Building Attachment Bonds in the Wake of Neglect and Abandonment
Through the lens and practice of AEDP, Attachment and Polyvagal Theory
By Karen Pando-Mars
This paper will illustrate the process of building attachment bonds in the context of the transformational journey of one patient by examining segments of four sessions over the course of a two-month period of psychotherapy. As the bond between patient and therapist develops, so develops the patient’s capacity to engage in the healing of her early attachment trauma and to reorganize her relationship with her self. This case study provides a window into the powerful impact of the AEDP therapist stance, which is positive, helpful, and goes beyond mirroring with empathic responsiveness that truly assists patients in getting what is needed to foster a secure sense of self. Polyvagal theory offers a neuroscience perspective to help us understand which neurological circuits get activated during trauma and how therapists can engage with patients to establish the kind of safety and regulation of affective experience that facilitates transformational process.
The breeze at dawn has secrets to tell you.
Don’t go back to sleep.
You must ask for what you really want.
Don’t go back to sleep.People are going back and forth across the doorsill
Where the two worlds touch.
The door is round and open.
Don’t go back to sleep.
The above poem keenly recognizes processes that occurred in the patient I am going to present in this article, for whom getting sleepy at inopportune times became a significant marker heralding this phase of our work together. I will point out occasions in which the AEDP therapist’s stance informed by attachment theory and my use of self as therapist, impact the patient’s developing sense of self. The work progresses through emergent state transformations (Fosha, 2000, 2006, Fosha & Yeung, 2006) that are identified by AEDP’s articulation of the phenomena of the healing journey (Fosha, 2000, 2002, 2004, 2006, 2008, 2009) providing valuable orientation and direction.
Polyvagal Theory (Porges, 2009) provides a perspective from which to understand how this patient’s nervous system was activated when early attachment trauma occurred. We can infer that those early neural pathways became fixed into specific defenses over time. It also provides a way to understand more about how our relationship, therapist to patient, draws upon “the social engagement system” (Porges 2009) to strengthen the experience of safety and build the capacity for connection. Just as the secure attachment with a therapist isn’t the sine qua non of therapy (Fosha, 2006), so this connection isn’t the be all and end all of treatment. What emerges through this patient’s deepened trust in listening to her body in the presence of a caring and responsive “other” (Fosha, 2000) is a willingness to pick up the unexpected and explore its meaning. This moves and truly elicits the healing potential of this therapeutic encounter in a powerful and intimate way and touches a wound that is simultaneously very personal while also profoundly universal.
POLYVAGAL THEORY IN A NUTSHELL
Polyvagal theory is based on the study of the evolution of the nervous system, (Porges, 2009) and expands the theory of the autonomic nervous system from having two branches — the sympathetic and parasympathetic — to having three neurological circuits. These circuits are hierarchically organized in how we react to our environment, meaning that one system can override the other, usually from the newest system back to the oldest. We engage these circuits as part of a process Porges calls neuroception: a non-conscious process that appraises threat and seeks safety. Central to Polyvagal theory is that most of parasympathetic innervation, which goes to the viscera and comes from the vagus nerve. There are two vagal systems, an old one and a new one. The newest circuit, the ventral vagal complex, goes to the heart and lungs. It is myelinated and connects to cranial nerves which affect and are affected by facial expressions and vocalizations and is activated through a feeling of safety. In this state, we can read faces and pick up social cues. It is most readily accessed with eye contact, gaze, voice tone, pace and prosody of speech. When AEDP therapists are meeting our patients, right-brain-to right-brain, and inviting them to slow down and become more present to moment–to-moment experience, we are likely in this circuit, which Porges refers to as the social engagement system. Being in this system gives rise to the self-at-best: having access to the depths of our emotional and relational experiences.
The middle, or second oldest circuit is the sympathetic/adrenal part of the autonomic nervous system, which is activated when we perceive ourselves to be in a state of danger. In fear, we are mobilized to take action via the fight or fight response. When this circuit is activated without fear, play can initiate mobilization, which I believe may have positive implications for use in a therapeutic situation (i.e. when a patient is slipping into an area of sleepy torpor.) The oldest circuit, the dorsal vagal complex, is unmyelinated, goes to the gut, and is activated in the case of something life threatening. In fear, it produces a state of immobilization in which a person shuts down, dissociates, loses contact with the capacity to act or think coherently and feels nauseous and weakened with a sense of heaviness and exhaustion. In AEDP terms, I think of this as a time when a person is their self-at-worst, meaning they are at the mercy of a paralyzing fear, without access to their emotional experiences and capacity for relating to another.
AEDP THERAPIST STANCE
AEDP (Accelerated Experiential Dynamic Psychotherapy) draws upon attachment theory in its understanding that how a patient meets experience is usually characterized by how they were met by caregivers in critical periods of their early development (Stern, 1985; Siegel, 2007). There are three different behavioral systems associated with attachment. The first, the attachment behavioral system, has protection as its primary function, i.e. running to an older, stronger, wise Other in moments of danger. The second, the care giving or parental behavioral system, is primarily facilitative: a warm smile and tender look to a nervous child reassures and soothes. The third, the exploratory system, has as its primary function to seek, roam and learn about the environment (Bowlby, 1988). The stance of the AEDP therapist is in part founded on this theory. The therapist offers proximity and contact to our patients with an attuned sensitivity to their response. This contact has as one of its primary objectives “to establish safety and undo aloneness” (Fosha, 2000) and, with our companionship, provides our patients a springboard from which to explore their environment, internally and externally, for the purpose of healing what has been wounded, finding what was lost and expanding their capacity for living well.
The therapist stance is affirming, positive, and helpful (Fosha, 2000, 2001; Fosha & Lipton, 2010; Prenn, 2010). In this paper, I am going to focus on elements of this therapist stance that address my patient’s needs by “going beyond mirroring” to helping (Fosha, 2000, 2010; Frederick, 2010) and beyond attunement to empathic responsiveness, which refers to the therapist being “moved outside of oneself in a compassionate gesture…to help, to offer something or simple to be a consciously comforting presence” (Russell, work in progress). I want to propose that the lengths to which we must go in order to truly help must be defined by what occurs in the therapeutic dyad itself. By noticing the impact of an intervention, the therapist can study what assists patients to move, with attuned accompaniment, toward that which is disturbing rather than away from it. For it is how we call upon ourselves in our relationship with our patients that has the capacity “to shift the motivational vector from moving away (fear activating shrinking or constriction) to moving toward (curiosity activating openness and expansiveness” (Fosha, 2006). This relationship capacity is most influenced by the therapist’s affective competence (Fosha, 2000) and willingness to show up no matter what.
AEDP also posits that, as the relationship between the therapist and patient deepens, they can enter coordinated relational states (Fosha, 2000) which are exemplified by the hum of the dyad that is moving along (The Boston Change Group, in Russell, work in progress). One way to picture this is imagining a mother and infant who are enjoying each other’s presence, feeling vital and alive through the ins and outs of simply being with each other, cooing and gurgling, smiling and looking away, looking back and smiling together again. Sometimes in the therapy process, we are being with our patients in ways that are not necessarily moving into deeper categorical emotions, yet the sense of being with each other feels alive and vital, fuels our bonding and as such lays the groundwork for further unfolding to occur.
In the case of neglect and early abandonment there is often a particular quality of absence that comes into the treatment room: an emptiness of contact with self that is at once palpable, yet vague, as it makes itself known through gaps in connectedness rather than flow. In the following case, noticing and tending to these gaps brought me, as the therapist, and my patient, N., quickly into the realm where pain and wounding from her early attachment trauma surfaced. Then, by developing our relationship and exploring what arose between us, glimmers of transformance: “naturally occurring adaptive change processes, such as emotion, dyadic affect regulation, empathic recognition of the self” (Fosha, 2008, p.3) emerged and gave way “for the interactions in relationship that bring about change” (Prenn 2010, p.1). To be seen and met, where once there was such failure of response, brings a whole new level of attachment security to relationship.
N. is a patient I first saw as part of a couple who had had fourteen 75 minute sessions approximately every other week, over the course of ten months. She and her husband had intimacy issues, unresolved hurt over an incident of betrayal and difficulties with trust, giving and receiving help and navigating “irrational fear” that arose during nights when her husband was away from home. The couple’s work progressed as each member of the couple broke through barriers of isolation, shared their feelings and processed misunderstandings. In preparing for the birth of their third child, she confronted her fear that he didn’t want to help her and that she had to do it alone. She also touched into significant anger about having needs and expressing them. The couple’s sessions clearly laid groundwork for the individual work ahead.
Beginning of individual work
N. returned to see me about sixteen months later when she was feeling “stuck, trapped and depressed.” She presented with confusion about her relationship with her husband, but there was a quality of emptiness about her speaking that drew my attention and brought us to a commitment to do some individual work together. The session that follows was our third. She began externally focused on whether her husband was the right guy for her. We entered our dialogue about twenty minutes into the session.
Pt: My sexuality has been dead for years.
Th: What’s it like to say that? Your leg is jiggling. (I pick up her movement signals to bring her attention to an internal focus)
Pt: Is it because he’s the wrong guy and I shouldn’t have married him? Or is it because I’m shut down for some reason…
Th: Go with jiggling, see where coming from, what’s stirring. (again directing her attention inside)
Pt: Anxiety…. heavy, dense and dead. Scared. Almost like I’m gonna get raped, reminds of date rape, let him do what I didn’t want, shut down, painful… not that … but similar. Especially if he does anything aggressive, I want…you; I get scared and close down. So it’s just awful… (as she turns toward her own experience, shame emerges)
Th: Um hm. So what’s it like to even say that, just to tell me, and just to kinda be here so far? (when I sense shame I check in about our relationship)
Pt: Not good.
Th: What’s the part that’s not good right now? (specifying the generalized judgment)
Pt: I just feel so broken, you know, so, like so, it’s not a normal response to having sex you know? (she looks down and away, closing her eyes)
Th: When you close your eyes, I kinda get the sense like, there’s a little shame maybe? Like you’re closing your eyes around this when you’re saying you’re broken… (my language matches her tentativeness; this is happening right-brain to right-brain)
Pt: Mmm. . .
Th: I’m actually checking in even through that sounded like a statement.
(I hear myself leading and want to give her the chance to check with her own experience)
Pt: I feel really kind of … starting to feel really little. (moves towards feeling underneath the judgment)
Th: Mmm . . .
Pt: Little and I just wanna like be curled up, you know? (she puts arms around knees, pulls them up to her chest and tucks her chin into her left shoulder) and be left alone. (avoidance)
Th: What are you feeling right now? Just right now? Just be with it.
Pt: I’m checking in and out a little bit. What happens a lot of times with this is I kinda go up here…(raises right hand up from in front of her torso to her head) (this is hard for her to stay with)
Pt: … and feel my … almost make myself unconscious (brushes her left hand over her head and behind) It sounds weird, dizzy. (shutting down, dorsal vagal activation)
Th: So I want you to look, if you can, to make contact with me, cause I feel like we need to work together. (I’m calling her out of what I experience as an alone place) And I’m afraid when your eyes are closed that you may dissociate a bit… (I mirror her movement putting my right hand over my head) (happens without my conscious awareness) That you’re going away, and, so let yourself see what happens if you let yourself see me, be with me. I really want to go with you. I don’t want you to go too far on your own, cause this is scary and it’s a hard journey… So what happens if we make eye contact? (I offer her clear direction for how to check in with me while also being explicit about my intention to accompany her: calling upon the social engagement system with eye contact and the calm, slow prosody of my voice)
Th: Mmm. (I start cooing tenderly upon seeing her face soften and become young)
Pt: (nodding, looking at therapist, sighs noticeably) I feel sad.
Th; You feel sad. (mirroring her words closely provides an opportunity to demonstrate I am hearing and being with her)
Th: So I want you to just start with that, to let it be.
Pt: (tears, looks at therapist, takes breath in and out) (she responds to the social engagement system, coordinating with therapist, resonating with the therapist’s calm, engaging her feelings more)
Th: (looks with concern and care, breathes in and out) Pretty deep sadness, huh. (both of us nod holding eye contact) Pretty deep pain around this stuff.
Pt: I feel really alone. It feels like that little … (drifts off) I close my eyes sometimes because that helps me go there, too. . . (hunches shoulders)
Th: (slowly) Right …
Pt: . . .really little, alone, kinda confused, like not knowing what to do and just disassociating, you know? (notice fragments of speech and shifting back and forth between feeling alone and feeling with me)
Th: Right and that’s why I want us to slow that down. Cause I understand, yeah, be in touch with the little one, on her own, but I’m here, and it’s really important (fingers motion back and forth between the two of us) that we stay connected to help, to help that little one. (offering therapist self to provide nurturing and comfort; dyadic regulation, while inviting the patient to engage her own maternal functions toward the young one in herself)
Pt: (head drops down and gentle sobbing begins… breath comes in as body racks a bit, holds and goes out, she looks back at therapist) (connection with therapist engaged)
Th: (very gently) Where are these tears coming from?
Pt: (crying renews, lips tremble)
Th: Just stay with them, I’m here. (I back off from verbalizing too quickly)
Pt: (blows out her breath) There’s a lot of anger in there too.
Th: Uh huh…
Pt: and the anger, I just felt so alone…. I didn’t have anyone to help me. (makes connection with the source of her feeling so alone in the past)
Th: SO much aloneness and the anger that you were so alone with no one to help you. (staying with her, explicitly mirroring)
Pt: (nodding, she continues crying)
Pt: My jaw is killing me. (she exhibits sensation in her jaw around anger here and at other times)
Th: Right now?
Th: Just be with that jaw killing you and just see what that needs…(my hand is on my jaw, and my mouth is opening with hers) yeah (right brain-to-right-brain physical mirroring)
Pt: (she drops her head and her shoulders begin to shake)
Th: Ahhhh… When I say I’m here and I want to be with you and help you, how does that land on you, does that make you realize what wasn’t there? Kind of stirs up anger, I’m kind of wondering… (I want to link our interactions to the impact they seem to be having, while checking in with her experience)
Pt: Yeah, (deep breath in and out… self-regulating)…There’s part of me that… I just want to know what happened to me. (discontinuous statement, yet heralding in the context of our exchanges)
Th: Yeah, You want to know what happened to you… oooh. (I repeat her words to underline how I am hearing her)
Pt: (nodding, starts crying some more) (as I join her she lets go into more feeling)
Th: Such a vulnerable place…
PT: (shaking head left and right) I don’t know…
Th: You don’t know, ohhhh.
Pt: (shakes head no, pained look takes deep breath) I just feel young. It feels younger than my date rape and all that stuff when I was older.
Th: Uh huh, mmm, hmm. I want to know too, and I want us to find out together, to see if we can be with you in a way that… (again, explicit joining)
Pt: (exhales deeply) (receptive moment)
Th: We can just follow what you feel and see where that takes us. (going with her, inviting bottom-up processing of the experience)
Pt: (breathes more)
Th: What’s happening right now?
Pt: I’m kind of coming out of it.
Th: Yeah, nodding… What’s it like to come out of it? What’s happening with that? How are you coming out?
Pt: I feel a little numb.
When N. begins to turn her attention to her body and what is happening internally, she becomes overwhelmed with the sadness that emerges. It is amorphous, undefined. She has no true sense of where it is coming from other than a young, sad place. When I offer a hand of support, she senses something she has never received. This moment heralds a deepened feeling, a body/emotion based recognition of the loss that preceded this moment (a glimmer of transformance, perhaps a glimmer of the unthought known, [Bollas, 1987]).
When she reports that she is feeling numb, I wonder if she reverted to one of the older neurological circuits to deal with the intensity of her feelings. Perhaps having me come in so close was both reassuring and scary, and she regulated the intensity in the way she knew how, shutting down to regain her bearings. Or perhaps the wave of feeling had passed, and she didn’t know another way to describe her experience (Piliero, 2011), which also seems plausible given the big exhale and breathing which preceded her shift out of feeling.
Two weeks and two sessions later
Two sessions later, the question of whether she is in the right relationship with her husband resurfaced. Yet her description of her experience included sadness, heaviness and something new, which I affirm.
Th: There’s a little sadness, but then there’s this thread of hope and the sense that there’s something real that happens in this touching Michael and this other stuff kinda feels like ‘stuff,’ ‘bout others… That’s lovely.
Pt: It’s very tenuous. (she is doubtful about having this feeling)
Th: What tells you it’s tenuous right now? (further exploration)
Pt: It just feels like a small sliver for some reason.
Th: Mmm, hmmm. That’s OK, It’s a small sliver. (I emphasize what is here — to counter the doubt.)
This is a moment I could have passed and moved towards the sadness or heaviness. But the thread of hope caught my interest. N.’s first few attempts to explore the hope didn’t gain much traction. Finally I asked her to open her eyes to check in with me, and she realized she had drifted far away, and she saw her tendency to stay with the negative. (defense recognition)
Pt: I don’t bask in positive things. (heralding) It’s much easier for me to know how to sit in depression or negativity. It’s just most familiar; my brain feels like it does that. (increasing self awareness)
Th: There’s this little statement from the neuroscience folks (Hansen and Mendius, 2009) that our brains are Velcro for negative, Teflon for positive. (psychoeducation to provide some left brain stimulation as a normalization of her experiences and offering an alternative to shame)
Pt: Umm hmm.
Th: … and that it takes sitting with the positive for twenty seconds to rewire the brain because it’s just so instantaneous (Hanson and Mendius, 2009)
Pt: I know, I’m usually like I just flash and it’s gone. It’s not something that I sit in and bask in and enjoy. I actually notice this, it’s really sad, with my kids sometimes, that I will be laughing. And then it’s like I can’t sustain it. If I’m really happy or I’m laughing I get exhausted almost and find myself wanting to stop and do something else… (identifies a pattern of dorsal vagal activation triggered by anxiety about feeling too happy in her daily life)
Th: It’s like your capacity is growing with your kids and you can feel yourself growing out of your comfort zone. (Positive reframe)
Pt: Um, hmm. Uh huh. That’s a good way to look at it. (smiles, looks down)
Th: Um, hmm. And, what else? (I tilt my head down as if under hers to look up at her)
Pt: No I was just laughing because my way of looking at it was — oh, look at how incapable you are, like you’re gonna fuck up your kids because you can’t be happy.
Th: Yeah, I like my voice better. (up-regulating shame with teasing humor)
Pt: Yeah, I like your voice better.
A few minutes later:
Pt: It’s interesting as I’m even starting to imagine feeling positive and laughing I’m starting to feel really tired. And that happens to me with my kids sometimes too. (increasing self-awareness of the relevance of present experience)
Th: So, slow… Tiredness can actually be anxiety going into sleepy defense.
Pt: YUP (affirms with a look that looks like she know exactly what I am talking about).
Th: … which is on the way to dissociation. So let’s try, I’m so glad you mentioned it. (quick circling back to affirm her growing connection to her disconnection) Let’s try to stay with what happens like right before you hit that tired edge. You and I talking about it, me having a positive view of this. (I want to find the trigger for this moment’s activation of the dissociation so we can get closer to regulating whatever has sparked the anxiety)
Pt: (nodding, looking receptive) Uh hmm.
Th: Touched you and we kind of laughed that it’s different than your voice, which is pretty damn critical, actually.
Pt: Uh hmm… (nods in agreement)
Th: Um, you know, and then you started getting sleepy right after that. Do you know exactly when you started getting sleepy? (reflecting on the self-at-worst from the platform of her experience with me, which gives her more access to her self-at-best)
Pt: Mum. (begins to close her eyes)
Th: You better not keep those eyes closed for too long! (now I’m seeing a potential slide into dorsal vagal activation; this teasing is my attempt to mobilize her energy though playfulness)
Pt: Um, yeah, um. I don’t know precisely, but I think it was even thinking about being positive and happy starts to make me feel tired. Sean always comments, like you fall asleep all the time. We’ll be having a conversation and I’ll want to get out of it and I’m yawning and getting exhausted like I’m too tired… It’s like clockwork. (something opened up in N. and she makes another connection about her patterning)
Th: (brings it back to us) So there’s something about contact even. (waves hand between us both)
Pt: Um, hmm. (appears to be stifling a yawn) It’s difficult situations or happy…
Th: Which makes me wonder… or me even being on your side, seeing something in a positive way, different from the critical way. I wonder if even that contact made you a little anxious like if that’s a new, like to have me on your side, being affirmative of you or seeing the big picture. It’s not even being positive, it’s more like seeing something differently than you see it. What does that feel like? (I am elaborating the experience of contact between us, to further this new direction while linking past, present and current relationships)
Pt: Hmmm, yeah. It’s definitely something.
Th: How do you know it’s something? What does it touch? (focusing on the sensory, perhaps energetic or emotional experience)
Pt: I feel a little anxious, feel a little anxiety. (yellow signal affect)
Pt: Here. (waves her hands up and down in front of her torso)
Th: In your core.
Pt: Um hmm.
Th: So if that little anxiety is going to speak, what words might be there? (using words brings left brain on line while noticing a right brain experience, to regulate, organize and deepen connection to the source)
Pt: I’m scared like somebody might be nice to me. (looks younger) (shift into state two core affective phenomena: relational experience)
Th: You’re scared cause somebody’s being nice to you? (I shift into small voice like talking to a child)
We explore that I am being nice to her. Pain arises in her shoulders. Moments later:
Pt: It’s like, like, you, you care… (receptive affective experience)
Th: Yeah, that actually feels like what I feel.
Pt: (nods) Um hmm.
Th: Like I care about you, and out of caring, I want to understand. And…
Pt: Wanting to be with me and understand me, yup… (she is receiving me receiving her)
Th: … Now, what’s happening as we acknowledge that there’s caring, that you can see caring and that’s where that comes from? How does that feel… to the part that feels scared or pain? (we are metaprocessing the experience of feeling understood and cared for)
Pt: I don’t know. I’m just going with it, but it just um, I had a flip to feeling really little again. (Back to state two)
Th: Hmmm, a flip to feeling really little again. (I mirror the same flipping gesture with my hand as she does with her hand)
Pt: Back there.
Th: Right now?
Pt: When I was in tears, felt really small again, like when I was four years old. (she is referring to that last session)
Th: What’s it like to feel that four year old? Can the four-year old part feel the caring, feel my caring?
Pt: Nods slowly, looking deeply into my eyes. (begins to gaze at me)
Th: I’m glad, actually. What’s happening right now?
Pt: (brushes across, referring to her shoulders) I’m just conscious of the anxiety and my body reaction.
And here is where a significant shift happened as N. stayed in eye contact with me for an extended time. The anxiety lessened and dissipated to the point where she felt a sense of being-ness with me. We dropped into core state: a calm place, free of static, where knowing emerged. I was struck that we were now basking in this moment, having crossed a precipitous edge between old familiar patterns and an unfamiliar new experience (Mindel, 1987). Through seizing an emergent thread of hope and persevering through an unknown terrain full of dissociative spaces, treading carefully in the zone of dorsal vagal drop outs, we went further than we did the last time. By seeking understanding and staying present where, once, there must have been such deep absence, we arrived at pure contact. Instead of contact initiating fear, sleepiness and avoidance she now experienced the recognition that something real could be had that felt warm and nourishing, true balm to the soul. And from here further understanding ensued (the truth sense) that the pain in her shoulders was her critic/protector – waiting to swoop in at any moment and take her away. While she was having a new experience of connection – the protector was also there, a reminder of its stalwart way of keeping her together and safe. But this time she realized that the critic voice was outside of her (meaning that she was no longer identified with it) and that what was truer and more real was our contact and the simplicity of being together.
One week later
The following week N. appeared brighter and she began the session by saying there had been a subtle thing in her: “more centered,” “ a nice undercurrent;” however, she was unable to describe it further before she stated that staying with the positive really was difficult for her. This acknowledgement had the sense of a deepened reflective self function that was now generating curiosity and noticed when her mind “wanted to go elsewhere.” She affirmed the desire to direct and empower her life from the place we contacted last week rather than her defenses. Then, she asked if she had ever told me her first memory. (I see this as entering the exploratory attachment system, evidence of having an increased secure base with me.)
Pt: Did I ever tell you my first memory?
Th: I don’t know.
Pt: I think I was two or three, I was walking. I was in a crib, probably two. It was dark and it was loud as all heck. We were living in Hawaii at the time. The memory is of cats and dogs hitting the roof and it was a huge storm and it was raining. Somehow I had heard this “It’s raining cats and dogs,” in a little kid’s mind. As I was hearing, all this boom, boom, boom boom BOOM, I was picturing dogs and cats falling all over the roof and I was terrified.
Th: Oh my gosh. (clearly moved, expressive authentic response)
Pt: I was absolutely terrified, like I have this clear memory. Terrified, terrified, terrified, terrified and I got out of my crib for the first time. I figured out how to get out of my crib. And I crawled out of it and went down the hall and it was dark and I had my hand like this and I remember trying to find my parents room. Like on the wall, by myself, it’s pitch black, like I’m fucking terrified, absolutely terrified out of my mind and I had to get out of my own crib and figure out how to get out, how to go to my parents room, find my parents and that’s always been my first memory. (emphasis: seven ‘terrifieds’ while she describes how her sympathetic/adrenal neurological circuit had engaged to mobilize her towards her caretaking attachment system)
Pt: And I talked to my mother about this, like as an adult. I’m like, “Do you remember this? Do you remember a big storm?” “Yeah, I do remember that and you got out of your crib all by your self. I was so surprised you showed up at my door. I couldn’t believe it.” And then, I was like, “I was so scared.” And she’s like, “Yeah.” And I’m like, “What did you do? What happened?” And she goes, “I put you back in your crib.”
Th: (gasps, open-mouthed, looking at N.’s closed mouth and searching eyes)
Pt: (nodding.) Can you believe it? First of all (hand on her chest) there was a huge fuckin’ storm, crashing and groaning, and I’m like two years old and she isn’t even checking on me, right, to see if I’m ok? One. You know, I figure out how to get out of my crib for the first time ever, find my way down the hall, which I’ve never done before, completely terrified, and she takes me and throws me back in my crib. (current sympathetic activation of her nervous system – anger, protest toward her mother for failing to provide protection and comfort)
Th: (still open mouthed, looking so surprised and pained)
Pt: And I’m like: that’s my first memory.
Th: You know when you were telling it your hand was right here on your heart, and I was like… Let your right hand speak to this memory that you’re saying. What would the right hand say to you when you put it on your heart, here? (I am bringing our attention to her body and her movement to explore feelings about this past memory in the present moment)
Pt: I just …having my own kids … like I don’t even understand it. I can’t even imagine that my mother or father would do that. Like, it’s heartbreaking. I must have made a decision at that moment that like I’m on my own. I can’t trust anybody. Like I’ve got to take care of myself even when I’m totally terrified. (identification of her internal working model of insecure attachment)
Th: So as you mobilize yourself to get what you need, you get put back as if, like, you know … start over, wrong … don’t leave…(speech is halting, disrupted) It makes my heart hurt. (I am moved by her adaptive mobilization and my own feeling fiercely, protectively attached to her; I feel disheartened as I witness (Adler, 2002) such a strong and healthy impulse be struck down)
Pt: Um, hmm, yeah …so . . . .
Th: How can we be with that little one in you, cause it feels like that was so important that impulse and that impulse to get what you need is so valiant and courageous and right. (I am determined to find a way to realign the motivational vector towards an Other for comfort and protection)
Pt: Um, hmmm, yup. I don’t remember the part of her putting me back in the crib. I only remember the part up until I got in the room and saw her, and my memory is blank after that…. (her adaptive action in response to her fear is “taken away from her” – she reverted to the oldest neurological circuit, the dorsal vagal complex, and shut down – blanked out)
Th: …So I wonder what makes that the part you don’t remember. Like why do you think that would be the part you don’t remember? (inquiring/ mentalizing)
Pt: Because as terrifying as this whole thing was that was probably the worst part of it. (significant error of omission of her parent to protect and comfort her)
Th: Reaching out and having someone not get you. (elaborating)
Pt: Or just putting me back in the situation where I’m scared. (disorganizing)
Th: Mm hmmm.
Pt: And alone… ooophh… (receiving the impact of what happened to her)
Th: So I feel like there’s a little little one in you, a little two year old who’s still holding this. I want us to somehow touch her or feel her or let her know that we want to do it differently. (working in the present moment to heal the past impact of trauma)
Pt: Yeah, I don’t have a lot of feeling connection to that. It’s like I’m telling it but I’m not feeling it. (disconnection/dissociation) I’m not really getting anything.
Th: OK, so see if on a sensation level if your arms just, if the touching feels like it relates, if there’s a touching feeling that feels like it can feel touched. And hearing, see if you can try hearing what that sound might have been like as you, as that little part of you got out of the crib and paddled down the hall. (start with senses of touch /sensation/movement and auditory)
Pt: I remember seeing the dark, like it was dark and shadowy and I felt really little cause the hall walls were so big. (there is visual memory too)
Th: So big. (I enter the memory with her)
Pt: And bang, bang, like huge bangs on the roof.
Th: Oh yeah, so the hearing’s really . . . .
Pt: I’m trying really hard with my hand; my hand is going against the wall like this trying to find my way to the room…
Th: Yeah… feeling that feeling in your hand, and hearing the sounds just letting that… cause those are two sensations that are awake to this memory.
Pt: And the pictures of the cats and dogs . . .
Th: . . . pounding, falling down on that roof. (amplifying the sensations: the sounds)
Panksepp (2009) describes situating the patient properly in affective space. In AEDP terms, “properly” is being with another and in touch with the somatic, sensory elements of emotional experience to facilitate bottom-up processing. N. has difficulty finding and offering comfort to her young self (even though as a mother she feels compassion for her own children). I ask her to tune into the channels of experience (Mindell, 1985; Mars, 2010) which are awake to the memory. This is similar to lighting up the neural networks in EMDR (Parnell, 1999). I do so by beginning to process with her around receiving what is happening and building a platform from there.
Th: I’m seeing you. I’m seeing this little baby girl in the dark, young enough . . . (becoming a true other I witness her)
Pt: I think I might have been less than two as well because I’m holding the wall because I’m not a great walker . . . .
Th: Yeah . . . .
Pt: because I’m still learning . . . .
Th: Oooohh . . . .
Pt: I’m having trouble, like, I’m not….
Th: Yeah, stay, stay here…maybe take in, see me seeing you, because you know sometimes when you go into that… because I just want you to know that I see this little, little one in the dark and that if I’m the mom, what I imagine, is just picking you up immediately, and just picking you up, and, and I imagine like listening with you to the sounds, like wow it’s really loud isn’t it? It’s loud, ooh you must be scared if you came here, right, you must be so scared. (I speak to our attachment system, and, sensitive to her fear, I sweep her up; the help I offer is more than understanding, it is empathetic responding to the connection that she NEEDED at that time)
Pt: Umm, hmm.
Th: Ooh, and then maybe you would say cats and dogs roof… Oh no, you hear cats and dogs on the roof, that’s a saying. It’s raining, really hard raining. It’s really loud.
Pt: It’s like cats and dogs, like dead cats and dogs landing on the roof, tons of them. (she joins my joining her)
Th: Dead cats and dogs, how awful; what an awful image, yeah, yeah. What happens if I say it’s not cats and dogs it’s just rain, rain, rain? That’s just how we speak about it, but it’s really rain. What happens? (like a mother with a child I am explaining the world to her: protective and caretaking attachment system)
Pt: I feel some relief.
Th: So feel that relief, where do you feel it?
Pt: I felt like a ahh, ahh, ahh, haaaa…
Th: Do you want to stay with me? Do you want to stay with your mom? (this is beyond mirroring, empathic responsiveness, I am moved out of myself – out of my role into the only response that seems right given the situation)
Th: Of course you do, I want you to stay with me.
Pt: That’s what I wanted. (CLICK of recognition)
Th: I want you to stay with me. I want you to stay with me… (affirming)
Pt: (her eyes tear up and her face softens)
Th: Keep breathing… yeah, just feel into it.
Pt: (crying) I felt like she didn’t want me.
Pt: I wanted her to want to take care of me.
Th: Of course you did, yes… yeah…, yeah… Ahhh, yeah…. Yeah…. Just be with that, be with that… you wanted her to want to take care of you, yeah you did… (now in state two: core affective experience moving into adaptive action: expressing what is wanted; I am following her affect, affirming and staying with her)
Th: Of course you did…. So much…. ah ha. You got you out of your crib down the hall in the dark holding onto the wall. Such a brave girl. Ooohhhh.
Pt: My jaw hurts again. (the wave of affect is moving into the upswing)
Th: Your jaw hurts again. So just tune in and see what your jaw needs right now, if it has words for what’s happening. (I bring the left brain on line as the right brain experiencing reaches a painful edge)
Pt: It’s tight, throbbing.
Th: I wonder if there’s something to say, wondering if there’s something that’s wanting to be said, on your behalf, is there like… something?
Pt: I want her to want to take care of me, and she didn’t want me….
Th: You want her to want to take care of you. (I mirror her words, validating her)
Th: What’s it like to let your self say that? You can say it to me. (portrayal)
Pt: You as my mother or you as my therapist?
Th: whichever feels more accur… whatever works right now. Who do you want to say it to? (the roles seem less important than the action; so I encourage her to move and to speak to who ever she can so that she can re-connect to the action tendency that was crimped, inactivated that night when she was put back into her crib)
Pt: I just feel like I wanted you to take care of me, and I wanted you to not have it be a burden.
Th: Um hmmm.
Pt: I wanted you to want to be there for me. I wanted you to want to be my mother. (she speaks up on her own behalf)
(We talk a bit about her memory of her mother and I ask her what it was like to verbalize her longing. Now we metaprocess, unpack and deepen the experience.)
Pt: It was the whole thing of, more than I did want her to take care of me and all of that, but it was when you said I want to take care of you that was what really did it, you know . . . .
Pt: Like OH, like wow, you can actually get someone who wants to do this.
Th: Right, it was like getting, it was almost like the un, what you didn’t receive came through and you got to hear; it was like, ‘Oh, that’s what I wanted.’
Pt: Um hmm…
Th: That just resonated.
Pt: I didn’t realize it until you said it. (click of recognition: transformance)
(She talks a about her difficulty receiving and not expecting much from her mother. I bring her back to herself.)
Th: And what about you? What does it tell you about you that what was evoked in me was just wanting to take care of you. (I inquire about the way she received what happened between us in order let this new experience generate a new (corrective) reflection about her self)
Pt: That I’m worthwhile. (moving towards core state, not yet declarative)
Th: Un huh. Is that a question or are you letting that in? Feel into it, feel into it cause I think that’s a really important recognition.
Th: You know, I just internalized that there was something wrong with me. (undoing shame)
Th: Yeah, that needs to be . . . .
Pt: . . . .that no one would . . . .
Th: . . . . dispelled, right?
Th: Cause you made a valiant effort to get something that you needed and you deserve to be given that comfort. Check in with me as I’m saying this, right? I just want to know if you can take that in if you’re needing to shut down a little or… (I was seeing her close her eyes and wanted to check in with what is happening)
Pt: Say it again.
Th: That I see that you made this valiant effort to get what you needed and you deserve to be responded to.
Pt: I feel very angry.
Th: Yeah. How do you know that, what are you feeling right now?
Pt: I feel, I just feel angry. It’s all well and good we can sit here and talk about it. You can pretend to be my mom, but it doesn’t make up for what happened. (strong assertion on her own behalf)
Pt: There’s like this feeling of like just anger and like I have to deal with the repercussions of this so deeply in my life you know and it wasn’t my fuckin’ fault. (part core state declaration, part adaptive anger realigns self concept)
In this process, I was committed to staying with the emergent healing and circled back with each piece, which deepened N’s connection to how she was impacted by that experience. Her mother had not responded sensitively to the fear that had motivated N.’s hallway journey. When I entered the memory, what was called up in me was to inhabit the position left unoccupied, to offer proximity and care to the frightened child who had mobilized herself with such courage into darkness in order to engage with her mother for comfort. I knew that this urge, beyond a shadow of a doubt, was a healthy drive towards the protective and care taking attachment system. As an AEDP therapist, my being biologically wired to care (Bowlby, 1985) and respond authentically to the cry for help had a place. N. received this gesture, not only with relief, but also with the experience of being wanted. The child’s mind had felt her mother’s ignorance as rejection and then turned that rejection inward to a defensive exclusion of reaching out and asking for help. When I stepped in to respond to N., the transformance click was the recognition that she had wanted to feel wanted and beyond that, feeling wanted made her feel worthwhile. What seems to me is that as N.’s and my attachment was strongly connected, through the social engagement system, a self-righting of the deepest kind occurred.
True to the practice of AEDP, the experience did not stop here. The next session N. was calmer, and described a subtle shift that this time she was able to stay with, enabling us to explore her experience more fully. We enter after a few exchanges:
Pt: Um, hmmm. I feel good. I think it was the last session that we had or maybe it was the one before that … I can’t remember… we, when we connected at that very deep level … when I was really young… when we were just being together just connecting for a long time. That really, I think that was really profound, and since then there’s a piece of me that has felt safer.
Th: Awww (gentle sing song tone).
Pt: You know, it’s just felt, it really touched me deeply. I really feel more ok… (she tears up) (now in state three: these are the healing affects of feeling moved)
Th: Yeah… Be with the tears that are coming, just to experience safer, how safer is in your body… yeah…
Pt: (head nodding, lips pressed together, she sniffs, looks at me)
Th: Ohhh, (I breathe) if you need, let that cry of crying happening, let it be cause it’s so sweet… ahhh, … (I encourage being and deepening into what is emerging)
Pt: (smiles) There’s um, just feels nice, you know… yeah.
Th: Yeah, (smiles too) What a sweet smile you just gave, and now? What’s that like to share? (I witness and metaprocess)
Pt: Okay. That’s reminding me I had a conversation with Sean after that session, just kind of explaining the session and what happened, the kind of work we’ve been doing, and the group and how I’m changing my whole schedule doing all this stuff to make this happen and I’m committing to this and I’m talking about working with you. And I felt like… There’s this feeling like I’m finally doing it (right hand pounds into left palm) You know? (she looks at me, smiles, shakes her head and cries)
Th: Ohh, Let it reverberate… I’m FINALLY doing it… ohhhh. (I repeat her words with emphasis, sensing the mastery affects)
Pt: (breathes in and exhales audibly and cries, shaking in her upper torso)
Th: Ohh… You’re doing it. I have these little bubbles in my heart and I hear the words, like “my heart is leaping. . .” (witnessing)
Th: as I hear you saying that. . . .
Pt: I finally…
Th: and doing it, what is that? What do you mean? (continue deepening and exploring the experience)
Pt: It feels like finally I’m getting to some of that core stuff. It feels like finally breaking through that wall that I have, finally putting it all down, and daring to go in there and sit in there. Like the way that we were together, and just sat together, for an extended period of time in there. I really think that’s like the first time I’ve ever done that, like really (hand brushes down the front of her torso). It felt really good.
Th: Un huh. What makes you smile and laugh as you say that, “It felt really good?”
Th: I guess I just really want you to unpack, “It felt really good,” because you’re talking about your own experience of some kind.
Pt: Umm. (she nods her head up and down and closes her eyes)
Th: And even now, you know, because it’s here now. So see if you can be with your own self in this moment.
Pt: (takes big inhale and exhale.) I’m a little dizzy in my head. (she reaches an edge)
Th: And just check in with me if you need to. (offering dyadic regulation and support)
Pt: Yeah, yeah. (looking straight at me) (draws on social engagement system) I felt like (right hand circles towards me and to herself speaks softly) I felt like I was reconnecting with that lost part of myself, very young (she demonstrates her expanded capacity for connecting with me to help her stay with an emerging experience; this facilitates her developing a more secure relationship to a young part of herself that she is now finding [Lamagna and Gleiser, 2007])
Pt: It was a place where you know, it wasn’t the pain, it was underneath the pain even. It was getting through the pain of that. There was actually like an okay feeling buried way under there.
Th: Ahhh… (soothing sound)
Pt: you know, like getting back to that, like, that, yeah.
Th: You’re talking about it “There was”, but I have a feeling that this still, it still is, right? (encouraging her to be in the present moment)
Pt: Yeah, it definitely feels like (breath in and out, shakes head left and right) It feels like some sort of integration, like something went (hands come together fingertip to fingertip, sound like crack, she smiles) like something snapped into place. (self-righting… core state)
Th: And what’s that like? The integration, something snapped into place.
Pt: (exhales… closes eyes) I feel a little bit calmer, a little bit more my, grounded in my own self, my body, feel, (looks up, exhales)
Th: grounded in my own body, seems something else….
Pt: There’s something about too feeling, like I’m terrified to let you in, you know, terrified to let anybody in there behind that wall, just mortified and scared. The funny, I think the “huh”, is that after finally getting in there was good feelings. It wasn’t what I expected. Cause I expected like hell you know? (core state reflection)
Th: Un huh…
Pt: I didn’t realize in that case that the wall was more of the hell,
Th: Yeah. (exhaling)
Pt: than actually getting there…? You know what I mean? (she tilts her head to the left, looking at me)
Th: Yeah. (I affirm)
Pt: I think I’ve always anticipated that underneath that was really bad, deep, painful stuff, you know?
Th: Un huh…
Pt: But part of the bad, painful stuff was the wall. You know what I mean? And, there’s pain there and there’s other stuff (voice shifts to lighter tone) but there’s also good stuff buried under there.
Th: Wow … So that’s really finding something, so essential.
Pt: Yeah, I mean, I feel like that’s what we’re doing, right, kind of journeying back to try to find the whole me.
Th: Hmmm. (sounding with her, appreciatively)
Pt: The me that’s okay, the me that’s whole, the me that’s buried under there…
Th: Un hmm.
Pt: So I feel like we (changes thought) there’s something about feeling really safe.
Th: Yeah. (serious tone)
Pt: And it was about feeling that you were kind of re-mothering me, in a way. (her voice shifts to a questioning tone as she looks at me)
Pt: Like it really felt that way too, like that little girl wanted to be mothered, you know? (fills with feeling) And just having you sit with me and be there.
Th: That’s still so touching right now…. (therapist brings attention into this moment) Let’s be with this, because there’s such a longing, such a longing right, to have a mother that’s really able to just be with you, right? (this is a complex expression of feeling her longing being met and a healing affect of being moved)
Pt: Yeah… (nodding, looking down)
Th: Ummmmm, and you dared to let that wall down and to let me be with you.
Pt: And right now, what’s it like right now… with this, to be sharing with me? (more metaprocessing this relational aspect of our work together)
Pt: (rolls head around, stretching, exhales, smiles) Okay… ummm, (exhales) I’m in touch with the sadness. (mourning the self)
Th: Un hmmm…
Pt: Or like you said, the longing, a little more of a longing for that, really wanting for that, the part of me that really wanted that…
P: That wants that… (nodding)
Th: I can so imagine and see that part of you so on your own, so unmet back then… so for that part of you to dare to come out a bit and to let me in a bit, such a risk in a way that you finally, like you said, finally are doing it.
Pt: I just had a flash, or a sense of something when I was talking about really wanting to be met and wanting, just this loss, or this feeling of like wow, I just really didn’t have someone like you, just present and there, who really got me and was really able to parent me, like I just didn’t even have that… and to experience that with you. . . . (head shakes left and right, crying starts)
Th: Um, hmmm, (exhales aloud) Yeah, yeah…
Th: What about that experiencing…
Pt: It’s really helping me get what I didn’t get…
Th: Um hmm.
Pt: More, viscerally…
Th: Yeah… mmm… SO many feelings about this… just really, I just feel such tenderness for this part of you, for these feelings. (I too am moved, and participate in this with her)
Pt: (crying deepens to gentle sobbing)
Th: So long, so long longing… (I’m talking to her, being with her, while she sobs for the lost and longing one: mourning the self)
(The wave ebbs, she comes out and looks at me and reenters eyes closed, sobbing some more…)
Th: I see you. Ummmm, (tenderly coos) umm there’s a lot there still…. Ummm.
Pt: (cries some more) (this crying has the feeling of tenderizing old pain and releasing it from the depths)
Th: Yeah, ummm.
Pt: My jaw hurts.
Th: Un huh… un huh… un huh… yeah.
(She sobs and shakes, a wave passing through. Her breath moves in and out a couple of times. I exhale audibly. Then she speaks.)
Pt: It’s saying, “I want you to take care of me. …”
Th: Yeah, ‘I want you to take care of me.’ That’s what your jaw wants to say. (by reflecting and making sure she knows I have heard her, I also give myself a moment to choose my response)
Th: Wow, and you get to say that now! (with affirmation…) Her sobbing turns into whining with exhaling sobs.
Th: I’m right here… (and presence…) She sobs more and I repeat: I’m right here.
Th: Ohhh, un huh, just let it move through you all the way …” I want you to take care of me.”
annnn, ahhh… Yeah…. Ohhhh…. (I encourage her to complete this release as her being able to finally ask for what didn’t get evokes another round of mourning for self)
It seems that the impulse towards mobilization that had been “put back to sleep” in this early experience was reawakened in our work together and reinstated the motivational drives of transformance. When we metaprocessed the journey, N. felt the mastery of her accomplishment to face the core of her fears. As she felt and received my care, healing affects surfaced. By staying with the emerging shifts and experiences in her body, more layers of pain and grief for what she had so long been deprived of appeared and released. With each moving interaction the bonds of our attachment relationship proved responsive and reliable. N.’s felt sense of security deepened, trust in her self was restored, and she delighted in her growing fascination with the wisdom and mystery of her body and what unfolded through listening to its signals.
The existential need for recognition and the functional
need for effective action on behalf of the self are powerful
motives: they are both manifestations of transformance.” (Fosha, 2008, p.3)
Throughout this article I have shown how the active and facilitative, deeply caring stance of the AEDP therapist maximized the potential of the therapeutic relationship and provided sensitive and responsive recognition to what was happening in the transformational process. Careful tracking of the patient’s body and her nervous system activation made it possible to head off slides into defensive dissociation by calling upon the social engagement system through eye contact, voice tones and prosody to reconnect the client to the “us” that was going through this journey together. So that when the patient and I reached into places where previously there had been the blankness of contact and neglect, the therapist was present and available to be called upon to provide missing elements of the attachment system. This willingness to be moved to action on behalf of the patient furthered the therapeutic impact and helped the patient connect to her sense of worth as a person, which gave rise to renewed joy, vitality and most importantly an expanded capacity from which to engage in her marriage and her life.
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