17. Therapy-Adapting for Mismatch - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Born that Way, Temperamental Challenges in Relationships and Therapy
Chapter 17: THERAPY –ADAPTING FOR MISMATCH
by Ronald Mah





Anxiety occurs in the brain, with behavior, and affects subjective interpretation of experiences.  It is not clear if M.R.I. scans interpreted as the brain showing anxiety is the same as the individual actually experiencing anxiety.  Self-reports may be inaccurate.  Some research subjects report their emotional states differently during testing versus later reports.  High-reactive temperament individuals tend to be hyper-sensitive to their bodily sensations, but may not have accurate insight since objective brain state and subjective experience of anxiety does not always match.  The subjective experience may differ from person to person.  Although high reactive individuals self-describe greater awareness of emotional states, other individuals with equally large amygdala signals depending on their experiences of nurturing and support may report little similar awareness.  Ambiguous physiological sensations may have been identified and thus, experienced as anxiety.  One person may describe a high brain arousal state as tense or anxious, while another may describe and experience it positively as being charged or alert (Henig, 2009).  "Nor does every brain state spark the same behavior: some might repress the bad feelings and act normally; others might withdraw.  But while the behavior and the subjective experience associated with an emotion like anxiety might be in a person's conscious control, physiology usually is not.  This is what Kagan calls 'the long shadow of temperament.'  The oldest high-reactive subjects in Kagan's and Fox's studies, like Baby 19, are in their 20s now, and for many of them, no matter how much they manage to avoid looking anxious to an outsider, fears still rattle in their skulls at 3 o'clock in the morning.  They remain anxious just below the surface, their subconscious brains still twitchy, still hypervigilant, still unable to shift attention away from perceived threats that aren't really there" (Henig, 2009).

Among brain, behavior, and experience, behavior intervention may be the most productive approach.  Two-thirds of individuals with a high-reactive temperament function relatively well.  Examination of why the two-thirds do well in addition to the one-third do poorly points to many environment influences.  For example, Kagan found that birth order seemed relevant.  Behaviorally inhibited children were much more likely to be younger siblings.  Two-thirds had older siblings compared to only one-third of uninhibited children who had older siblings.  Kagan hypothesized that older siblings' ill treatment of younger siblings created chronic stress, amplifying any negative biological predispositions.  Aliya was similar to Baby 19 temperamentally at birth.  She was a younger child and had an older brother who not only could be mean to her, but also temperamentally was similar to Charlie.  Her older brother created a fair amount of family chaos and drew the emotional and practical attention of the family to him.  As a result, the family system did not give Aliya the support she needed as a sensitive emotionally reactive child.  The unpredictability of the household exacerbated her anxiety throughout her childhood.  Samuel and his temperament would have been a better, although not necessarily effective match for her difficult family experience.  

Another study found high-reactive babies who went to day care when young were significantly less fearful at age 4 than those who stayed home with mothers (Henig, 2009).  This finding can suggest that babies' separation from their mothers where in day care they experienced supportive nurturing helped build babies' resiliency and confidence.  The therapist should explore family-of-origin experiences for early influences on stress issues and attachment style that may be relevant to the current relationship issues.  A combination of addressing temperamental vulnerability and psychodynamic processing of familial stress or trauma may be useful to address and explain couple's interactions.  A partner may be inadvertently triggering old stress responses in the other.  Sometimes, Samuel did this to Aliya with his assertive high-energy temperament when Aliya was already triggered by Charlie's behavior.  The trigger may be behavior from the partner's temperamental style as well as from culture, family-of-origin, and other dynamics.  Working with the couple could have Samuel trying to slightly mute or adjust his behavior, while helping Aliya distinguish her impotence as a child from her power and control as an adult in their current household.

Individuals and children with adverse temperamental dispositions combined with any additional challenging characteristics can have great difficulty managing the challenges of academic/work and social development.  Learning deficits or learning disabilities increase the challenge and exacerbate the mismatch.  Both Charlie and Samuel have the three defining characteristics of ADHD: hyperactivity, impulsiveness, and distractibility.  In temperament parlance the comparable traits are high activity, high approach, and high distractibility.  Charlie has the ADHD diagnosis.  Samuel was considered for it when he was in school.  However, he avoided the ADHD label because his high adaptability allowed him to problem-solve his other temperamental challenges to his academic tasks.  Also his high sensory threshold kept him from reactive behavior that would have created discipline and management problems in the classroom.  These traits continue to aid him with Charlie and with Aliya.  However, his ADHD type behaviors stressed Aliya.  The therapist worked with him to identify his ADHD behaviors or (from a temperament perspective) his temperamental traits that resulted in behavior annoying to Aliya.  Until Aliya understood that the behavior came from ADHD or temperament, she thought Samuel was disregarding how it affected her.  

The goal of therapy was not to change Samuel or anyone else, but to minimize potential negative consequences of their temperament.  The therapist helped Samuel and Aliya develop more productive behaviors through self and mutual monitoring and self and mutual regulation to moderate any problematic traits.  Since temperamental traits interact differentially in various situations and demands, learning about the positive and the negative applications of traits becomes important for the couple.  For a couple, the therapist would need to formulate specific interventions or behavior change depending on each situation and the relevant temperamental traits of the partners.  Examination of prior successful or unsuccessful behaviors in childhood, family, and earlier in the relationship can help anticipate preventing and addressing future situations.  Overall, the therapy may need to incorporate all the ways temperament can challenge learning and adjustment in many domains.  Essentially, these recommendations for relationship work or couple's therapy reflect recommendations for managing and intervening with problematic temperament in children from Teglasi et al. (2004, page 16-17).

Individuals that are temperamentally challenged in common social, works, or academic circumstances sometimes cannot self-monitor or self-regulate easily.  They have difficulty shifting their responses to better meet shifting demands.  They have to be guided by aware and knowledgeable others.  People who do not understand or accept temperamental theory will insist that individuals self-monitor and self-regulate.  Everyone becomes frustrated as they fail, and then pathologize the temperamentally challenged person as "bad."  The therapist's main task is to get each individual and the couple to accept temperamental theory as applied to themselves and to each other.  They also need to be aware of the cultural ramifications of support for or resistance against various temperamental traits on their personalities.  Only then, can they work on the compensations to the challenges of their individual temperamental styles and their fit or misfit.  If a relationship includes a high anxiety member, the therapist may find that the other person may have responded from two extremes: to be coddling and deferential or to set strict boundaries and be intolerant of reactivity.  The first approach attempts to protect the anxious person from stressful experiences and worry, while the second approach forces him or her to deal with the anxiety.  In the case of dealing with anxiety, the individual may have been left to his or her own devices or may seek support from others, including another person and the therapist.  

Consideration of research on best supporting high reactive children gives direction to the couple and therapist.  "…one study, by Kagan's graduate student Doreen Arcus in the early 1990s, found that what seemed to be best for high-reactive babies were mothers who set firm limits and did not rush too quickly to comfort them when they cried.  And the other, by Fox's postdoctoral fellow Amie Ashley Hane a decade later, found something slightly different: that the best fit for high-strung babies were sensitive mothers, who met their fearful children on their own terms and interacted with them in a way that was accepting and supportive without being intrusive.  Sometimes, of course, there's a fine line between firm and hardhearted, and a fine line between supportive and intrusive.  This makes it especially tough to turn research findings like Arcus's and Hane's into clear guidance on how best to care for a fretful child" (Henig, 2009).  Some individuals manage to work through their anxieties on their own.  They activate a personal intuitive cognitive behavioral therapy to interrupt the negative thought process.  They focus on the subjective interpretation aspect of the brain-physiology-subjective interpretation triad and successfully identify any brain or physiological experiences logically versus becoming sensationalized by reactive analysis.  

A personal moment for the author on a Saturday morning many years ago at the University of California, Berkeley illustrates this.  Thirty minutes into sitting in a continuing education class, I experienced a bit of mild tachycardia (rapid heartbeat).  "What?"  Immediately, I catastrophized the physiological feelings with the thought, "I'm having a heart attack!"  Anxiety and fear surged through my mind and body.  "What's going on with me?"  My mind raced… I was only 38 years old then… been exercising regularly… was in decent shape… did not drink or do drugs… did have a thing about potato chips, but…  Then I realized that on the way to the seminar not having eaten breakfast, I had bought and eaten a gigantic apple fritter and drank a huge cup of coffee.  I was loaded up with the sugar and caffeine from my "breakfast."  Not a heart attack but a combined sugar and caffeine rush!  With this insight, I was able to shift from fear and anxiety to a bemused- albeit still slightly anxious, experiencing of the physiological sensations.  "Wow!  That's a trip!"

A classic theoretical chicken or the egg question arises.  Is the ability to logically explore emotional reactions for non-catastrophic explanations an instinctive quality that leads to muting potential emotional over-reactivity?  Calm thoughtful choices mitigate potential problems and increase positive outcomes.  Or, does successful outcomes in the face of stress and emotional reactivity lead to experiences and confidence that one will manage and survive challenges?  Raised and supported in stable healthy circumstances by nurturing caregivers, a sense of mastery and security develops to approach stress constructively using learned problem-solving skills.  Conversely, does high emotionally reactive temperament lead to emotional over-reaction that leads to behavioral miscalculations that result in a self-fulfilling negative prophecy?  Or, does a pattern of distressing outcomes from poor nurturing and erratic if not harmful treatment sensitize individuals to become hyper-vigilant, hyper-sensitive, and highly emotionally reactive?  The most likely answer is that there are multiple bi-directional dynamics that combine to create individuals' personality and relationship habits and style.  Emotionally reactive temperament and earlier developmental experiences including attachment deficiencies from poor parental nurturing interact to make someone like Aliya the person she is.  Therapy can address many of these dynamics but it cannot undo the temperament of clients.  

"An important question… is whether, over time, mates can bring about changes in the temperaments of their partners… there is evidence of the stability of personality and temperamental characteristics.  Personality traits have been found to be relatively stable across the life span (Veroff, Reuman, & Feld, 1984) and particularly so beyond the age of 30 (Costa & McCrae, 1994) … intermate influences on one another's personality and temperament characteristics are likely to be negligible" (Blum and Mehrabian, 1999, page 119).  The challenge to therapy and to the individual, couple, or family is how to incorporate individual temperament into the relationship.  Therapy cannot undo the past formative experiences of clients, including those influenced by innate temperament.  The therapist can help the individuals understand their temperament, family and other experiences, and current emotional and behavioral tendencies.  Furthermore, the therapist can help the individual, couple, or couple develop the new emotional processes and behavior choices that can be more productive in the relationship.  The nine traits from the model of Chess and Thomas and the New York Longitudinal Study can be very powerful to use in couples analysis.  The therapist promotes self-awareness and cross awareness of the temperamental makeup of each person and encourages acceptance of the traits as temperamentally defined.  Therapy should directly contest how a person often thinks that the other chooses to manifest negative behavior because he or she doesn't care about or respect the other. That is, such behavior cannot coexist with love or respect.  Accepting the temperamental origins of the traits that virtually compel such behavior helps prevent or preclude the belief of evil motivations behind them.  

Clarisse who had a very "proper" upper-class upbringing felt that her boyfriend was disrespectful of her because the television would often distract him when they were talking.  It hurt her very much.  Upon processing, it was revealed that Pablo had constant attention/distraction issues throughout his academic career.  He had trouble working on projects when there was a lot of visual and auditory stimulation around him.  He worked best when he was alone, in a secluded cubicle, and with no distractions.  His temperamental evaluation found he had high distractibility and a low sensory threshold.  When this was revealed, Clarisse realized it was not about him not caring about her.  He had trouble being distracted no matter who it would have been.  She relaxed, "Pablo is distracted because that is his makeup- not because he doesn't respect what I have to say."  Her understanding and acceptance of Pablo's temperament allowed them to work on behavioral adjustments that were no longer sensationalized by the specter of rejection and abandonment.

In evaluating the temperamental match or mismatch between or among members of the couple or family, each individuals' cultural expectation of appropriate temperament both for him or herself and for another may need to be examined.  A friend, partner, classmate, or colleague may feel disappointed or betrayed because the other person does not fulfill the expectations that are defined culturally.  In addition, cross-cultural values may become an issue when more mainstream or community values become internalized in conflict with the older values of the family, traditional community, or workplace.  For example, a traditional (for example, immigrant) husband may feel betrayed if his wife becomes more "liberated" in a more mainstream American model for a wife.  Various temperamental traits are more or less supported depending on the cultural background of the individual.  As a result, an individual may end up struggling his or her entire life trying to adhere to culturally defined temperamental traits that are not intrinsic to his or her personality.  This would tend to cause tension, anxiety, depression, and low self-esteem.  This underlying set of issues may be what is disrupting the relationship.  Or, the attempts to find and assert a more personally authentic set of temperamental traits may or may not be well received by the partner who has come to expect the inauthentic temperamental traits.

Jung who was raised in an upper-class Chinese immigrant family in Britain that functioned with very high regularity in order to follow both Chinese and British cultural commandants to be precise and orderly.  This was difficult for him because of instincts to be more irregular, spontaneous, and impulsive.  Even more stressful, his family had immigrated to the United States in the late 1950s, just in time for Jonathan and his siblings to be teenagers during the hippie era of the 1960s.  He was able to resist "free love" and a radical departure from his parents' standards even though he attended UC Berkeley during the heyday of college liberal activism.  He got his business degree and got married to a nice conservative woman Nancy and successfully provided for family and children.  As he reached his late forties and early fifties, he decides to indulge himself in the more free-spirited behavior he had always had a desire to do.  He bought a motorcycle, got a tattoo, and his ear pierced.  This was very disturbing to his partner who chose him because he was such a "rock."  Rocks don't get tattoos or ear piercings.  Therapy uncovered not only Jung's attempt to adhere to his parents' expectations, but also how doing so had been so counter-intuitive for him.  His life choices had not matched his innate temperament.  Comparable exploration of Nancy's upbringing and values and her temperament profile helped them also identify what she brought to the relationship.  The therapy then proceeded to renegotiate the relationship foundation with greater ownership of individual personalities.

Therapy may focus in part on addressing the direct effects of temperament.  Teglasi et al. present suggestions for children that are adaptable to adults, couples, and families.  Individuals can be coached to take preventive measures to minimize one being overwhelmed by intense negative reactivity.  Fostering feelings of safety may facilitate countering anxiety.  This may involve teaching activities and exercises in therapy or behaviors at home.  It may require more intensive work to address problematic insecure attachment styles.  Aliya and Samuel both have early attachment issues that influence their relationship.  Partners and the couple may also benefit from creating opportunities to release stress and energy that can become eruptive and disruptive.  The therapist may coach them to take breaks or time outs and incorporate regular activities into individual, couple, and family scheduling.  Aliya would benefit from time outs when Samuel and Charlie get going.  She may benefit from time outs from them altogether- for example, having a Samuel/Charlie-free-day.  Therapy should emphasize that problematic emotions such as frustration, anger, and anxiety and resultant behavioral expressions will occur and to have plans to address them.  The therapist can help Aliya and Samuel identify and predict the situations that cause conflict between them, and make plans to deal with ahead of time.  Interventions can include removing the stressor, helping an individual calm down, and normalizing feelings, "instituting judicious management techniques that are sensitive to the self-regulatory functions of the behavior… but do not contribute to maladaptive cycles.  For instance, time-out from learning may come as a relief when the work is frustrating" (Teglasi et al., 2004, page 15).

Therapy may focus on addressing the indirect effects of temperament.  With young children, "the focus of intervention is on averting the long-term negative impact on the development of selective attention, minimal information processing, and approach-avoidance" (Teglasi et al., 2004, page 15).  In the couple, many of these long-term consequences have manifested in the personality of individuals, and are presenting challenges to the relationship.  Nevertheless, recommendations for children by Teglasi et al. remain applicable for adult clients.  The couple can foster positive experiences and interpersonal bonds by engaging in activities that bring out the best in both partners.  The therapist should encourage individuals couple to do things that are temperamentally challenging personally or for one or the other in a relationship.  Preparation for being challenged will improve positive experiences and the mastering of compensating skills.  Taking on something difficult is best done incrementally rather than expecting a fundamental flip in temperament.  Teglasi et al. make a recommendation for working with children that is fundamental to working with adult clients.  The therapist can help individuals reduce threatening triggers by helping them "gain insight and resources to anticipate, plan, and cope with temperamental reactivity" (page 15).  The therapist can work with Aliya and Samuel on understanding each individual's temperamental traits and develop resources to address them.  If Samuel understands how his high activity and high approach stress Aliya, he can plan to modulate his energy.  If Aliya understands Samuel's energy is intrinsic to his makeup, she can activate measures to soothe herself rather than fall into resentment.  

The therapist may focus on addressing bi-directional effects of temperament. The individuals in a couple have endured and benefited and suffered from years of bi-direction effects of temperament.  The couple itself and the fact of coming to couple's therapy is a continuation of that process.  The characteristics within each partner interact with the various task demands and conditions of the couple.  A partner's responsiveness to a request or behavior of the other is qualified by his or her ability to access or become engaged.  The partner's ability to connect is jointly influenced by his or her personality and characteristics and the quality of the other and the relationship.  Guidance for healthy relationships and communication cannot be separated from the ability of individuals to select, organize, and integrate knowledge.  Teglasi et al. gives the same qualification with respect to instructional techniques and strategies and children's ability to access instruction (page 16).  The therapist may need to move beyond generic couple's communication training for a couple such as Samuel and Aliya.  Specific avenues are available or unavailable, simple or complex for Samuel to communicate to Aliya and vice versa due to temperamental traits.  Since both of them are distractible, communication between the two individuals and therapy itself should avoid distracting elements that would harm the process.  The therapist can expect Samuel to be willing to try new ideas and behaviors because of his high approach and high adaptability, but may need to be more patient introducing the same to Aliya who has low approach and low adaptability.  As a result, she may be resistant in therapy or in following through at home to suggestions.  In the highly charged dynamics of therapy, Aliya's low sensory threshold may cause her to get overwhelmed dealing with Samuel and interacting with the therapist's contributions.  In contrast, Samuel with his high sensory threshold may be relatively comfortable with pressing on with the complexity of emotions, ideas, and activity of therapy.  The therapist should anticipate that Samuel and Aliya would mutually frustrate each other because of these temperamental differences.  

The therapist may be frustrated in therapy since by role, he or she encourages high approach and high adaptability.  The therapist often offers insight and suggestions, alternative perspectives, and evokes or places things on the therapeutic table emotionally and cognitively.  The therapist's role is to facilitate change.  Individuals, couples, and families present a request for change in their life processes.  The therapist is challenged to consider a multitude of assessment possibilities that lead to a multitude of therapeutic strategies.  Temperamental theory and evaluation of individual and dynamic interactions can be complementary to other theoretical perspectives, or in some cases be the key to diagnosis and successful treatment.  Since the therapist enters into a dyadic relationship with an individual client or creates a triad with the two partners of a couple or joins in a larger group with a family, the therapist's temperamental profile may be a significant influence to successful therapy.  A productive hypothetical temperamental profile for a therapist may be:

High Activity Level + High Approach + High & Low Distractibility
+ High Sensory Threshold + Low Intensity
+ High Persistence + High Adaptability
+ Low Regularity + Positive Mood

High activity level and high sensory threshold may allow the therapist to stay engaged in high energy interactions without being overwhelmed.  Couple or family therapy in particular can require very active therapist participation to deal with a lot to deal with.  High approach would draw the therapist to deal with provocative and sensitive issues that arise in therapy.  A low approach therapist may fail to pursue important but possibly sensational subjects.  High distractibility would also promote noting subtle cues presented by clients in therapy.  In couple's therapy, the therapist may notice during an interaction with one partner, the other partner fidgeting or giving some other non-verbal commentary that may be worth pursuing.  On the other hand, low distractibility may keep the therapist focused on relevant but sensitive issues even as avoidant clients try to distract them.  In general, low intensity may be a positive therapist trait that helps him or her from getting too emotionally activated by intense emotional client presentations.  A high intensity therapist may get so ignited that his or her energy joins an already over-wrought client to take it to a point of despair and subsequent poor behavior choices.  Low regularity would also be useful since clients often cannot maintain set appointments and have to reschedule frequently.  In addition, although the appointment may be regularly set, any given session may be mundane, interesting, challenging, crisis driven, or emotionally joyous, angry, sad, or devastating.  Shifting client energy may frequently disrupt a high regularity therapist.  Since clients often evoke a mutual emotional atmosphere, the therapist may be susceptible to assuming the emotional energy of clients.  Client energy tends to be sad, frustrated, distressed, despairing, empty, upset, angry, or furious, which is why clients come to therapy.  The therapist who has a positive mood offers positive energy and hope to clients who need both.  A positive mood can moreover also deflect negative client moods that can contaminate therapy and the therapist.  Doubtful or distressed clients would probably not find a therapist with a negative mood to be very encouraging at their time of stress and need.  Since mood can be bi-directionally influential, negative therapist mood may deepen pessimistic client moods.  

High adaptability is almost certainly a positive and productive temperament trait for the therapist.  High adaptability would facilitate the high versus low distractibility choice to meet client/therapy needs as described earlier.  Low adaptability would imply that the therapist once frustrated by challenging clients would have difficulty altering therapy for more productive work.  If a cognitive behavioral approach does not work well for clients, the highly adaptive therapist may shift to a communications approach.  If a psychodynamic approach is ineffective, the highly adaptive therapist may shift to a humanistic orientation or narrative therapy or gestalt therapy… or some other approach until therapy becomes effective.  The high persistence therapist with high adaptive traits tends to be the most effective therapist.  Not only is he or she determined to make therapy work, but he or she also can make the adjustments that may be necessary.  A high persistence therapist without high adaptive traits may persist, but unfortunately grind the clients over and over with unproductive techniques and strategies.  A high adaptive therapist without persistence may be willing to shift techniques and strategies too readily.  Sometimes, persistence is appropriate and effective.  Differing theoretical orientations and therapeutic approaches may hold as productive some variations regarding the value of high or low traits.  However, it is still arguable as with all the temperamental traits, the most effective therapist may be the adaptive therapist.  Such a therapist judiciously applies whatever high or low end temperamental tendency and whatever technique or strategy that fits the individuality of the client and matches the needs of therapy.  Among the fundamental premises of using temperamental theory is teaching clients to self-monitor and self-regulate their temperamental strengths and challenges.  Therapy serves as a weekly monitoring and regulation process.  The clients report weekly activities, conflicts, and problems and the therapist helps them understand the dynamics.  Therapy makes suggestions and guidance to individuals to mutually monitor and regulate for temperament and other issues.  Over time and therapy, the therapist should take a gradually decreasing role monitoring and regulating the individual, couple, or family, as the individual, partners, or members develop greater ability to self-monitor and self-regulate their behavior and interactions.  

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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