Working Bottom Up in PACT


by Karen Berry, PhD, PACT faculty, New York, NY
Email:  [email protected]

Bottom-up interventions are the bread and butter of PACT. These interventions can be simple to execute, yet powerful in their effect. For example, the therapist can ask partners to face one another, with the therapeutic intention of using eye gazing to reduce their allostatic load. Compared with habitual long, slow, top-down conversations, bottom-up interventions more readily empower the couple to use their neurological systems to affect change in the relationship.

All clinicians have seen how a couple can become reactive and operated out of conditioned responses from childhood. Their brains can register threat in nano seconds. The autonomic nervous system (ANS) moves at lightning speed in response to facial gestures, dangerous words and phrases, jerky gestures, tone and prosody, as well as general body language. PACT therapists watch moment-to-moment shifts of the ANS, implicit expressions in the face, voice, eyes, and body posture and body language to assess what is happening between partners' two nervous systems. Content takes a backseat to process.

Sam and Margaret have been married for almost 10 years, and their marriage has been sexless for the last 5 years. Margaret is troubled by their lack of sex and wants closeness in their relationship again. Sam bows his head and shamefully admits he has had no interest. Using an enactment of the couple reuniting after a day apart allows me as a PACT therapist to take a closer look at what's actually going on for them.

Sam is in the den with the boys, and Margaret comes in to say a momentary hello, but then launches into questioning him about the whys and hows of his day with the children. As she is standing over him, he is sinking into the couch, disinterested. His guard is clearly up.

I have them reenact this event several times. I ask Margaret to give a sincerely warm hello to her man, who has been at home caring for the kids all day. I begin to notice subtle shifts in both their bodies, which reflects their increased friendliness. Then I ask her to sit alongside Sam after the warm hello and make eye contact while she checks in with him about the day. As they do this, I observe more shifts in both their nervous systems. They are more relaxed and they begin to move closer to each other.

Lastly I ask Margaret to sit on the floor while inquiring about the boys. The result is amazing. Sam shifts dramatically. She looks at me and says, “Do you see what I see?” I nod. Sam’s face is soft and engaged, and he's leaning in warmly toward her. As they continue talking, the warmth becomes sensual and exciting for both of them. This couple have begun to lay the groundwork for increased friendliness and possibilities for play between them.

As PACT therapists, we regard sex as an aspect of play. If partners are unable to play together, it is highly unlikely they will engage sexually. And when the partner who wants sex operates in ways that are perceived as threatening, with little or no self-awareness, her or she is unlikely to attract the other to genuinely say yes to sex.

The use of bottom-up interventions makes PACT a “show me therapy,” rather than a “tell me therapy.” PACT therapists work in real time with couples in the office, reenacting psychobiological scenarios that can make palpable and possible differences at home.

Copyright Karen Berry


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