9

Physiological Considerations
in Systemic Family Therapy
The Role of Internal Systems
in Relational ­Contexts
Angela B. Bradford and Eran Bar‐Kalifa

It was an introductory family science course and one book—The Family Crucible
(Napier & Whitaker, 1978)—that awakened me (A.B.) professionally. Intending to
study psychology, I had mistakenly registered for a family science class to fill a general
education requirement. As I read about Carl Whitaker’s approach, it was as though all
the pieces of a universe I hadn’t known was fragmented fell into place. “This is it!” I
thought. “It’s not about the individual; it’s about the system!” From that point for-
ward, I was an adamant disciple of systems theory.
More than 20 years later, I am struck by my own myopic approach to systemic
thinking and work. While I was busying myself studying and treating family systems,
I almost completely ignored a literally vital system of human functioning—that of the
body. Just as we must view so‐called individual functioning in the context of relation-
ships, so too must we view individual and relational functioning in the context of
human physiology.
The mind–body connection, or the link between human physiology and cognition,
emotion, and behavior, makes it highly relevant to our field. Human physiology refers
to the processes and functions of the body and its parts. It encompasses the interrela-
tion of the body’s nerves, organs, genes, chemicals, and hormones—internal systems
that affect individuals’ interactions with their external systems. To some extent, the
relationship between our internal and external systems is common knowledge. Most
are familiar with the fact that getting insufficient sleep is associated with physiological
processes that result in irritability, which may result in relationship conflict. Thus,
poor sleep has behavioral and physiological consequences (Banks & Dinges, 2007;
Rossa, Smith, Allan, & Sullivan, 2014). Another example is the use of psychotropic
drugs to alter specific elements of human physiology (e.g., SSRIs impact serotonin
levels in the brain), which in turn can have significant impact on behaviors that are
expressed within the families and systems of which the user is a part. For systems

The Handbook of Systemic Family Therapy: Volume 1, First Edition. Edited by Karen S. Wampler,
Richard B Miller, and Ryan B. Seedall.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
206 Angela B. Bradford and Eran Bar‐Kalifa

therapists, an understanding of internal systems as well as external systems is key to

intervening appropriately with clients.
Although many physiological processes are preconscious and therefore beyond our
control, increasing our awareness of their role in family systems gives systemic family
therapists another level from which to understand clients’ experiences and intervene.
Because entire volumes have been dedicated to psychophysiology or the role of physi-
ology in human cognition, emotion, and behavior (Andreassi, 2007; Cacioppo,
Tassinary, & Berntson, 2017), we will not attempt to provide a comprehensive descrip-
tion or analysis of how physiological processes are related to systemic therapy. Instead,
our objective in this chapter is to review the field’s historical understanding of physiol-
ogy, provide a basic overview of the physiological processes most relevant to systemic
family therapy (SFT), highlight the unique role of systemic therapists and therapy in
accessing and utilizing principles of psychophysiology to promote healing, and provide
some initial guidance about physiologically informed interventions for practitioners.

Physiology in Our History

Although physiology’s role in relationships has received increased and substantial

attention only recently, it has resided—sometimes silently—at the core of much SFT
theory and thought. John Bowlby used primate research to help him conceptualize
and theorize that humans require attachment for survival and that our physiology
mediates the process of avoiding or creating safe attachment relationships. (See Seedall
and Sandberg (2020), vol. 1, for further discussion of attachment theory.) Bowlby
described physiological regulation as necessary to a person’s ability to form the
­security he called attachment. That attachment then helps the individual maintain a
regulated physiology (Bowlby, 1973). As a central feature of attachment, physiology
was then theorized and examined as core to the self‐regulatory processes that facilitate
human connection.
As systems theory began to take hold among psychoanalysts and SFT as a field
grew, emphasis was placed on communication patterns and interactional cycles.
Individual physiology became somewhat sidelined, with interpersonal physiological
processes almost completely ignored. Eventually psychotherapists began revisiting the
role of the body and self‐regulation (e.g., Greenberg & Pascual‐Leone, 2006;
Levenson & Gottman, 1983), with particular emphasis on the notion that dysregula-
tion and arousal are problematic in the formation and maintenance of healthy rela-
tionships. Since that time, some interest has grown among clinicians and scholars,
who have largely worked to compile and summarize what we know about the brain
and body and their relevance to the field (e.g., Badenoch, 2008; Fishbane, 2013;
Hanna, 2013). Still, although increased emphasis has been placed on the need to
more fully integrate physiologic concepts into our work (e.g., Atkinson, 2005), most
structured and published interventions are limited to suggesting therapists under-
stand physiological processes and then work to intervene in behavioral (rather than
biobehavioral) ways. Expanding our ability to integrate multiple levels of systems (as
in a biopsychosocial approach) will entail sufficiently considering and addressing indi-
vidual physiology and interpersonal physiological processes, including couple and
family processes, therapist–client processes, and physiologically based interventions.
 Physiological Systems in SFT 207

Psychophysiological Processes

Because self‐regulation is core to attachment and the skills necessary for developing
and maintaining healthy relationships (e.g., effective conflict management), the physi-
ological processes associated with emotional regulation are among the most relevant
to SFT. These are evidenced in such experiences as outbursts of anger or cowering
away from an argument (i.e., “fight or flight”), feeling emotionally connected or “in
sync” with family members, and having a prolonged stress response after negative
interactions. Such experiences are largely mediated by the balancing of the sympa-
thetic and parasympathetic branches of the autonomic nervous system (ANS) and the
functioning of the endocrine system. Additionally, there are instances in which indica-
tors of these physiological systems come into concordance or synchrony between
family members, suggesting that family members impact each other in unconscious
and automatic ways. For instance, securely attached infants and their mothers have
concordant heart rates when reunified after a brief period of separation (Donovan &
Leavitt, 1985), which allows them to reestablish their bonded relationship and facili-
tates further adaptive functioning. Thus, we review here how the ANS and endocrine
system work and their relevance to SFT.

Autonomic nervous system

Perhaps the most common physiological processes under consideration and investiga-
tion in relational research and practice are those involving the heart and brain.
Although physiological researchers since Darwin have known that the ANS is core to
bidirectional heart–brain interaction, we can largely credit Stephen Porges for focus-
ing the field’s attention on the relationship between the ANS and social behavior.
After writing several papers illuminating the fact that the heart and brain work to
facilitate social engagement and attachment, Porges synthesized his work in his influ-
ential polyvagal theory (Porges, 2011).
Polyvagal theory posits that one of the primary functions of the heart–brain con-
nection is to facilitate connection with others. This is done by unconsciously assessing
for and responding to the relative safety (or, in its absence, danger/threat) of a situa-
tion. If a situation is threatening, the body’s response is to engage protective mecha-
nisms that remove it from the threat. This sympathetic nervous system (SNS) response
includes increased heart rate, diverting blood and energy from smaller to larger mus-
cle groups, and hypervigilance. It is often referred to as the fight‐or‐flight response
because it allows an individual to either resist a threatening situation or escape it. In
circumstances devoid of threat, the heart–brain connection regulates self‐soothing via
the parasympathetic nervous system (PNS). As part of the PNS, a vagal brake serves
to inhibit SNS activation by sending signals along the vagus nerve to the heart, lungs,
and digestive track enabling a rest, digest, and connect state. Because the vagus nerve
innervates the face, throat, and ears as well as the heart, PNS regulation results in
increased eye contact, calm vocal timbre, auditory receptivity, and more open body
posture, all of which facilitate social connection. Thus, active engagement of the PNS
is necessary for life‐sustaining, healthy relationships.
Because social connection is a vital need for humans (Holt‐Lunstad, Smith, &
Layton, 2010), assessment of the safety or danger of a situation includes its relational
components. Consider what occurs when one perceives that another dislikes or is
208 Angela B. Bradford and Eran Bar‐Kalifa

angry at him. The SNS responds as to any other threat, and he may experience an
increased heart rate, difficulty making eye contact, or sweating. This physiological
experience accompanies the desire to fight back or escape (i.e., fight or flight), which
moves the individual to engage in behaviors that are designed to protect him from the
relationship (e.g., escalating conflict or withdrawing from further interaction). In
contrast, relational safety cues from a partner (expressed as a result of their PNS func-
tioning, such as in the form of an open posture, eye contact, or a calm vocal tone) help
one feel at ease and active his PNS, facilitating connection between the two. This is
evidence for the assertion made in the polyvagal theory that the role of the PNS in
facilitating connection is not unidirectional. A basic illustration of this process is
shown in Figure 9.1, which demonstrates that behaviors and experiences in relation-
ships serve to inform the heart–brain connection and shape individuals’ responses to
future interactions via conscious and unconscious processes.
Consider a child who grows up in a home with an alcoholic mother who gets angry
and physically violent each night after drinking. With repeated experiences over time

Physiology,
person A

Appraisal, Appraisal,
person A person A

Behavior, Behavior,
person B person A

Appraisal, Appraisal,
person B person B

Physiology,
person B

Figure 9.1 Cycle of physiologic processes and behavior. The dotted line between each per-
son’s behavior does not represent an automatic or unconscious process, but rather a conscious
process that acts as a potential intervention point.
 Physiological Systems in SFT 209

signaling to the child (and his body) that he is not safe, his body begins to have a
physiological reaction to triggers, or reminders, of the violent circumstances (e.g., the
smell of a certain alcoholic beverage, angry shouting). In such instances, the vagal
brake is released, suppressing the PNS and allowing the SNS to become the more
dominant system working to keep the child safe. As a child, he may physically hide
himself in his room or elsewhere. As an adult, without a cognitive appraisal (such as
positive sentiment override) to interrupt his physio‐behavioral response, he may
become fearful when his wife becomes angry and will similarly hide or withdraw. This
withdrawal or avoidance serves to protect; however, it also inhibits the ability to
­connect and maintain a meaningful relationship.
Conversely, there are those whose PNS effectively inhibits premature acceleration
of the SNS. A child with a secure attachment to her parents, who consistently
­experiences relational safety and appropriate repairs after relational ruptures, may, in
adulthood, tolerate a higher level of threat before the vagal brake is released because
her vagus nerve is more adept at maintaining a self‐regulatory state (quantified by
higher vagal tone). Research has demonstrated that those with higher vagal tone (and
therefore a greater propensity to be self‐regulated; see Beauchaine, 2001; Beauchaine,
Gatzke‐Kopp, & Mead, 2007) have higher marital quality or relationship satisfaction
(Helm, Sbarra, & Ferrer, 2014; Smith et al., 2011) and use more positive social
engagement skills (Geisler, Kubiak, Siewert, & Weber, 2013).
Polyvagal theory provides an important lens for understanding how ANS responses
to the relational environment shape human interactions. It also helps us understand
how relational patterns become programmed into the brain and continue to shape
behavior. In clarifying the role of the vagus nerve and its affiliated organs in social
connection and how vagal tone mediates interactions between internal systems and
external systems, polyvagal theory explains how the heart–brain connection influences
areas of the body that enable us to make appraisals about others’ emotional states,
thereby facilitating relationship‐maintaining behaviors. The role of the ANS in assess-
ing for relational safety or threat highlights that human beings are organized in such
a way that connection is a central feature of lived experience. This further underscores
the importance of clinicians recognizing what is happening within themselves and
clients in order to intervene appropriately.
Common clinical measures of ANS functioning are heart rate, pulse oximetry
(measuring oxygen levels), and electrodermal activity (EDA). These, together with
others such as respiratory sinus arrhythmia (RSA) and cardiac impedance, are also
used in couple and family research. Sympathetic activation can be identified by an
increased heart rate, irregular breathing (i.e., drop in oxygen saturation in blood), a
drop in RSA, an increase in EDA, and a drop in cardiac impedance. Parasympathetic
activation is usually accompanied by an increase in RSA, with stable levels (reflecting
baseline) of blood oxygenation, EDA, and heart rate.

Hormones and neurochemicals of the endocrine system

The ANS and affiliated organs are only one part of the psychophysiological system
affecting relational processes, however. Hormones of the endocrine system also medi-
ate social interactions. The nervous and endocrine systems are linked in the brain by
the hypothalamus via the pituitary gland. The hypothalamus maintains homeostasis in
the body by producing and directing the release of certain hormones such as oxytocin
210 Angela B. Bradford and Eran Bar‐Kalifa

and vasopressin. These hormones are stored in and released by the pituitary gland,
which also produces hormones including cortisol. Among their other functions,
­oxytocin, vasopressin, and cortisol facilitate affect and behaviors that either promote
or inhibit social connection. As systemic therapists seek to understand the internal
systems and the processes by which those systems influence social interactions, it is
beneficial to be aware of these hormones and their roles.
Oxytocin is positively correlated with increased trust, trustworthiness, ability to
decode positive facial cues, empathy, increased eye gaze, more positive communication
between couples, and bonding to parents (see Bachner‐Melman & Ebstein, 2014). It
is robustly implicated in the process of falling in love, bonding, and maintaining bonds
through gaze, touch, and affect (see Algoe, Kurtz, & Grewen, 2017; Feldman, 2012;
Szymanska, Schneider, Chateau‐Smith, Nezelof, & Vulliez‐Coady, 2017). Oxytocin
plays a vital role in parent–infant and couple bonding. Higher oxytocin facilitates
mothers’ ability to respond positively to their infants; it is associated with greater
reward‐system activity (i.e. dopamine response) during interactions and longer
episodes of shared social gaze (see Feldman, 2012). Higher oxytocin in fathers is
­associated with greater stimulatory play (e.g., encouraging object exploration and posi-
tive arousal such as moving the child’s limbs), more frequent touch, and higher vagal
tone, indicating greater physiological readiness to engage with their children (see
Feldman, 2012). In couples, oxytocin appears to promote positive perceptions of the
other partner, bonding behaviors, and social receptivity (Algoe, Kurtz, & Grewen,
2017; Feldman, 2012). Thus, oxytocin provides an important biological foundation
for the relationship couples develop with each other and with their young children.
In contrast, emerging evidence suggests vasopressin may be positively associated
with behaviors that impede connection in romantic relationships. There is some indi-
cation that higher levels of vasopressin are associated with aggression, increased stress
in social contexts, and decreased cognitive empathy among men (see Bachner‐Melman
& Ebstein, 2014). Additionally, higher vasopressin levels are associated with nega-
tively biased perceptions of neutral or friendly faces among men, and studies imply
that these associations influence marital satisfaction (see Heinrichs, von Dawans, &
Domes, 2009). However, the research paints more than simply a bleak picture of
vasopressin. There is some evidence that higher vasopressin is associated with more
stimulatory play with infants among mothers and fathers (Apter‐Levi, Zagoory‐
Sharon, & Feldman, 2014). Thus, it appears that vasopressin plays a role in somewhat
excitatory or aroused interactions, which may be developmentally necessary in par-
ent–child interactions, though less beneficial in romantic relationships.
Cortisol has also received significant empirical attention, elucidating its role in rela-
tionship processes. Cortisol is produced as part of the hypothalamic–pituitary–adrenal
(HPA) axis, the body’s central stress response system. Essentially, when an individual
is under stress, the HPA axis releases cortisol. Because the HPA axis is sensitive to the
individual’s social experiences, cortisol studies have been able to identify the effects of
relationship distress on the individual. Research has shown that when partners experi-
ence conflict or marital relationships are distressed, the HPA axis is activated and
cortisol release increases (Burke, Davis, Otte, & Mohr, 2005; Ditzen et al., 2007;
Kiecolt‐Glaser et al., 1997; Saxbe, Repetti, & Nishina, 2008). Low support from a
romantic partner is also associated with a heightened cortisol response (Seeman,
McEwen, Singer, Albert, & Rowe, 1997; Uchino, Cacioppo, & Kiecolt‐Glaser,
1996). Because high or dysregulated cortisol levels are related to serious health issues
 Physiological Systems in SFT 211

including cardiovascular disease and poor immune system functioning, it is important

for SFTs to be aware of how relational distress may manifest in physical ways. Also, as
relationship distress is usually experienced by both partners, it is not surprising that
Saxbe and Repetti (2010) found that spouses’ cortisol patterns are linked over several
days. This association is moderated by marital satisfaction, indicating that co‐regula-
tion of some physiological systems may depend on relational dynamics.

Synchrony/co‐regulation
In understanding the psychophysiological systems that affect social interaction, an
awareness of both the components and the processes is important. Not only are the
ANS and endocrine systems linked, as previously noted, but individuals’ internal
systems affect each other. The synchronization of family members’ physiological
­
markers is an important phenomenon when considering SFT processes. Most research
has focused on mother–infant co‐regulation and has established that heart rhythms
and oxytocin levels synchronize during interactions (Feldman, 2012; Feldman,
Magori‐Cohen, Galili, Singer, & Louzoun, 2011), upregulating in moments of stim-
ulatory or object‐focused play and downregulating in times of soothing, gazing, and
nurturing interaction. These co‐regulatory processes are considered foundational to
the child’s ability to form and maintain relationships into childhood and throughout
life (Feldman, 2007a).
A comprehensive review on physiological linkage between couples (Timmons,
Margolin, & Saxbe, 2015) adeptly highlights when such synchrony may be helpful
versus problematic in romantic relationships. Evidence indicates that co‐activation of
the HPA axis (i.e., stress response) is generally problematic because it is related to
poorer relationship functioning. This is also often true for co‐activation of the SNS,
which can indicate a pattern of negative affect reciprocity or conflict escalation
(Gottman, Coan, Carrere, & Swanson, 1998; Levenson & Gottman, 1983). However,
synchrony in the SNS is a nuanced phenomenon because there is some indication that
co‐regulation is also associated with increased empathy (see Timmons et al., 2015).
Indeed, Sbarra and Hazan (2008) suggest that co‐regulation is an important feature
of adult romantic attachment, and research has found some evidence to suggest that
greater SNS co‐regulation is associated with greater marital satisfaction (Helm, Sbarra,
& Ferrer, 2014). Thus, the relationship between synchrony in SNS and relationship
outcomes is likely linked to the emotional contexts and processes wherein the SNS is
activated.

Therapist–Client Physiologic Synchrony

One phenomenon that has been receiving growing attention in adult individual psy-
chotherapy over the last decade, but has yet to be adequately addressed in SFT litera-
ture, is the process through which therapists’ and clients’ physiology often become
interlocked and synchronized, thus creating a shared system that involves feedback
loops among the interactants’ physiology. Therapy is at its heart an interpersonal
encounter in which therapists and their clients become cognitively and emotionally
involved with each other. Thus, fundamental phenomena that dominate interpersonal
212 Angela B. Bradford and Eran Bar‐Kalifa

processes in general, such as synchrony, are of high relevance to the therapeutic context
(Koole & Tschacher, 2016). Indeed, when involved in an interpersonal interaction,
people tend to involuntarily synchronize their perceptual, affective, physiological, and
behavioral responses with each other (Wheatley, Kang, Parkinson, & Looser, 2012).
Moreover, it has been argued that such multimodal synchrony facilitates effective
and coordinated social interactions, as it allows people to obtain partial access to the
internal states of those they interact with and through this process to get “on the same
page” (Semin & Cacioppo, 2008). Consistent with this idea, synchrony was found to
be associated with trust (Bernieri, 1988), relationship satisfaction (Julien, Brault,
Chartrand, & Bégin, 2000), cooperation (Wiltermuth & Heath, 2009), and altruistic
pro‐social behaviors (Valdesolo & DeSteno, 2011).
Drawing upon such findings, Koole and Tschacher (2016) have recently intro-
duced the interpersonal synchrony model of psychotherapy, which postulates that the
therapeutic alliance is grounded on the synchronization of client’s and therapist’s
behavior and physiology. Specifically, the model suggests that such client–therapist
synchrony allows the dyad to construct mutual understanding and shared emotional
experience, which consequently deepen the client–therapist bond. Support for this
idea can be found, for example, in a study that monitored in‐session clients’ and
therapists’ EDA, an index of the SNS (Marci et al., 2007); in this study, clients from
dyads who exhibited higher EDA synchrony during the session reported that their
therapists were more empathically understanding. Moreover, in moments of high syn-
chrony, both clients and therapists demonstrated more positive behaviors toward each
other (e.g., showed positive regard).
Koole and Tschacher’s (2016) model goes one step further to suggest that client–
therapist synchrony has a central role in improving clients’ regulatory capacities and,
thus, in reducing clients’ psychological distress. Specifically, the model argues that cli-
ents’ experience of having a therapist who is synchronized with their affective and physi-
ological arousal, but at the same time is capable of regulating both parties’ arousal,
keeping it within an optimal arousal zone, provides clients the valuable opportunity to
process their emotional hardship in a safe environment. Over the course of treatment,
such recurrent interpersonal experiences of co‐regulation (Butler, 2011) are internal-
ized, thus ultimately facilitating the development of clients’ own regulatory capacities.
No study to date has explicitly examined the suggested association between client–
therapist synchrony and improvement in clients’ emotional regulation capacities; how-
ever, indirect evidence can be drawn from the mother–infant primary attachment bond
in which the beneficial effects of synchrony on infants’ development are widely docu-
mented (e.g., Davis, Bilms, & Suveg, 2017; Granat, Gadassi, Gilboa‐Schechtman, &
Feldman, 2017; Moore & Calkins, 2004). Specifically, it was found that mother–infant
behavioral and physiological synchrony helps to regulate children’s emotional distress;
furthermore, mother–infant synchrony was found to predict children’s capacity for emo-
tional regulation even in the absence of their mothers (for review see Feldman, 2007b).
Importantly, in all effective SFTs, emotional regulatory processes are key. For exam-
ple, therapists often find themselves working with family members on de‐escalating
maladaptive emotional cycles, reestablishing emotional bonds, and facilitating posi-
tive emotional experiences (Gottman, 2002; Harway, 2005; Johnson & Greenberg,
1985). Such therapeutic tasks are most frequently emotionally and physiologically
engaging for therapists as well. It is assumed that skillful therapists are equipped with
the ability to notice both their own and the family members’ physiological and
 Physiological Systems in SFT 213

e­ motional reactions and to use this information to navigate the therapeutic interac-
tion into a more regulated and constructive one (e.g., helping family members be in
touch with their own as well as with each other’s emotions).
In light of these theoretical assumptions, it is quite surprising that the role of therapists’
emotions and physiology in the therapeutic endeavor is hardly examined. In fact, to our
knowledge, only one research group has directly examined the therapists’ physiology
effects in couple therapy (Seikkula, Karvonen, Kykyri, Kaartinen, & Penttonen, 2015).
Their work elucidates how complex and multifaceted the interpersonal physiological
dynamics that occur in the context of SFT are, as these dynamics involve at least two cli-
ents and sometimes more than one therapist. For example, in one study (Karvonen,
Kykyri, Kaartinen, Penttonen, & Seikkula, 2016), the EDA synchrony between 10 cou-
ples and their therapists at the beginning of therapy was examined; in this study two thera-
pists worked together with each couple, and, thus, the existence and effects of the six
unique dyads’ synchrony could be examined. Interestingly, their results indicated that 85%
of all dyads showed a significant EDA synchrony; however, among all three possible sets
of dyads (therapist–therapist, therapist–client, and client–client), therapist–therapist dyads
displayed the strongest synchrony, whereas client–client dyads displayed the weakest one.
These results trigger intriguing questions, such as the following: (a) Do family
members who become more synchronous over the course of treatment also become
more attuned to each other and thus benefit more from treatment? (b) Should
moments of therapist–client synchrony be equally distributed among the family mem-
bers to facilitate alliance and engagement of all parties? (c) What is the role of thera-
pist–therapist synchrony? Does it model collaborative interactions and dyadic
attunement? These questions, and others, still await an empirical examination; in our
view, answering them can provide valuable insights for SFT therapists into the best
ways to attend, understand, and make constructive use of their own and their clients’
embodied physiological reactions.
One direct implication of the interpersonal synchrony model of psychotherapy is
that SFT therapists should continuously attend to and if needed try to improve the
physiological synchrony with their clients. Notably, there is consistent variability in
therapists’ effectiveness (Baldwin & Imel, 2013), some of which is attributed to thera-
pists’ interpersonal skills (e.g., Anderson, Ogles, Patterson, Lambert, & Vermeersch,
2009). Based on the documented beneficial effects of therapist–client synchrony, it is
quite possible that finding ways to improve such synchrony may improve the ultimate
outcome of therapy. For example, with current technological advancement, it becomes
more and more feasible to use noninvasive monitoring devices. Such monitoring can
be useful in providing therapists with feedback regarding the changing levels of syn-
chrony with their clients throughout the session, as well as in identifying moments of
heightened (dis)connection. Integrated with video recording, this feedback can help
sensitize therapists to the shared embodied experience with their clients and thus
facilitate beneficial verbal and nonverbal communication patterns.

Intervention

Considering the inseparable link between physiology and relationship functioning,

together with the evidence that therapist–client physiological processes are an impor-
tant consideration, it becomes important to identify ways therapists can integrate a
214 Angela B. Bradford and Eran Bar‐Kalifa

physiological perspective into their work. Here, we address three approaches thera-
pists can take: (a) use assessment to learn their clients’ key/relevant physiological
markers so they can create more physiologically informed treatment plans and inter-
vene where necessary; (b) promote awareness and educate clients about physiological
processes; and (c) work to change client physiology using in‐ and out‐of‐session inter-
ventions to promote psychosocial change.

Assessment
Because there are physiologic indicators of poor relationship functioning (e.g., low
vagal tone, heightened cortisol functioning), therapists can benefit from gaining a
clearer picture of their clients’ physiologic profiles and functioning. This is especially
important because there is great variability between people in their physiologic pro-
files (i.e., baseline levels of physiologic functioning), which should be accounted for
in all assessment and intervention. Establishing healthy collaborative care networks
will be beneficial for therapists routinely seeking this kind of information because
primary care physicians can help provide necessary data. When a medical record is
only sparsely notated or little history exists, therapists can recommend or request cli-
ents complete a physical examination that will provide relevant information. For
instance, a therapist working with a high‐conflict couple may be interested in know-
ing more about the biological bases for their escalation. Referring the couple to a
physician who can provide RSA (i.e., an indicator of vagal tone) levels, basic arousal
patterns (e.g., how long before heart rate increases significantly under stress), and
diurnal cortisol patterns for each spouse would provide the therapist practical infor-
mation to use when planning interventions to interrupt the physiologic arousal that
accompanies behavioral escalation. Most of these tests can be conducted in physician’s
offices (e.g., the heart’s stress response) or ordered from qualified labs (e.g., that
perform cortisol assays).
Some therapists may choose to invest in equipment that provides this kind of basic
information for in‐session assessment and use. In fact, many individual and some SFT
therapists are already using this approach successfully. Although those biofeedback
devices and software that provide moment‐to‐moment readings and the possibility of
user‐controlled settings represent more of a significant financial investment (e.g.,
NeXus biofeedback system; www.mindmedia.com) than those devices usually ori-
ented toward clinical work (e.g., HeartMath system; www.heartmath.com), they
allow clinicians to efficiently assess baseline physiologic functioning, providing perti-
nent information for treatment planning. For example, if a client’s baseline skin con-
ductance level (signifying SNS activation and behavioral inhibition) is elevated, this
indicates that the client “at rest” is more aroused or “on edge,” which suggests he/
she may avoid emotional stimuli. The therapist can then incorporate that insight into
his/her approach.
When collaborative care or acquiring a biofeedback device is not feasible, therapists
may also use in‐session techniques to have clients describe their own physiology.
Facilitating interoception—or awareness of the body and its sensations—serves the
dual purpose of identifying what is happening physiologically and beginning physio‐
related intervention. This can be as simple as the therapist asking clients to sit quietly
and identify physical sensations. Gottman recommends having clients find their own
pulse and count beats per minute at baseline as well as after a conflict discussion,
 Physiological Systems in SFT 215

which provides a picture of their physiologic functioning and tendency toward arousal
(Gottman, 1999). For some (such as in the case of play with children), having clients
describe physical experiences through art can be helpful. This is because art expression
is a sensory activity, which taps into the limbic system and right hemisphere, both of
which are areas of the brain associated with intense emotional processing and the
physiology of emotions (Malchiodi, 2012).

Promoting awareness
Promoting client’s awareness of their own physiology is a basic first step in integrating
physiological principles in an SFT context. Often, clients are so unaware of what is
happening internally that they may adamantly deny feeling or being influenced by
internal processes. One example is the husband who denies being angry while he is
red in the face and scowling. Another example may be a wife who denies being upset
while refusing to make eye contact, maintaining a closed posture, and repeatedly pro-
fessing “It doesn’t matter” in response to strong emotions her husband has expressed.
Helping clients own their internal state and the implications it has in their relation-
ships puts physiology on the table as meaningful in therapy.
In SFT, helping members of a family system become aware of each other’s physiol-
ogy is another valuable precursor to change. Parents can learn to recognize, for
instance, that criticism suppresses children’s parasympathetic activity (Skowron et al.,
2011) and can send a child into a defensive “fight‐or‐flight” mode and inhibit logic.
Spouses can recognize receptive vs. closed states in each other and use this informa-
tion to inform their decision about when to bring up a difficult subject. As awareness
increases, family members can also tune into how their own physiology affects their
family members. A wife might learn to recognize that her anger and “fight” physiol-
ogy is perceived as unsafe and activates her husband’s “flight” mode, which under-
mines her ability to engage with him. Increasing awareness of client physiology sets
the stage for other physiologically informed interventions.

Psychoeducation Once clients and therapist have an awareness of what is happening

physiologically for themselves and others in their systems, interpreting their experi-
ence using psychoeducation is helpful. The psychoeducation offered by therapists can
normalize client experiences and help them externalize problematic relational pat-
terns. Touching on the basics that were explained earlier in this chapter is a good place
to start. Recognizing that the body has physiological processes to ensure survival and
that relational danger is interpreted as a threat the same way a tiger would be is core
to understanding how the internal and external systems interact. Giving further expla-
nations of what various physiological states (e.g., “fight or flight,” “rest, digest, con-
nect”) mean in terms of brain functioning can further elucidate common interactions.
Most people recognize the experience of becoming irrational when highly angry or
stressed and of “shutting down” in the face of what feels like an insurmountable
obstacle. Tying in endocrine system functioning and the emotionally positive experi-
ences of connection or the emotional disconnect that comes with stress can also be
helpful and further set the stage for effective intervention.
Psychoeducation is most effective when a system is not in immediate crisis. When
emotions are high, as noted, the brain is not capable of processing information the
216 Angela B. Bradford and Eran Bar‐Kalifa

way it is when the environment feels safe. Once psychoeducation has happened, how-
ever, it can be used in crisis moments to diffuse conflict. Pointing out what is happen-
ing physiologically for a client, and why, validates their experience and promotes a
feeling of safety. For example, when a couple starts yelling at each other in session, the
therapist can step in, slow the process, point out their current “fight‐or‐flight” physi-
ology, and note the relational pattern that is in process. In a parent–child interaction,
helping the child recognize his physiology and how it is manifesting in his behavior
can be calming and informative to both parent and child. Therapists can also provide
psychoeducation about how clients’ biological and experiential differences inform
their physiologic profiles and consequently their psychosocial functioning. For
instance, when a family has one child who is typically calm and another child who is
often reactive, it can be useful to teach parents the potential effects different parenting
behaviors (e.g., shouting, intensity of physical play/contact, gaze) have on each child
(Slagt, Dubas, Deković, & van Aken, 2016). This can serve to destigmatize some
“problematic” child behaviors that occur due to automatic, nonconscious biological
factors. It can also help the parents tailor their approaches to better complement each
child’s temperament.

Intervention to change physiology

Just as using interoceptive techniques provides the clinician with information about
physiological factors that influence relationship functioning, it can be key to clients’
change process. Specifically, therapists can use mindfulness techniques to promote
client self‐awareness of physiologic processes (Siegel, 2011). That awareness can act
as the impetus for behavioral changes to help the client engage in more constructive
relationship processes (e.g., sharing baseline physiological state information with
family members, who are then more informed and enabled to be other‐aware or
empathic).
Considering that some physiologic states are associated with better social connec-
tion and relationship functioning than others (Feldman, 2012; Porges, 2011), it
behooves SFT therapists to promote physiology that is conducive to healthy interac-
tions and relationships. These are interventions that access multiple parts of the brain,
rather than being localized to one, enabling the ANS and endocrine systems to func-
tion more holistically. Such interventions utilize the frontal cortex (associated with
rational decision making) as well as the limbic system (associated with emotional reac-
tivity). There are options for both in‐session and out‐of‐session, therapist‐directed
interventions.

In‐session therapeutic interventions As touched upon in the assessment section,

­therapists can use psychoeducation about physiology to help clients shift their own
physiological states (Siegel, 2011). Simply teaching clients how their bodies work,
how they respond to threat or safety, and what their bodies are doing in moments
of emotional intensity or calm can help normalize processes, facilitate cognitive or
behavioral attempts to calm/self‐soothe, and encourage healthier habits that will
result in more regulated physiology.
In addition to psychoeducation, therapists can use in‐session techniques to help
clients self‐regulate. Techniques range from expensive technological options like
biofeedback to simpler but less researched options like body scans and progressive
 Physiological Systems in SFT 217

muscle relaxation. Biofeedback may be particularly appropriate for clients who

favor objectivity or who struggle with self‐awareness. Biofeedback devices can be
used to improve client awareness of and ability to change muscle tension, respira-
tion patterns, cardiac reactivity, and other physiological factors that influence social
behaviors. The Association for Applied Psychophysiology and Biofeedback, Inc.
(aapb.org), is a good resource and network for those interested in incorporating
biofeedback into their practices. Alternatively, therapists can incorporate body
scans, guided imagery, or progressive muscle relaxation, all of which serve the pur-
pose of regulating physiology (Sheehan, 2012), so that clients are in a better state
to engage with each other. These techniques can be practiced out of session as well
and are easy to learn.
Relational interventions to help clients regulate physiology are particularly appro-
priate for SFT. Therapists may encourage partners to make physical contact during
session (e.g., holding hands) as there is evidence that touch changes physiology and
promotes physiological synchrony between couples (Chatel‐Goldman, Congedo,
Jutten, & Schwartz, 2014). Touch has also been shown to stimulate the release of
oxytocin and endorphins, which are associated with anxiety reduction and increased
calm and trust, making it a potentially powerful intervention when used in therapy
(Marcher, Jarlnaes, Münster, & van Dijke, 2007). Therapist discretion is essential,
however, because touch can be perceived as intrusive when a relationship feels par-
ticularly unsafe and may, therefore, further activate the SNS.
There are additional relationally oriented physiological regulatory interventions
therapists can use in session. These include gratitude expression, which can
increase parasympathetic activity (McCraty, Atkinson, Tiller, Rein, & Watkins,
1995); use of music, which has been shown to increase autonomic activity associ-
ated with immunity (McCraty, Atkins, Rein, & Watkins, 1996) or (when singing
together) synchronize cardiac patterns (Müller & Lindenberger, 2011); and help-
ing family members forgive. Research has shown that simply visualizing granting
forgiveness is associated with a lower physiological stress response than harboring
a grudge (vanOyen Witvliet, Ludwig, & Vander Laan, 2001). In appropriate
instances, therapists can encourage conciliatory behavior (such as offering com-
fort), as this has been associated with lower blood pressure in both spouses—the
person extending forgiveness and the person receiving it (Hannon, Finkel,
Kumashiro, & Rusbult, 2012).
Lastly, considering the emerging literature on therapist–client physiological pro-
cesses, therapists can consider their own effect in therapy. At the most basic level,
therapists can cultivate their own “therapeutic presence” by working on their own
regulation and incorporating a person‐centered approach, which then sends the mes-
sage that clients are safe and allows them to become more regulated and primed for
connection (Geller & Porges, 2014). Additionally, there is a strong tradition of
encouraging mimesis in SFT (e.g., Minuchin, 1974), which has received empirical
support in recent years. Namely, the more therapists and clients engage in synchro-
nized movements, the better the client’s assessment of the relationship and the better
the therapeutic outcomes (Ramseyer & Tschacher, 2011). Because behavioral m ­ imicry
is associated with greater self‐regulation (see Chartrand & Lakin, 2013), therapists
can both engage in mimesis and coordinate activities between clients that would facili-
tate such synchrony for them (e.g., an experiential sculpting activity) (see behavioral
correlation in Figure 9.1).
218 Angela B. Bradford and Eran Bar‐Kalifa

Out‐of‐session interventions SFTs can also use the field’s strong tradition of assigning
homework to facilitate physiological changes. In fact, out‐of‐session work is likely
necessary given the complex interplay of myriad factors influencing how our bodies
function. One of the most influential activities therapists can assign clients is regular
aerobic exercise. Aerobic exercise is consistently associated with decreased self‐
reported anxiety and physiological correlates thereof (Petruzzello, Landers, Hatfield,
Kubitz, & Salazar, 1991) and decreased depression, stress, and negative affect (see
Penedo & Dahn, 2005). Because of the robust relationship between exercise and
improved mental health, it has been recommended that clinicians integrate exercise
interventions into their work with clients (Stathopoulou, Powers, Berry, Smits, &
Otto, 2006).
One of the hypothesized mechanisms by which exercise helps improve psychologi-
cal health is through its regulatory effect on the sleep cycle. With more consistent,
healthier sleep patterns, individuals tend to function better. For instance, research has
found that men who report better sleep efficiency also have less negative interactions
in their marriage the following day. The same study found that greater discrepancy in
bed‐ and wake‐time between husbands and wives was associated with wife reports of
more negative interactions and fewer positive interactions the next day (Hasler &
Troxel, 2010). It is hypothesized that the association between sleep and marital qual-
ity is in part due to a secure relationship’s ability to help individuals be more regulated
and improve HPA functioning (see Troxel, 2010; Troxel, Robles, Hall, & Buysse,
2007). Thus, educating clients about good sleep hygiene and assigning healthy sleep
routines is another way to help clients’ physiology adjust and increase self‐regulation,
thereby facilitating improved relationship functioning.
A growing and popular approach to improving physiological regulation is
through mindfulness practices. Mindfulness, like meditation, is thought to pro-
mote psychophysiological regulation, reducing arousal and reactive responses. This
is accomplished through awareness of the present experience and nonjudgment,
reducing reactivity. Growing evidence links mindfulness with self‐regulation
(Siegel, 2011), greater relationship satisfaction (Barnes, Brown, Krusemark,
Campbell, & Rogge, 2007), and enhancement of non‐distressed relationships
(Carson, Carson, Gil, & Baucom, 2004) and has been suggested as a healthy par-
enting model (Duncan, Coatsworth, & Greenberg, 2009). SFTs can teach mind-
fulness skills and encourage continued use of such techniques outside of session.
Indeed, couples who continue to use mindfulness‐based techniques over time show
better relationship functioning in the long term than those who do not (Carson,
Carson, Gil, & Baucom, 2004).

Other Considerations and Future Directions

The study of psychophysiology in SFT processes is an exciting and intriguing area of

the field. Because the mind–body connection is so clearly relevant to our understand-
ing and work with relationships, it can appear to be a crystal ball that holds a multi-
tude of answers, drawing us as scholars and practitioners in. Although there certainly
are answers to be found in considering how physiology relates to SFT processes, we
encourage some caution in this area.
 Physiological Systems in SFT 219

It is important that we take care not to submit to reductionist explanations of com-

plex internal systems. For instance, research has implicated a specific area of the
brain—the insular cortex, especially the anterior insula—as responsible for visceral
processes associated with emotional experiences (see Critchley & Harrison, 2013). It
may be tempting, therefore, for researchers to hone in on this region of the brain
when trying to understand why a child reacts the way she does to perceived disap-
proval from her parents. Perhaps, however, the child’s emotional response is influ-
enced by a synchronous process with her protective older sibling, in which it would
be prudent to additionally examine the sibling’s physiological/neural response and
other systems known for synchronous responding. Emotional experiencing, like so
many processes, is multifaceted and nuanced and only becomes more so in the con-
text of dyads, triads, and more complex family systems. Although an in‐depth exami-
nation of singular processes can be informative, they should exist in the context of
systemic theory and investigation.
The psychophysiology literature dealing with family systems is usually based on
sound theory, most often polyvagal theory (Porges, 2011), although other estab-
lished human science theories are also integrated or otherwise foundational for such
studies (e.g., attachment theory; Seedall & Wampler, 2012). The use of these theories
notwithstanding, much of the literature still only gives a snapshot of singular physio-
logical processes in the context of small subsystems (e.g., examining RSA in the con-
text of couple interactions; Smith et al., 2011). Because the internal human system
comprises many processes, the interrelation of which affect and are affected by exter-
nal processes and behaviors, such limited examinations and their implications are akin
to describing a complex, dynamic rain forest based on examining a single tree. What
is needed is a more comprehensive investigation of psychophysiological processes and
their association with myriad relational systems. For example, research has found that
EDA, which indicates SNS activation, is higher among anxiously attached spouses
during a conflict discussion when their spouse is more avoidantly attached (Taylor,
Seedall, Robinson, & Bradford, 2018); however, perhaps this SNS response is contin-
gent on the individual’s propensity for a heightened stress response, which would be
evident in his HPA axis functioning. Or, perhaps the SNS response during that con-
flict is different based on whether the couple has a crying infant in the room, which
has been shown to lower the mother’s heart rate (see Hane & Fox, 2016). Further,
whether (or how) these system responses vary in or out of therapy sessions is unknown.
Multifaceted studies are needed to truly understand the interplay of intra‐ and inter-
individual systems.
One reason such studies do not exist in the SFT literature is that they require a lot
of resources, in terms of both financial cost and time. Additionally, this kind of work
is intrusive and demands a lot from research participants. This then raises the ethical
question of whether we are asking too much of research participants who are also
therapy clients. Even with good compensation, asking this much of clients may
amount to compulsion. As a result, the psychophysiology literature related to SFT is
still in its infancy. This is further evident in the fact that the vast majority of studies are
correlational and cross‐sectional in nature. A manageable first step would be to dis-
tribute the burden asked of research participants and use a planned missingness
design, wherein each research participant is randomly assigned to provide a subset of
the overall items used in the study (Little & Rhemtulla, 2013).
220 Angela B. Bradford and Eran Bar‐Kalifa

This would allow for multiple measures of internal and interpersonal functioning
without taxing any one person. Of course, the sample size needed for this would be
higher; for this, we recommend establishing collaborations with like‐minded research-
ers and practitioners so data may be aggregated across sites, thereby facilitating larger
and more diverse datasets.

Conclusion

Just as I (A.B.) was surprised to realize how constricted my view of systemic thinking
and work has been, SFT as a field is awakening to the broader reality that internal
systems shape the external systems we have been studying and vice versa. Our bodies,
how they function, and how they subconsciously interact are integral to relational
processes. As our understanding of these phenomena deepens, we are presented with
more holistic intervention opportunities, including in‐ and out‐of‐session techniques.
Even our physiological roles as therapists are an important consideration, suggesting
that physiologically informed systemic thinking will influence our being as much as
our practice. We encourage researchers and practitioners to attend to physiology as a
pathway toward more effective therapy and greater integration and collaboration with
those in other helping professions.

References

Algoe, S. B., Kurtz, L. E., & Grewen, K. (2017). Oxytocin and social bonds: The role of oxy-
tocin in perceptions of romantic partners’ bonding behavior. Psychological Science, 28(12),
1763–1772.
Anderson, T., Ogles, B. M., Patterson, C. L., Lambert, M. J., & Vermeersch, D. A. (2009).
Therapist effects: Facilitative interpersonal skills as a predictor of therapist success. Journal
of Clinical Psychology, 65(7), 755–768.
Andreassi, J. L. (2007). Psychophysiology: Human behavior and physiological response. Mahwah,
NJ: Lawrence Erlbaum.
Apter‐Levi, Y., Zagoory‐Sharon, O., & Feldman, R. (2014). Oxytocin and vasopressin support
distinct configurations of social synchrony. Brain Research, 1580, 124–132. doi:10.1016/j.
brainres.2013.10.052
Atkinson, B. J. (2005). Emotional intelligence in couples therapy: Advances from neurobiology
and the science of intimate relationships. New York, NY: W.W. Norton & Co, Inc.
Bachner‐Melman, R., & Ebstein, R. P. (2014). The role of oxytocin and vasopressin in emo-
tional and social behaviors. In E. Fliers, M. Korbonits, & J. A. Romijn (Eds.), Clinical
neuroendocrinology (Vol. 124, pp. 53–68). of M.J. Aminoff, F. Boller, & D.F. Swaab
(Eds.), Handbook of Clinical Neurology, 3rd series. Amsterdam, Netherlands: Elsevier B.V.
Badenoch, B. B. (2008). Being a brain‐wise therapist: A practical guide to interpersonal neuro-
biology. New York, NY: W.W. Norton & Co., Inc.
Baldwin, S. A., & Imel, Z. E. (2013). Therapist effects: Findings and methods. Bergin and
Garfield’s Handbook of Psychotherapy and Behavior Change, 6, 258–297.
Banks, S., & Dinges, D. F. (2007). Behavioral and physiological consequences of sleep restric-
tion. Journal of Clinical Sleep Medicine, 3(5), 519–528.
Barnes, S., Brown, K. W., Krusemark, E., Campbell, W. K., & Rogge, R. D. (2007). The role
of mindfulness in romantic relationship satisfaction and responses to relationship stress.
 Physiological Systems in SFT 221

Journal of Marital and Family Therapy, 33(4), 482–500. doi:10.1111/j.1752‐0606.

2007.00033.x
Beauchaine, T. P. (2001). Vagal tone, development, and Gray’s motivational theory: Toward an
integrated model of autonomic nervous system functioning in psychopathology.
Development and Psychopathology, 13(2), 183–214.
Beauchaine, T. P., Gatzke‐Kopp, L., & Mead, H. K. (2007). Polyvagal theory and develop-
mental psychopathology: Emotion dysregulation and conduct problems from preschool to
adolescence. Biological Psychology, 74(2), 174–184. doi:10.1016/j.biopsycho.2005.
08.008
Bernieri, F. J. (1988). Coordinated movement and rapport in teacher‐student interactions.
Journal of Nonverbal Behavior, 12, 120–138.
Bowlby, J. (1973). Attachment and loss: Vol 2. Separation. New York, NY: Basic Books.
Burke, H. M., Davis, M. C., Otte, C., & Mohr, D. (2005). Depression and cortisol responses
to psychological stress: A meta‐analysis. Psychoneuroendocrinology, 30, 846–856.
Butler, E. A. (2011). Temporal interpersonal emotion systems: The “TIES” that form relation-
ships. Personality and Social Psychology Review, 15, 367–393.
Cacioppo, J. T., Tassinary, L. G., & Berntson, G. G. (Eds.) (2017). Handbook of psychophysiol-
ogy (4th ed.). New York, NY: Cambridge University Press.
Carson, J. W., Carson, K. M., Gil, K. M., & Baucom, D. H. (2004). Mindfulness‐based rela-
tionship enhancement. Behavior Therapy, 35(3), 471–494. doi:10.1016/
S0005‐7894(04)80028‐5
Chartrand, T. L., & Lakin, J. L. (2013). The antecedents and consequences of human behav-
ioral mimicry. Annual Review of Psychology, 64(1), 285–308. doi:10.1146/
annurev‐psych‐113011‐143754
Chatel‐Goldman, J., Congedo, M., Jutten, C., & Schwartz, J.‐L. (2014). Touch increases
autonomic coupling between romantic partners. Frontiers in Behavioral Neuroscience, 8,
1–12. doi:10.3389/fnbeh.2014.00095
Critchley, H., & Harrison, N. (2013). Visceral influences on brain and behavior. Neuron,
77(4), 624–638. doi:10.1016/j.neuron.2013.02.008
Davis, M., Bilms, J., & Suveg, C. (2017). In sync and in control: A meta‐analysis of parent–
child positive behavioral synchrony and youth self‐regulation. Family Process, 56(4),
962–980.
Ditzen, B., Neumann, I. D., Doenmann, G., von Dawans, B., Turner, R. A., Ehlert, U., &
Heinrichs, M. (2007). Effects of different kinds of couple interaction on cortisol and heart
rate responses to stress in women. Psychoneuroendocrinology, 32(5), 565–574.
Donovan, W. L., & Leavitt, L. A. (1985). Physiologic assessment of mother‐infant attachment.
Journal of the American Academy of Child & Adolescent Psychiatry, 24, 65–70.
Duncan, L. G., Coatsworth, J. D., & Greenberg, M. T. (2009). A model of mindful parenting:
Implications for parent–child relationships and prevention research. Clinical Child and
Family Psychology Review, 12(3), 255–270. doi:10.1007/s10567‐009‐0046‐3
Feldman, R. (2007a). Parent–infant synchrony: Biological foundations and developmental out-
comes. Current Directions in Psychological Science, 16, 340–345.
Feldman, R. (2007b). Mother‐infant synchrony and the development of moral orientation in
childhood and adolescence: Direct and indirect mechanisms of developmental continuity.
American Journal of Orthopsychiatry, 77(4), 582–597.
Feldman, R. (2012). Oxytocin and social affiliation in humans. Hormones and Behavior, 61(3),
380–391. doi:10.1016/j.yhbeh.2012.01.008
Feldman, R., Magori‐Cohen, R., Galili, G., Singer, M., & Louzoun, Y. (2011). Mother and
infant coordinate heart rhythms through episodes of interaction synchrony. Infant
Behavior and Development, 34(4), 569–577. doi:10.1016/j.infbeh.2011.06.008
Fishbane, M. D. (2013). Loving with the brain in mind: Neurobiology and couple therapy. New
York, NY: W.W. Norton and Company, Inc.
222 Angela B. Bradford and Eran Bar‐Kalifa

Geisler, F. C. M., Kubiak, T., Siewert, K., & Weber, H. (2013). Cardiac vagal tone is associated
with social engagement and self‐regulation. Biological Psychology, 93(2), 279–286.
doi:10.1016/j.biopsycho.2013.02.013
Geller, S. M., & Porges, S. W. (2014). Therapeutic presence: Neurophysiological mechanisms
mediating feeling safe in therapeutic relationships. Journal of Psychotherapy Integration,
24(3), 178–192. doi:10.1037/a0037511
Gottman, J. M. (1999). The Marriage Clinic: A scientifically based marital therapy. New York,
NY: WW. Norton & Company, Inc.
Gottman, J. M. (2002). The mathematics of marriage: Dynamic nonlinear models. Cambridge,
MA: MIT Press.
Gottman, J. M., Coan, J., Carrere, S., & Swanson, C. (1998). Predicting marital happiness and
stability from newlywed interactions. Journal of Marriage and the Family, 60, 5–22.
Granat, A., Gadassi, R., Gilboa‐Schechtman, E., & Feldman, R. (2017). Maternal depression
and anxiety, social synchrony, and infant regulation of negative and positive emotions.
Emotion, 17, 11–27.
Greenberg, L. S., & Pascual‐Leone, A. (2006). Emotion in psychotherapy: A practice‐friendly
research review. Journal of Clinical Psychology, 62(5), 611–630.
Hane, A. A., & Fox, N. A. (2016). Studying the biology of human attachment. In J. Cassidy &
P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications
(3rd ed., pp. 223–241). New York, NY: The Guilford Press.
Hanna, S. M. (2013). The transparent brain in couple and family therapy: Mindful integrations
with neuroscience. New York, NY: Routledge.
Hannon, P. A., Finkel, E. J., Kumashiro, M., & Rusbult, C. E. (2012). The soothing effects of
forgiveness on victims’ and perpetrators’ blood pressure. Personal Relationships, 19(2),
279–289. doi:10.1111/j.1475‐6811.2011.01356.x
Harway, M. (2005). Handbook of couples therapy. New York, NY: Wiley.
Hasler, B. P., & Troxel, W. M. (2010). Couples’ nighttime sleep efficiency and concordance:
Evidence for bidirectional associations with daytime relationship functioning. Psychosomatic
Medicine, 72(8), 794–801. doi:10.1097/PSY.0b013e3181ecd08a
Heinrichs, M., von Dawans, B., & Domes, G. (2009). Oxytocin, vasopressin, and human social
behavior. Frontiers in Neuroendocrinology, 30(4), 548–557. doi:10.1016/j.
yfrne.2009.05.005
Helm, J. L., Sbarra, D. A., & Ferrer, E. (2014). Coregulation of respiratory sinus arrhythmia
in adult romantic partners. Emotion, 14, 522–531. doi:10.1037/a0035960
Holt‐Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk:
A meta‐analytic review. PLoS Medicine, 7(7), e1000316. doi:10.1371/journal.
pmed.1000316
Johnson, S. M., & Greenberg, L. S. (1985). Emotionally focused couples therapy: An outcome
study. Journal of Marital and Family Therapy, 11, 313–317.
Julien, D., Brault, M., Chartrand, É., & Bégin, J. (2000). Immediacy behaviours and syn-
chrony in satisfied and dissatisfied couples. Canadian Journal of Behavioral Science, 32,
84–90.
Karvonen, A., Kykyri, V. L., Kaartinen, J., Penttonen, M., & Seikkula, J. (2016). Sympathetic
nervous system synchrony in couple therapy. Journal of Marital and Family Therapy, 42,
383–395.
Kiecolt‐Glaser, J. K., Glaser, R., Cacioppo, J. T., MacCallum, R. C., Snydersmith, M., Kim, C.,
& Malarkey, W. B. (1997). Marital conflict in older adults: Endocrinological and immuno-
logical correlates. Psychosomatic Medicine, 59(4), 339–349.
Koole, S. L., & Tschacher, W. (2016). Synchrony in psychotherapy: A review and an integrative
framework for the therapeutic alliance. Frontiers in Psychology, 7, 862.
Levenson, R. W., & Gottman, J. M. (1983). Marital interaction: Physiological linkage and
affective exchange. Journal of Personality and Social Psychology, 45, 587–597.
 Physiological Systems in SFT 223

Little, T., & Rhemtulla, M. (2013). Planned missing data designs for developmental research-
ers. Child Developmental Perspectives, 7, 199–204. doi:10.1111/cdep.12043
Malchiodi, C. A. (2012). Art therapy and the brain. In C. A. Malchiodi (Ed.), Handbook of art
therapy (2nd ed., pp. 17–26). New York, NY: The Guilford Press.
Marcher, L., Jarlnaes, E., Münster, K., & van Dijke, R. (2007). The somatics of touch. USA
Body Psychotherapy Journal, 6(2), 29–36.
Marci, C. D., Ham, J., Moran, E., & Orr, S. P. (2007). Physiologic Correlates of Perceived Therapist
Empathy and Social‐Emotional Process During Psychotherapy. The Journal of Nervous and
Mental Disease, 195(2), 103–111. doi:10.1097/01.nmd.0000253731.71025.fc
McCraty, R., Atkins, M., Rein, G., & Watkins, A. D. (1996). Music enhances the effect of posi-
tive emotional states on salivary IgA. Stress Medicine, 12, 167–175.
McCraty, R., Atkinson, M., Tiller, W., Rein, G., & Watkins, A. D. (1995). The effects of emo-
tions on short‐term power spectrum analysis of heart rate variability. American Journal of
Cardiology, 76, 1089–1093.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.
Moore, G. A., & Calkins, S. D. (2004). Infants’ vagal regulation in the still‐face paradigm is
related to dyadic coordination of mother‐infant interaction. Developmental Psychology, 40,
1068–1080.
Müller, V., & Lindenberger, U. (2011). Cardiac and respiratory patterns synchronize between
persons during choir singing. PLoS One, 6(9), e24893. doi:10.1371/journal.pone.0024893
Napier, A. Y., & Whitaker, C. (1978). The family crucible. New York, NY: Harper & Row.
Penedo, F. J., & Dahn, J. R. (2005). Exercise and well‐being: A review of mental and physical
health benefits associated with physical activity. Current Opinion in Psychiatry, 18(2), 189.
Petruzzello, S. J., Landers, D. M., Hatfield, B. D., Kubitz, K. A., & Salazar, W. (1991). A
meta‐analysis on the anxiety‐reducing effects of acute and chronic exercise: Outcomes and
mechanisms. Sports Medicine, 11, 143–182.
Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attach-
ment, communication, and self‐regulation. New York, NY: W.W. Norton & Co.
Ramseyer, F., & Tschacher, W. (2011). Nonverbal synchrony in psychotherapy: Coordinated
body‐movement reflects relationship quality and outcome. Journal of Consulting and
Clinical Psychology, 79, 284–295.
Rossa, K. R., Smith, S. S., Allan, A. C., & Sullivan, K. A. (2014). The effects of sleep restriction
on executive inhibitory control and affect in young adults. Journal of Adolescent Health,
55(2), 287–292. doi:10.1016/j.jadohealth.2013.12.034
Saxbe, D. E., & Repetti, R. L. (2010). For better or worse? Coregulation of couples’ cortisol
levels and mood states. Journal of Personality and Social Psychology, 98(1), 92–103.
doi:10.1037/a0016959
Saxbe, D. E., Repetti, R. L., & Nishina, A. (2008). Marital satisfaction, recovery from work,
and diurnal cortisol among men and women. Health Psychology, 27(1), 15–25.
doi:10.1037/0278‐6133.27.1.15
Sbarra, D. A., & Hazan, C. (2008). Coregulation, dysregulation, self‐regulation: An integra-
tive analysis and empirical agenda for understanding adult attachment, separation, loss,
and recovery. Personality and Social Psychology Review, 12, 141–167.
Seedall, R. B., & Sandberg, J. G. (2020). Attachment and other emotion‐based systemic
approaches. In K. S. Wampler, R. B. Miller, & R. B. Seedall (Eds.), The handbook of systemic
family therapy: The profession of systemic family therapy (1). Hoboken, NJ: Wiley.
Seedall, R. B., & Wampler, K. S. (2012). Emotional congruence within couple interaction: The
role of attachment avoidance. Journal of Family Psychology, 26(6), 948–958. doi:10.1037/
a0030479
Seeman, T. E., McEwen, B. S., Singer, B. H., Albert, M. S., & Rowe, J. W. (1997). Increase in
urinary cortisol excretion and memory declines: MacArthur studies of successful aging.
Journal of Clinical Endocrinology and Metabolism, 82(8), 2458–2465.
224 Angela B. Bradford and Eran Bar‐Kalifa

Seikkula, J., Karvonen, A., Kykyri, V. L., Kaartinen, J., & Penttonen, M. (2015). The embod-
ied attunement of therapists and a couple within dialogical psychotherapy: An introduc-
tion to the relational mind research project. Family Process, 54, 703–715.
Semin, G. R., & Cacioppo, J. T. (2008). Grounding social cognition: Synchronization, coor-
dination, and co‐regulation. In G. R. Semin & E. R. Smith (Eds.), Embodied grounding:
Social, cognitive, affective, and neuroscientific approaches (pp. 119–147). New York, NY:
Cambridge University Press.
Sheehan, J. L. (2012). Relaxation techniques. In L. Damon, J. M. Matthew, J. L. Sheehan, &
L. A. Uebelacker (Eds.), Inpatient psychiatric nursing: Clinical strategies and practical
interventions (pp. 229–333). New York, NY: Springer Publishing Co.
Siegel, D. J. (2011). Mindsight: The new science of personal transformation. New York, NY:
Bantam Books.
Skowron, E. A., Loke, E., Gatzke‐Kopp, L. M., Cipriano‐Essel, E. A., Woehrle, P. L., Van
Epps, J. J., … Ammerman, R. T. (2011). Mapping cardiac physiology and parenting pro-
cesses in maltreating mother‐child dyads. Journal of Family Psychology, 25, 663–674.
doi:10.1037/a0024528
Slagt, M., Dubas, J. S., Deković, M., & van Aken, M. G. (2016). Differences in sensitivity to
parenting depending on child temperament: A meta‐analysis. Psychological Bulletin,
142(10), 1068–1110.
Smith, T. W., Cribbet, M. R., Nealey‐Moore, J. B., Uchino, B. N., Williams, P. G., MacKenzie,
J., & Thayer, J. F. (2011). Matters of the variable heart: Respiratory sinus arrhythmia
response to marital interaction and associations with marital quality. Journal of Personality
and Social Psychology, 100(1), 103–119. doi:10.1037/a0021136
Stathopoulou, G., Powers, M. B., Berry, A. C., Smits, J. A. J., & Otto, M. W. (2006). Exercise
interventions for mental health: A quantitative and qualitative review. Clinical Psychology:
Science and Practice, 13(2), 179–193. doi:10.1111/j.1468‐2850.2006.00021.x
Szymanska, M., Schneider, M., Chateau‐Smith, C., Nezelof, S., & Vulliez‐Coady, L. (2017).
Psychophysiological effects of oxytocin on parent–child interactions: A literature review on
oxytocin and parent–child interactions. Psychiatry and Clinical Neurosciences, 71(10),
690–705.
Taylor, N. C., Seedall, R. B., Robinson, W. D., & Bradford, K. (2018). The systemic interac-
tion of attachment on psychophysiological arousal in couple conflict. Journal of Marital
and Family Therapy, 44, 46–60. doi:10.1111/jmft.12239
Timmons, A. C., Margolin, G., & Saxbe, D. E. (2015). Physiological linkage in couples and its
implications for individual and interpersonal functioning: A literature review. Journal of
Family Psychology, 29(5), 720–731. doi:10.1037/fam0000115
Troxel, W. M. (2010). It’s more than sex: Exploring the dyadic nature of sleep and implications
for health. Psychosomatic Medicine, 72(6), 578–586. doi:10.1097/PSY.0b013e3181de7ff8
Troxel, W. M., Robles, T. F., Hall, M., & Buysse, D. J. (2007). Marital quality and the marital
bed: Examining the covariation between relationship quality and sleep. Sleep Medicine
Reviews, 11(5), 389–404. doi:10.1016/j.smrv.2007.05.002
Uchino, B. N., Cacioppo, J. T., & Kiecolt‐Glaser, J. K. (1996). The relationship between social
support and physiological processes: A review with emphasis on underlying mechanisms
and implications for health. Psychological Bulletin, 119(3), 488–531.
Valdesolo, P., & DeSteno, D. (2011). Synchrony and the social tuning of compassion. Emotion,
11, 262–266.
vanOyen Witvliet, C., Ludwig, T. E., & Vander Laan, K. L. (2001). Granting forgiveness or
Harboring grudges: Implications for emotion, physiology, and health. Psychological Science,
12(2), 117–123.
Wheatley, T., Kang, O., Parkinson, C., & Looser, C. E. (2012). From mind perception to
mental connection: Synchrony as a mechanism for social understanding. Social and
Personality Psychology Compass, 6, 589–606.
Wiltermuth, S. S., & Heath, C. (2009). Synchrony and cooperation. Psychological Science, 20, 1–5.