perspective. Then, how do we do it from more of an embodied perspective? We do exercises, and breathing, and reflections. And then we bring to the partner, let's learn how to regulate together.
Keith Sutton, Psy.D. (16:26):
Got it.
Heather MacIntosh, Ph.D. (16:27):
Only after we've done all of that and spent a lot of time with this idea of mentalizing and how can we stay curious? What does it look like when we lose that capacity? How can we stay attuned and responsive to our partner? It's only then that we move into, "okay, so now let's look at what has the trauma done to your sexual selves? Your attachment self? How is trauma in infusing itself into the cycle of how you connect and communicate? How is trauma being recycled in your day-to-day life, where are the triggers? What are the thing?" And it's only then that we start to really take all of that apart and it's not an overnight thing. But it is certainly my couples would say that it feels more tolerable and a little safer, a little more contained. It's slower. It can feel frustrating because we're not diving into the big stuff. So we're not going there until we're ready. So that's kind of how it came to be.
Keith Sutton, Psy.D. (17:37):
That's great, yeah. Exactly like you're saying, the trauma aspect, bringing that in into the couple's dynamic does make it very difficult. And particularly too, sometimes the, the way I've thought about, sometimes people can go into individual therapy and they can talk about their trauma and intellectualize and so on and such, and almost distance a bit from it, but then you bring---
Heather MacIntosh, Ph.D. (17:59):
They become good at it.
Keith Sutton, Psy.D. (18:00):
Yeah, and then you bring the couple's therapy them into a session and it triggers all their trauma--attachment trauma-- in there, in that moment, and brings it all out. What maybe was kind of a bit more distanced in an individual therapy and so, having ways to work with that because it can be hard especially if there's the emotional flashbacks and then the person is disconnected, like, you're kind of saying-- and let me ask, so couple pieces... let me start with, how do you conceptualize complex PTSD?
Heather MacIntosh, Ph.D. (18:37):
Oh, me personally, as opposed to the international classic?
Keith Sutton, Psy.D. (18:42):
Yeah. Yeah. I'm always interested. How do you conceptualize it? How do you explain it to a client? Like what do you--
Heather MacIntosh, Ph.D. (18:47):
So I like to think about PTSD as being very much a thing that is...I hate the word symptom. But, you know, you can demarcate PTSD quite well. Are you having flashbacks? Are you having nightmares? Is your heart running a mile a minute? Are your emotions feeling all over the place? Are you feeling like a lunatic? Are you avoiding things that remind you of the trauma? There's a, it's, it's easy to demarcate and usually PTSD of the... I hate this word too, but the "simple kind," is fairly traceable to an event, and often that event is noteworthy. There's a before and an after with PTSD. So before this event happened, I felt like this in the world. After this event happened, I felt like this in the world. And there's a sort of a comfortable way of approaching that bit by bit by bit. You know, we desensitize, we explore, and expose the memories, we somatically try to work them through the body. I guess in a way it feels a little clean. It's horrible. It's awful, but complex trauma is not so clean for most of us-- there isn't a "before".
Keith Sutton, Psy.D. (20:11):
Mm-Hmm
Heather MacIntosh, Ph.D. (20:11):
And this is a false story that a lot of trauma researchers, many who are not trauma survivors, put out into the world. Because for most of us, there isn't a "before".
Keith Sutton, Psy.D. (20:26):
Yeah.
Heather MacIntosh, Ph.D. (20:26):
We're not walking around with a sense of ourselves "before bad things happened". And then how that changed after. For many, it's like early, early childhood. And for many, there are those with what would be called a "Type A Trauma," so life threatening, terrifying. Those events are often interspersed with what we would think of as normal life. But normal life in a traumatizing household is anything but normal. But the kid growing up in the house doesn't know that that's not normal. They're like, "Well, this is, this is life. My mother's drunk on the floor. I clean her up, I put her to bed, I get myself out of bed in the morning. I go to school. I don't have any lunch because there's no food in the house." That's normal, but it's not normal.
Heather MacIntosh, Ph.D. (21:33):
So complex trauma is often those big events like a sexual assault or, being physically abused by a parent. Those big events interspersed with a lot of daily events that are just, "I had to go dumpster diving because my siblings didn't have any food." And all of that creates a lack of trust in others, a lack of awareness of like, 'who am I?' a lack of sense of value in yourself: 'Who am I? Why am I, what's it all about?' There's nobody to model emotion regulation. There's no attachment figure who's safe. So maybe we need to do a lot of attachment, sort of tango: 'I go close to you because I need you, but then I run from you because you're terrifying.' So all of this sets up this perfect storm of "I want to be close to people, but I can't trust them." "I want to feel safe in my body, but everything feels wacky and weird and I don't, I don't really know what's real, what's normal."
Heather MacIntosh, Ph.D. (22:41):
And so imagine, you know, getting into a couple relationship, wanting to have kids wanting to do all these things, but no models for-- and I sometimes think it's this hilarious thing of no models for "boring"--you know, we often think about that: "I get up in the morning, I ate my breakfast, I went to work, or I went to school. I did some things. I had some lunch. I did some more things. I went home." That's just like bizarre for most of us. We're like, "what is that all about?"
Keith Sutton, Psy.D. (23:19):
Not survival mode.
Heather MacIntosh, Ph.D. (23:21):
Not survival mode. And it wasn't actually for me until I bought this farm-- I live on a farm with a lot of animals. It's like I didn't have people to model that for me, although my partner is very regulated person. Living on this farm, the animals are very like, "yo, yo, I know it's nine o'clock, It's time!"
Heather MacIntosh, Ph.D. (23:45):
Because they know. They know about, you know, 'the sun's up. I'm hungry.' 'Oh, I'm, I'm just going to go check out that tree that I was chewing on yesterday, because It was kind of yummy.' So they know all about regulation because they just, that's just what they are. They are constantly regulating creatures. But it wasn't until I lived with them and was responsible for making sure they had their breakfast, that I started to be surrounded by a sense of, "oh, okay. These creatures are very regulated. I, I guess I need--" but it's, it's anxiety provoking because when you're used to chaos or used to not eating a certain meal, because staying home is dangerous, or you're used to not connecting with other people after work because that's dangerous. Like, most of the folks who come to see me have these almost like holes in their relational system. The idea that you could turn to a partner when you were upset is just often like, "what??"
Keith Sutton, Psy.D. (24:50):
Yeah. Mind blowing.
Heather MacIntosh, Ph.D. (24:51):
No, no, no, no. That's not how this works.
Keith Sutton, Psy.D. (24:53):
Yeah. Yeah. Well, and, and I think too that, like you're talking about, I think about as like the hypervigilance, you know is there, right? And so when things are going well, it's like, "wait a second, the shoe's going to drop". Or as many folks, you know, it's hard to be happy, that's scary, to even feel at peace or happy or safe because then other shoe's going to drop.
Heather MacIntosh, Ph.D. (25:18):
And there's also this mythology that happy is the goal.
Heather MacIntosh, Ph.D. (25:23):
Because when you're living in sort of trauma land, you look over the fence and you see these imaginary non-traumatized people, not knowing that happy of them are traumatized too, but these imaginary people-- and because you can't connect with them because you're terrified, you think, "well, they're very happy, these people, and so the goal of my life is to be like them." As opposed to actually the goal is to feel quiet and content and balanced in life, to be able to connect with your partner when you need to, and for the mundane to be lovely. Like, the "what are you having for dinner?"
Heather MacIntosh, Ph.D. (26:08):
"Oh yes. Well, actually I was at the neighbors and picked up some corn"-- like, for that to be lovely. And that's what we're working for with our couples because there's often so much conflict and distress that it's all noise. And when we start to bring all of the noise down, and start to reduce the 'AAAaaaah', then there's a bit of a fear there... Now what? There's nothing to fill this space. This space, we know. How do we fill this space?
Keith Sutton, Psy.D. (26:47):
Yeah. Well, and one of the ways I've been conceptualizing complex PTSD is, you know, if the person grew up in prolonged periods of fight or flight, could be as bad as physical sexual abuse, could have been an unpredictable parent or neglect. And just essentially, you know, not feeling like you can just sit back and go along for the ride as a kid that you had to be in, keeping an eye out, making sure everything's okay that you, you were taking care of you because you couldn't just like, kind of abdicate that to your caregiver because it wasn't safe or they weren't predictable or they weren't whatever it might be. And so therefore, the nervous system gets so dysregulated, so triggered.
Keith Sutton, Psy.D. (27:27):
And I want to ask about the mentalization because-- I've been-- it's interesting, it's, it's come up at a few different places in the last few weeks, and I didn't quite know-- and I was kind of like trying to figure out, what's the difference between mentalization, cognitive diffusion, mindfulness and so on? And so I'd love to hear about how you conceptualize mentalization and, and how that plays out in the couples.
Heather MacIntosh, Ph.D. (27:54):
It's a tricky one. When I was first starting to really immerse myself in these EFT sessions to understand what's going on here, all I was really noticing was that everybody was losing each other. I didn't quite understand what was going on, but I could, you know, I could just see and feel that folks couldn't hold each other's needs, perspectives, thoughts, feelings in mind. And even some couples couldn't tolerate at all any difference. So, "if she/he/they feel differently about this thing than I do, one of us has to be wrong."
Heather MacIntosh, Ph.D. (28:41):
There can't be any complexity-- complexity's very dangerous. So when I was first starting to figure this thing out and to really look at it closely, I was reading the work of Peter Fonagy, who's like the mentalizing god. And I had to read every paper about 20 times. because It was so dense. It was like, what is this guy trying to say? But I think if we bring it down to the brass tax, mentalizing is fundamentally, how do I navigate my social world at an embodied level, at a cognitive level, at an emotional level where I can still hold myself in mind, while also being attuned to others. So in a situation like this, we are on zoom, so I can see your face, and I can see your body. So the part of me that's other-oriented in my mentalizing can notice, "well, he looks calm, he looks content, he's affirming, he's nodding his head."
Heather MacIntosh, Ph.D. (29:45):
So my brain is going to take all those signals and tell me a story about that. That "it's okay, he doesn't think you're an idiot" and then I'm going to take that in. Then I'm going to have my own experience of what's going on with me. But when we add trauma to the mix, often there's a kind of a booboo in either the self mentalizing or the other mentalizing. Now most folks have experienced trauma, are very, very good at noticing something's wrong, right?-- that hypervigilance and picking up on little cues and signals that another person is unhappy, worried, something. Where it falls apart is that that then triggers a trauma response instead of a curiosity response. So instead of being like, "oh, gee, I wonder what's going on with Joe today? He looks a little...", it's *sharp breath in*, and then instead of turning to Joe to be curious, we shut down because it's potential danger.
Heather MacIntosh, Ph.D. (30:59):
And the same can happen in ourselves if we notice some anxiety or some fearfulness about something that we can shut down our curiosity mechanisms and stop exploring our own minds, our own bodies. Like, "gee, I wonder what's going on and feel my heart, my heart's racing a little bit, and I, nothing kind of going on, but I wonder whether that is." So mentalizing is kind of a meta. It's kind of an umbrella term for all of the things you said. Mindfulness is a part of it. Empathy is a part of it. Theory of mind is a part of it. It's that social-regulating mechanism of being attuned to what's happening in the 'other' while also being able to be attuned to what's happening in yourself, even being able to tolerate difference. So whether that's a cultural difference, political difference, a you know, "I like Chinese food. You like pizza." Being able to be like, "yeah, that's cool. I don't really like", you know--- it's the pineapple on pizza phenomenon, right? "I don't like the pineapple on the pizza, but I can tolerate that you do." And I'll ask you lots of questions about it because I think it's, you know, a bit wacky, but I can tolerate all of that.
Keith Sutton, Psy.D. (32:33):
Versus being intolerant in meaning that it has some connotation about our dynamic or how that person feels about me or, or some--
Heather MacIntosh, Ph.D. (32:42):
Or that there's something wrong with them, like, super simple. Like when we're mentalizing well, we're curious, we're playful, we're interested, we're interested in what's going on in ourselves, we're interested in what's going on the other, and we can tolerate difference. We can tolerate that we can have lots of cues about what's going on in another person, but we can't ever really know, you know? There's a capacity to tolerate the fact that, we know some things, but we don't know others. When we're not mentalizing, well, when we're struggling to mentalize, our curiosity disappears, we become rigid, we start making assumptions rather than asking questions. "I know." And in couple therapy, you'll hear this a lot when people are triggered into their stuff.
Heather MacIntosh, Ph.D. (33:43):
My favorite is two people sitting next to each other, one is like, genuinely "I'm here, I care, you matter to me" looking all soft and loving. And the other who's so triggered into trauma stuff being like, "I know that they hate me" or "I know that they don't love me", or "I know that--" very, very certain. Meanwhile the partner's sitting next to them going, "but that's not how I'm feeling". And, and as we facilitate that conversation, it's like, 'nope, the walls are up, you may be saying that, but it's not true'. And I know the truth, but how do you know the truth about them? But it's safer to know that truth.
Keith Sutton, Psy.D. (34:23):
Yes.
Heather MacIntosh, Ph.D. (34:23):
And there's all sorts of reasons why that truth makes sense. And it takes a very long time to soften the edges of that truth to allow the sort of subjective experience of 'the other'. Because letting folks in is super scary.
Keith Sutton, Psy.D. (34:45):
Definitely. And I think too, that you mentioned earlier about the shame and the shame being triggered and particularly, you know-- inPete Walker and his 'Complex PTSD: Surviving to Thriving" talks about the toxic shame as the core piece or the you know, with structural dissociation, kind of models and and such--- And I oftentimes find with many of my couples that, especially with the trauma, there's the shame aspect. And there's oftentimes that black or white 'shame and blame' kind of, you know, coin. If if they're saying, "you hurt me", then it either means I'm bad or they're bad. It's their fault bad. And that, particularly the way I conceptualize it too with CPTSD, the sense of self is not developed or trusted so much because the parent, the invalidating environment--
Keith Sutton, Psy.D. (35:42):
So the parent smacks a kid, kid's crying, and said, well, "why are you crying?" And the kid begins to question their own perception of self. And that's where a lot of the codependency kind of like "my sense of self is dependent on how the other person is feeling about in that moment". And I'm curious about any thoughts on that or how that plays in, or if this is something that's taken into account in this model. because I think that is one of the hardest things, especially with the stage two piece of EFT where you're doing the re bonding work and as somebody is getting vulnerable about maybe the hurt that's happened or about the disconnect and so on. And then, you know, like, "I feel like you don't love me"-- that is then blaming, it feels like to the other person of "you're saying I'm doing it wrong", or what, again, we do a lot of work through that. So in stage two, the person's able to hear that, hold that and see. I'm just curious about any of your thoughts on that aspect within the couple dynamic.
Heather MacIntosh, Ph.D. (36:37):
It's huge. It's huge. And in our first study, none of the couples consistently made it past stage one. None of them one kind of dallied. And this is 35-40 sessions. We're not talking about 12 sessions. They kind of dallied around in stage two, one couple, but they didn't stay there. And, and shame is a huge part of that.
Heather MacIntosh, Ph.D. (37:04):
When I was tracking emotion regulation in sessions, what I was noticing was that every time someone got triggered-- didn't matter who-- it was almost as though... If we think of emotion as a complex thing, where we can feel a little anxious, a little worried, but also curious and happy... Like we can feel lots of different things at the same time-- then what was happening was that all complexity was eradicated and only one emotion was kind of allowed in the clubhouse. And 90% of time it was shame that was the only emotion. The other 10% of time it was anger.
Heather MacIntosh, Ph.D. (37:57):
But the capacity to hold complexity and to hold multiple states of emotion at the same time was just eradicated. When the triggers came, "I'm a bad person", "you don't love me", "it's all my fault". And often it would be a partner saying, you know, "I really wish that you wouldn't, you know, mark my calendar as complete before I did the task." Something like the family calendar, it was not a big thing, but it would go straight into, "I'm horrible", "I don't deserve". And two things happen here: one, the partner who's being asked a genuinely important thing can't actually acknowledge it and take responsibility for it. Because shame actually-- as much as it might seem this way-- shame works in opposition to taking responsibility for our actions, because it just squishies everything. And the other thing is the partner who made the request gets lost in the, you know, massiveness of the shame. So it's so important to start with, we do the simple thing, the workbooks that just came out, we have a really big feeling chart in it. And we start with like, "can you feel one feeling?" "can we feel two at the same time?" And we just start with the basics because shame often just like 'Pacman's, everything just eats everything else. We lose. All of, we lose hurt, we lose sadness, we lose grief, we lose all of the things when shame just like eats everything.
Keith Sutton, Psy.D. (39:55):
--takes everything up.
Heather MacIntosh, Ph.D. (39:56):
And it's just so crappy because the shame is not about today, it's not about your partner, it's about whoever Made you feel like you were just not worthy of existing in the world and, you know, eating the food and breathing the air. Someone(s) made us feel like we were all the bad things. So we have to work our way backwards, almost building up capacity to be curious, to be interested, to notice the little cues, before we go straight into the shame hole.
Keith Sutton, Psy.D. (40:51):
Yeah.
Heather MacIntosh, Ph.D. (40:53):
Because it's not a good place for anybody.
Keith Sutton, Psy.D. (40:55):
Yeah. And I'm curious about the you know, the idea of like the emotional flashback. I might do some stage two work with client where you have a really nice kind of connecting session, the person's able to be vulnerable, their partner's there, but then when that's when triggered in a future session, all that's out the window.
Heather MacIntosh, Ph.D. (41:18):
Oh, bye.
Keith Sutton, Psy.D. (41:19):
And just back to that place of not feeling, seen, feeling safe, feeling it going to that protective place. And I'm curious about that aspect in the work of the couples or if there's anything, because I think part, like you're saying that-- and I think that's the hardest part is the, you know, even realizing it's that emotional flashback to then be able to even use any of that regulation or the mentalization all those skills like out the window in those moments.
Heather MacIntosh, Ph.D. (41:53):
Yeah. Many of our couples are really like walking in the door with a lot of curiosity and take on the psychoeducation really like, you know, a buffet. Like, "We need this understanding." "This is so helpful." And starting to identify the ways that trauma, whether it's past, present, or, you know, for, for many of our folks who are Indigenous or Black or Queer or Trans, there's a lot of contemporary trauma going on. And that contemporary trauma is really triggering old trauma, and it just makes it super complex. So when we, when we take on some of the psychoeducation that's cognitive, right? We're scaffolding something. But that thing, that thing that we're trying to work our way through is an embodied state. "I have an embodied sense of myself as no good" or an embodied sense of myself as 'not being able to trust' or whatever the emotional reality might. And so an emotional flashback might be "in this situation, in my couple relationship, every time we get to a point where my partner is asking me for a need to be met, I am immediately brought back to my father asking me for sexual favor, and you know, abusing me." And so those things become twinned.
Heather MacIntosh, Ph.D. (43:28):
And the only way to move through those things is to disentangle them. Like, I like to think about those really nasty brain tumors, the glial ones that just stick onto everything. And so I'm like, okay, let's find all the tendrils of this nasty thing--where does it live? And find all the places that it's living. And yes, we have to start cognitively because if we start in the body, it's just so big and overwhelming, and confusing, and complicated. So we start with, 'okay, this makes sense'. Sexual abuse, partner request for-- ok, makes sense cognitively. Yes. And how long can we hold it? How long can we hold it? How much work do we need to do on those trauma memories, those experiences to put it in its place, to put it on the shelf to say, "Okay, you're there. I know you're there, you're a real story, bad story, but you're a historical story."
Heather MacIntosh, Ph.D. (44:33):
And then how do we have the historical story sitting quietly next to the contemporary story? That just takes all of those little brain thingies and we have to pull them out and look at them and say, "Hey, you are absolutely a real thing. You make sense. You make all the sense in the world, but the thing you're afraid of happening has already happened." So how can we just tuck that guy in? --The partners are a part of this, partners are a part of this. Partners are like coached on how to re-orient a response by being an 'other', a different, okay, I'm going to approach my partner for something that I need, but I'm really aware that this is a trigger for them, so I'm going to approach them and say, "I know that this might feel like a trigger, so let's just take a breath together. It's important to me that we have this conversation. Can you hold my hands? Can you look me in the eye? Let's just be really grounded. This is a thing I need." And then they're working together to keep that emotional, traumatic embodied reality sitting on the shelf where it belongs.
Keith Sutton, Psy.D. (46:02):
Yeah.
Heather MacIntosh, Ph.D. (46:03):
This stuff takes a long time.
Keith Sutton, Psy.D. (46:05):
Yeah. Well I was going to say that it's also gotta be a delicate dance, I imagine. As one of my couples I was working with I was asking, you know, "what happens for you as you're hearing this from your husband?" because She had, he was upset because she had hung up the phone on him and she said, "I feel so sad. I feel so sad that his mom messed him up so badly." Yes. It was like...well, you know, even though that was happening, you know, still anybody might be hurt about that, you know, but yeah. The trauma turns
Heather MacIntosh, Ph.D. (46:34):
Also don't hang up!
Keith Sutton, Psy.D. (46:35):
Yeah, exactly. Like holding all of that all at the same . Anything in the work you were doing or the reviewing of tapes and research around CPTSD/CPTSD couples when both of them have-- as you've been talking about partners kind of coaching and oftentimes it sounds like kind of, if the partner doesn't have complex trauma.
Heather MacIntosh, Ph.D. (46:59):
Well, first thing to say is it almost never happens. I thought it did when I started this research because we foolishly put together a research grant application, all the things based on the assumption that only one person in the couple would've been a trauma survivor. Well, in fact, only one person in the couple had experienced sexual abuse, but 80% of the other partners had experienced some other kind of trauma. So it doesn't actually happen that often that a couple shows up and one has had a really fabulous childhood and never had an experience of a crappy thing and the other is, you know, navigating the train wreck that is having experienced a lot of different difficult things. It happens, but it doesn't happen so often. More often what we see is that one partner might have more childhood stuff and another might have more alive-in-the-world stuff.
Heather MacIntosh, Ph.D. (48:03):
So like adult things or, or maybe experienced bullying or maybe they're dealing with some mental health stuff not related to trauma. But they had a caregiver maybe, you know, one caregiver who was pretty reliable. So when there is a little bit of a imbalance in terms of trauma Often the person with less trauma is more able to scaffold or hold onto, or, you know, help their partner do the training wheels of trying new things that are scary. When there are two trauma survivors, both dealing with lots of stuff, we kind of have to figure out ways to take turns. Okay. So how are you going to support him, her, them in this moment of this new stretchy thing? And it only gets really challenging when the perfect storm is their norm. So like the most traumatizing thing I experienced totally fits with the trigger that you have and vice versa--That's when it gets really complicated. And as we try to untangle that sometimes, sometimes it can feel like we're in that maze. It doesn't have an exit.
Keith Sutton, Psy.D. (49:24):
Yeah.
Heather MacIntosh, Ph.D. (49:25):
It just takes a long, long time.
Keith Sutton, Psy.D. (49:26):
Definitely. well this is great that it sounds amazing the research you're doing and the work you're doing. You mentioned there's a workbook that's come out.
Heather MacIntosh, Ph.D. (49:36):
Yeah. We just, we just published a workbook with Rutledge called "Healing Broken Bonds" and it goes through developmental couple therapy for complex trauma step-by-step arom a client perspective. So it has lots of handouts with educational stuff, journal reflections, lots of activities, exercises, things you can do on your own, things you can do with your partner. I find it's really helpful for my couples I'm working with so that we can be tracking how things are going, but I'm also hearing from people who are farther away, like couldn't come to see me, that have been using it on their own. I've even been hearing from people who are like, "I have not been able to have a relationship because things are just so messed up for me right now, but I'm working through it so that at some point I'll be able to". And so finding it so far it is being received well, the first book was a treatment manual for therapists. Yeah. But I just kept getting emails from people saying, do you have anything for us for the couples? Yeah. So that's where this came from. And we also have a few episodes of a podcast that kind of go with it.
Keith Sutton, Psy.D. (50:53):
Oh, great.
Heather MacIntosh, Ph.D. (50:54):
That walk folks through some of these ideas.
Keith Sutton, Psy.D. (50:58):
Definitely. Wonderful. And I realize the last piece of the question I was wondering-- it sounds like it's a lot of a primer for the couples work in the affect regulation, the mentalization engaging the cognitive, you know, kind of top-down processing to then help them stay in it to do. And is there a particular influence of when it gets into the couple's work, is it an EFT attachment based? Is it more of like a skills based? Is it, what is the influence in the--
Heather MacIntosh, Ph.D. (51:33):
That's a really good question. I would say, so in stage three, that's where we start to really dive deep. And it's primarily an attachment emotion focused type frame. So we're trying to help the couples practice being able to really be tuned into each other to build secure attachment with each other. But I wouldn't say that it's not all the things, you know, some of it is pretty cognitive. Okay, this is a moment when-- if we think about secure enhancing behaviors or earn secure enhancing behaviors-- so think about the four steps in an attachment cycle. So one partner expresses a need, the other partner receives that expression, and then responds. And then the first partner also then has to receive the support. So there's those four steps and it's really helpful for couples to be like, "Oh, step three, that's where we really fall apart" and to practice that over and over again. "Okay. I'm, I'm going to make a bid for support right now and it's going to be something small, something that's not going to, you know, rock our world and then we're going to try it". But what we're trying to do is change something so deeply, not conscious, so deeply in our bones. But if we just sort of say, well, we're not conscious of it, therefore there's not much we can do about it, that's no fun.
Keith Sutton, Psy.D. (53:20):
Yes. Yes.
Heather MacIntosh, Ph.D. (53:21):
So we just try these. Okay, let's try a new sequence. Yeah. Let's see what happens if when my favorite one and it's an off-- a frequent one-- where they do great. Step one, "I tell you that I have a need." "Oh, I hear the need, I respond", but then either 'I can't receive the response because somehow it's not right or I didn't even hear it'. Or, you know, there's so many different ways that that third and fourth step can kind of fall apart-- that we have to be conscious of the thing, but trying to be conscious of it does give us access to the part that's not conscious based on how we feel, what we think, what we do. So if my trauma has taught me that I should never tell people how I'm feeling, and I'm trying to practice asking my partner for what I need, I'm first going to go through telling them in kind of vague ways.
Heather MacIntosh, Ph.D. (54:34):
And feeling hurt that they don't pick up on it, or "I'm going to be crying in my bedroom with the door closed" and feeling hurt that they're not picking up on it. So I'm going to notice when I'm trying to set a clear specific request, 'oh it's not clear,' 'it's not specific'-- the partner couldn't possibly know what I need-- that it's only through that process that I become aware of all of the anxiety, all of the fear, all of the dread, all of the embodied yuckiness of what it means to ask for something specifically and clearly.
Keith Sutton, Psy.D. (55:15):
Well, this has been wonderful. You're doing great work and it's really great to hear about it and definitely going to check out that workbook. I've got some couples that, that would definitely benefit from that. Thank you so much for taking the time, I really appreciate it. This is great.
Heather MacIntosh, Ph.D. (55:30):
Oh, it's great to talk to you.
Keith Sutton, Psy.D. (55:31):
Great. Thanks a lot. Take care. Bye-Bye.
Heather MacIntosh, Ph.D. (55:34):
Bye-Bye.
Keith Sutton, Psy.D. (55:35):
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