Facilitating Transformance for Couples

A Comparison between Structural Family Therapy and AEDP

By Gil Tunnell

Abstract.  The author compares the similarities and differences between Structural Family Therapy and Accelerated Experiential Dynamic Psychology applied to couples, and then discusses how he incorporates principles of both models in his work with couples.   Bowlby’s attachment theory is described, with an emphasis on the importance of balancing both the need for connection and the need for autonomy with couples.  A clinical case illustrates how he integrates Minuchin’s concept of complementarity with AEDP’s emphasis on experiencing core affects, resulting in a healing experience for the couple.

Diana Fosha (2008, 2013b) has defined “transformance” as an individual’s innate drive to be transformed, to self-heal, to right one’s self, to grow, to be authentic and be known, connected, and recognized by the other, even in the face of misfortune and trauma.  Accelerated Experiential Dynamic Psychotherapy (AEDP; Fosha, 2000) is a model of individual treatment that sets up conditions for transformance to unfold.  From family therapy, Salvador Minuchin (1974) also believed that couples desire to heal and grow with one another, even in the face of relational conflict, and his model of treatment is designed to help them discover their own “hidden resources” to accomplish that (Genijovich, 1994).

I have been very fortunate to have been trained by both Fosha and Minuchin.  Not only are they master clinicians, they are creative theoreticians with very different ideas about the conditions required for transformation and growth.  In brief, Minuchin believes people change when they are challenged and made to feel anxious; Fosha believes people change when they feel safe.  Despite this striking theoretical difference, they share several therapeutic similarities, the key one being:  Making something happen in the session.  Both are highly “active” therapies.  Minuchin challenges and confronts couples to change their behavioral interaction in the here and now of the session, whereas Fosha empathically and affirmatively supports the individual to feel deep affects in the safety of the session, pushing the usual defenses aside.  This paper focuses mainly on the differences between the two models, expands the definition of “transformance” to include couples, and then presents ways of adapting individual AEDP to more traditional couple therapy.

Structural Family Therapy

Structural family therapy is a systemic therapy that focuses on the interpersonal context of behavior.  In initial sessions the structural therapist maps out the interactional dance of the couple and delineates what is dysfunctional.  After a period of “joining” with a new couple, in which the therapist builds trust and forms a “good enough” therapeutic relationship, the structural family therapist asks the couple to do an “enactment,” (Talk to one another rather than to me).  Enactments are necessary because only then can the therapist witness the couple’s systemic dynamic.  As the couple talks to one another, structuralists step back to observe the couple’s circular interactions, and then identify the complementarity of the positions they take with one another.  Much like individual AEDP does “moment-to-moment” tracking of the patient’s nonverbal behavior, structuralists put far more weight on the partners’ nonverbal styles as they talk, than on the content of their words.

With this systemic map in hand, the structural therapist goes about creating change within the session (Greenan & Tunnell, 2003).  In structural family theory, the fundamental mechanism of change is unbalancing, that is, to challenge and confront the couple’s behaviors head on (Nichols & Minuchin, 1999).  To change relational dynamics, the couple is made to feel anxious about their dynamic, usually challenging one person at a time.  Minuchin believed that if someone was not made to feel anxious during the session, it was not a productive session that would produce change.  Hence structural treatment is purposely designed to raise anxiety to effect change (Tunnell, 2006a, 2006b).  AEDP believes the opposite: That lowering anxiety and making the individual feel safe is the way to effect change.  Again, although their therapeutic methods are vastly different, Fosha and Minuchin share a belief in transformance.  Just as Fosha believes there is a “self-at-best” lying latent underneath the defenses of the individual patient (and mines for it), Minuchin believes that healthier relational behavior exists beneath the maladaptive behavior and challenges the couple to find it (Greenan, 2010).  Just as Fosha believes there is a “self-at-best” dormant under the defenses, Minuchin would argue that there is a “couple-at-best” hiding beneath dysfunctional dynamics.

The structural therapist is not always a confrontational provocateur. Throughout treatment, the structural therapist alternates between joining and challenging.  Minuchin was fond of describing structural interventions as a two-step combination of “stroke and kick,”  “stroking” and being softer and more supportive when people begin to change, but “kicking” when they persist in old behaviors.  In my four years training with Minuchin, I never got comfortable with the kicking part.  In search of treatment models that that did not require the therapist to take such adversarial and challenging positions, I began applying to couple therapy (Tunnell, 2006a; 2012) several principles of individual AEDP.

Individual AEDP and Its Implications for Couple Therapy

As an individual treatment, AEDP in early sessions creates a safe attachment bond between therapist and patient, as a platform to help the patient begin to uncover and process warded-off emotions.  All attachment bonds are based initially on positive affective experiences.  Thus in the very first session, the AEDP therapist explicitly expresses affirmation, empathy and compassion for the patient.  In the first and in all subsequent sessions of treatment, an AEDP therapist offers safety and remains explicitly positive toward the patient, always affirming and complimentary, at times praising the patient’s ability to cope and survive thus far in life, all the while recognizing the desire for symptom relief.

Once safety is established, the AEDP therapist actively helps the patient—by providing continual empathic support—to identify and access “core affects” somatically in his body (sadness/despair, fear, anger, joy, pleasure, shame, disgust), moving from State 1 “top of the triangle” where anxiety and defenses reside, to State 2 core affects (Fosha, 2000), which have often been repressed or warded off by means of some other defense.  “Core affects” are naturally occurring, universal and hard wired into our physiological systems (Tomkins, 1962, 1963), because they have survival value, have adaptive action tendencies, and are a guide to living (Frederick, 2009).  Feelings do not necessarily have to be acted upon, but they are ignored at our peril.  Most individuals as children learned to repress some (or all) emotions in order to maintain an attachment relationship with one or both parents; many parents can’t handle affect. As Fosha (2000) has written, expounding on Bowlby, in sacrificing emotional authenticity for attachment security, children learn it is not safe to express affects that could upset the attachment figure on whom they depend.  To cope with that dilemma, they develop defenses against feeling in general, and a reticence to express emotion to intimate others in particular.  While defenses may have been partly adaptive then—because they preserved their attachment ties to the parent—defenses also left them cut off from their innermost feelings, as well as thwarting the development of a deeper relationship with the parent.

The flow of an individual AEDP session is quite different from traditional individual psychodynamic therapy:  The AEDP individual therapist actively and frequently interrupts the patient’s narrative and slows him down as he tells his story, even in the very first session.  Through moment-to-moment tracking of nonverbal signs that the patient is experiencing emerging signs of affect (e.g., a sigh, a change in facial expression, a shift in gaze, nervous twitching), the AEDP therapist attempts to down-regulate any anxiety and bypass the patient’s usual defenses, so that he begins to experience the core emotions that accompany his narrative.

Unlike the parent reproachful of the child’s affects, the AEDP therapist provides a safe space where the patient can connect with her body physiologically, describe the somatic sensations verbally, and express the emotion in its entirety, e.g., cry in response to sadness, feel the anger in the body.  In AEDP’s technical terms, this sequence in which the therapist actively helps the patient access, express and manage warded-off emotional states is called “dyadic regulation of affect”  (Fosha, 2001).  The emotional experience is processed to completion and shared with the therapist.  The AEDP therapist functions as a midwife for the patient to have a full emotional experience.

As the wave of fully expressed emotion subsides, and that experience is processed with the therapist (State 3), Fosha discovered that patients almost always enter a transformation she has labeled “core state,” (State 4), where feelings of tranquility, mastery, authenticity and relatedness spring forward, along with a new openness to experience free of anxiety and defense.  This final “core state” transformation is profoundly calming, utterly safe, and extremely positive.   As Fosha (2005) has written, all emotional experiences, if processed to completion, end in positive affect states.

The mechanism by which the therapist helps the patient move from State 2 (releasing core affects) to State 3 (reflecting on the emotional experience) to State 4 (core state) is metaprocessing.  AEDP holds that metaprocessing is crucial to effect lasting change. Having an emotional breakthrough in the presence of an empathic other may be cathartic but by itself is insufficient for significant transformation.  Hence the emotional experience must also be cognitively integrated and consolidated.   AEDP is unique among all other psychotherapies in its extensive emphasis on metaprocessing, although after Fosha introduced it some traditional psychotherapies are incorporating it.   Metaprocessing asks the patient to reflect on the emotional experience that just occurred (what was that like for you just now?), thereby cognitively integrating (in the analytical left brain) what was happening affectively (in the emotional right brain).  Continued metaprocessing in State 4 (core state) usually sets off a spiral of even deeper emotion.

The individual AEDP therapist also engages the patient in relational metaprocessing, (What was it like to have this experience with me?).  The patient’s response to the relational question is also invariably positive.  Relational metaprocessing fortifies the attachment bond to the therapist, as it draws the patient’s attention to the fact that he was able to share his emotion completely with another person, without being shamed, an experience that not only had no negative consequences, but, in fact, produced positive feelings of connection, warmth, closeness and attachment.   Relational metaprocessing helps the patient realize that the therapist is indeed “safe,” and sets the stage for further rounds of emotional work.  As Lipton and Fosha (2011) have written, the ability to express feelings within a relationship and attachment bonds develop in tandem, each building upon the other.  Relational metaprocessing  is a powerful way to undo the patient’s heretofore aloneness.

In short, as an individual treatment, AEDP engages the patient in an in vivo “corrective emotional experience” where warded-off feelings are felt in the body and expressed in the presence of a caring and encouraging attachment figure.  Not only does emotional release occur, the patient-therapist attachment bond is strengthened further, which leads to uncovering even deeper emotion and feeling more authentic.

The implications of individual AEDP for Couple AEDP can be summarized as follows:  (a) viewing the couple as an attachment system; (b) creating conditions of safety to allow for emotional processing between the couple; (c) moment-to-moment tracking of the couple’s affects and interrupting their narrative to focus on the underlying feelings; (d) encouraging deeper expression of affect while bypassing the defenses of both partners, (e) encouraging the listening partner to be empathic and supportive, and (f) metaprocessing the entire experience.  This type of experience can provide the individuals with a sense of being “couple-at-best” and can strengthen their attachment bond.

The Importance of Attachment Bonds for Couples: Connection and Autonomy

The same infant-caregiver phenomenon that can result in adult psychopathology—choosing attachment security over expression of feeling—occurs with many couples:  To preserve the attachment tie with the partner, emotion is repressed because one fears, or already knows, that the partner cannot handle it.  Choosing whatever relationship security exists over personal authenticity, the individual represses deep affect.  Yet repressed emotion ironically deprives the individual of a deeper, more satisfying, and more genuine relationship with the partner.

Similar to the goal of Emotionally Focused Therapy (Johnson, 2004; 2008)  a major objective of Couple AEDP is to help partners overcome their fear of being emotional and vulnerable with one another by creating an in vivo  therapeutic experience that viscerally and explicitly demonstrates to them that they can be “safe havens” and “secure bases” for one another.

Marion Solomon (2009) believes couples in therapy, whether they are conscious of it or not, are often seeking a safer, more authentic relationship:  “Empathy, listening, touching, dyadic resonance, a sense of seeing and being seen by each other, and ultimately, an opportunity to be in touch with core emotions while remaining present with each other” (p. 232).  Solomon seems to be addressing a facet of the transformance drive that exists in couples:  To be recognized by the other in all one’s authenticity, and to recognize the other’s as well.

Another facet of transformance in couples comes from the ideas of Bowlby and others, that all individuals are hard-wired not only to connect emotionally with the other (seeing and being seen), but also to be separate and autonomous from the other.  In a self-at-best couple, the deep connection allows each partner to trust the other to function autonomously away from one another, each knowing that emotional support is always there.  In its original form, John Bowlby’s (1969/82, 1973) attachment theory offered an elegant account of how infants become attached to their primary caregivers, a process which, when it went well, culminated in the child’s ability to be separate and autonomous, as well as the ability to be relational and dependent.

To emphasize, Bowlby believed secure attachment had two equally important outcomes—autonomy and connection.  The infant learns to trust the caregiver to be present to care for its physical needs and to provide a reassuring emotional presence that minimizes fear and anxiety.  The attachment figure, usually the mother, provides a “safe haven” and “secure base” for the infant.  From this context of feeling the caregiver’s physical presence and emotional engagement through eye contact, voice and touch (all right-brain to right-brain phenomena), the infant feels safe enough to explore the outside world, with the caregiver encouraging the infant’s natural desire to separate and be autonomous, welcoming the infant back from its independent exploration to reconnect with him or her (Cassidy, 2001).  Moreover, even in secure attachment, the individual turns to the other when in emotional distress, knowing that the attachment figure can help manage and make sense of his emotions (Cassidy, 2001).

Bowlby’s theory, long recognized by child developmental psychologists, was re-discovered in the 1990s, first by social psychologists who applied it to understanding adult romantic relationships and other “pair bonds,” (Hazan & Shaver, 1987; Feeny, 1999) and later by clinicians such as Diana Fosha and Sue Johnson.  Yet personality theorists (Angyl, 1951; Bakan, 1966) had even earlier recognized the dual needs for autonomy and connection, which they believed were universal among all human beings.  In family therapy, Murray Bowen’s (1966) concept of differentiation emphasizes both: the ability to stay connected without losing oneself; the ability to be autonomous while staying connected.  Without using attachment language, Bowen’s concept of differentiation is actually a definition of secure attachment. The problem faced by many couples is often one person has trouble being separate (for fear of losing the connection), and the other has trouble being connected (for fear of losing the self).  Minuchin (Nichols & Minuchin, 1999) also implicitly recognized the connection/autonomy dichotomy in that the couple must find ways “to regulate closeness and distance,” to accommodate both individuals’ dual needs to be separate/autonomous (without becoming disengaged) as well as the need to connect (without becoming enmeshed).

Marion Solomon (2009) has also written:  For most of us there is, on the one hand, a universal yearning to bare their darkest core feelings with someone and be accepted as lovable, and on the other hand is fear of whether the other person can really be trusted.  As suggested earlier, for couples, the tendency to withhold affect is especially problematic because it undermines forming more secure attachment bonds, since attachment bonds require shared emotional experience in order to develop (Fosha, 2000; Johnson, 2004, Solomon, 2009).  A couple can exist indefinitely without having formed a secure attachment bond, and for many couples seeking therapy, as Johnson suggests, insecure attachment, or a rupture in the attachment system, is the underlying problem.

Moreover, simply because two people are coupled or married does not mean they have formed an attachment bond.  If the relationship is very new, they probably have not created “secure base” and “safe haven” aspects, which form only when each experiences the other as emotionally present when one is vulnerable. I recently worked with an older unmarried heterosexual couple where the man told me how, in their first year of dating, the woman jumped in her car at midnight and drove 100 miles to him when she learned his Father had died.  No one had ever really been there for him emotionally; he cried in session as he described it.  In my mind, that experience began the formation of their attachment bond.   Indeed, creating similar experiences in session becomes the primary work of an attachment-based couple therapy.

Yet couples are scared.  Gillian Walker (Siegel & Walker, 1999) has described this fear from her work with gay male couples:

Gay men grow up forced to keep everything that is precious about themselves secret, thus confusing what is valued with what is the subject of shame and disavowal.  The effects of this growing-up experience are ingrained and long lasting.  One man said that, as he revealed something about himself, he would scan his partner for the effect of his revelation.  The moment the other person was about to answer, he could feel himself withdrawing, every inch of his body filled with defensiveness and silence, expecting punishment for any act that revealed his authentic experience.  It was reflexive—in his muscles.  He longed for an authentically honest relationship, but of course his reflexive behavior was not conducive to trust and dialogue, nor was he in fact trained to be comfortable with intimacy (p. 40).

Although Johnson’s EFT and Solomon’s couple therapies focus on helping the couple become more emotionally connected, both Minuchin and Bowen have pointed out that other couples need help being more autonomous and separate.  This “gender bias” among master female and male therapists has long fascinated me, as it follows traditional gender stereotyping where the male therapist privileges autonomy and the female therapist privileges connection.  In studying with Minuchin, I observed that he became far more challenging with families who were enmeshed than with those who were disengaged.  Certainly for Bowen, enmeshment was a much thornier problem than disengagement.  As a male couple therapist practicing AEDP, I try to privilege both needs for autonomy and connection.

Couple AEDP

In contrast to structural family therapy that emphasizes unbalancing, challenge and confrontation, Couple AEDP is an unquestionably “softer” therapy designed to create changes in relational dynamics and rarely, if ever, requires the therapist to take an adversarial position.  Throughout the entire treatment, the Couple AEDP therapist remains in an affirming, encouraging, supportive position.

From the first session on, the Couple AEDP therapist explicitly affirms and supports the couple as a unit (Tunnell, 2006a, 2012), much like the AEDP individual therapist does with her patient.  Although some attachment by the couple to the therapist occurs, the ultimate goal is to help the couple become more securely attached to one another through processing emotional experience together.  In brief, if therapists want conflictual couples to be gentler, kinder and softer with one another, should not the therapy itself be of that ilk?

As described previously, the structural therapist deliberately raises the couple’s anxiety by pushing “interactions beyond their usual homeostatic cutoffs” (Nichols & Minuchin, 1999, p. 134) where the couple is forced to try new behaviors.  In contrast, the Couple AEDP therapist from the get-go is affirming, compassionate, and supportive to both the couple as a unit and to each individual (Tunnell, 2006a; Tunnell, 2012).  The AEDP therapeutic stance is to lower  the couple’s anxiety, bypass defensive behaviors, and encourage positive emotional connection, while also respecting each individual’s autonomy.

The contrast between the two models is illustrated in an Aesop fable (Osimo, 2003; Tunnell, 2006b):  An argument occurs between the Wind and the Sun over who is better in getting a man to take off his shirt as he walks down the road:  The Wind proposes to blow the man’s shirt off, while the Sun proposes to warm the body so that the man takes off his shirt on his own accord.  In brief, Minuchin : Fosha :: The Wind : The Sun.  Whereas Minuchin believes significant change occurs only when people are made anxious about their behavior (i.e., people change only when they are forced to), Fosha believes change begins more organically when people can feel safe.  Somewhat paradoxically, in adopting the Sun approach, helping a couple feel safe to be more vulnerable with one another may initially be just as uncomfortable and anxiety arousing initially as being subjected to Minuchin’s unbalancing methods!  But unlike Minuchin who steadily increases anxiety until the couple behaves differently, AEDP down-regulates anxiety when it emerges.

With a new couple, “joining” is the first phase in both structural and AEDP treatments.  In the “joining” phase, the therapist gets the couple’s relationship history.  A Couple AEDP therapist spends more time joining, taking time to get beneath the factual details of how the couple met (what attracted each to the other, who made the first move) by asking more affect-evoking questions (What was that like emotionally when he came over to speak with you at the party? How did it feel when this man you found so handsome asked for your number?)  Similar to how the AEDP individual therapist affirms the patient in the very first session, the AEDP couple therapist in the first session not only affirms the couple by saying something positive about them as a couple, but actively helps the partners affirm one another.  One way to do this is to ask the couple in the first session what they like about one another, and even more crucially, to metaprocess what they say (What’s it like to hear your partner pay you that compliment?)  Like parent-child attachment, couples become attached first by sharing positive affective experiences, i.e., enjoying the early infatuation, experiencing glee in each other’s presence, seeing the glee in the other’s eye.  It is useful in the early stage of couple therapy to draw upon the positive affect that was present at the start of their courtship and bring it forward.  To use David Mars’ (2014) phrase, the therapist must in the first session “find the love in the room.”  The goal here is to create (at least memories of) positive affective experiences, and to engage the transformance drive that has brought the couple to treatment, i.e., to function more happily with one another.

After the initial joining, the therapist must deal with the problem or conflict the couple presents.  As described previously, the structural therapist will ask the couple to do an enactment (Now, instead of talking to me, can you turn to one another and talk about the issue?).    As they talk, the structural therapist tracks the nonverbal communication between the couple.  Minuchin is interested mostly in tracking behavior  in order to identify the couple’s complementarity:  Is one person more dominant and active while the other is more submissive and passive?  Is one person overfunctioning, and the other underfunctioning? After witnessing the enactment and identifying their behavioral  complementarity, the structural therapist then makes an unbalancing intervention that directly challenges one or the other’s behavior.

Couple AEDP also utilizes enactments between the couple to get them to discuss the problem with each other, and also does moment-to-moment tracking of the nonverbal communication as they address one another, not so much looking for behavioral complementarity, but for signs of emerging affect, especially how the couple deals systemically with affect.  Unlike structural therapy, the Couple AEDP therapist does not use her observations as “ammunition” to unbalance, challenge, criticize or confront the couple.  But like Minuchin, an AEDP therapist is very active in interrupting the couple’s dialog.  Rather than unbalance the couple, AEDP interventions are designed to elicit, and explicitly expound upon, the affect underlying what the couple is saying.    We intervene as follows:

(a) When nonverbal affect emerges (I noticed you just smiled.  What is behind that smile?  I just noticed a tear. What is happening inside?  What was your sigh just now?  To the partner:  Did you notice her smile, tear, or sigh? What do you make of it?  How did it make you feel?).

(b) When there is an absence of affect when there ought to be, based on what is being spoken  (What are you feeling in your body as you say that?  And to the partner: What do you experience when she says that?).

(c) When our clinical intuition makes us ask leading questions that probe for affect.  This involves a bit of risk, but if we are wrong, patients will edit us.  For example, if the wife appears lonely without saying so explicitly, even though there is a sad facial expression, we might say, “I’m not sure, but you seem lonely to me…. is that possible?”  If she resonates, “What does the loneliness feel like?”  and then asking the husband, “Did you know your wife felt so lonely? What is it like for you to know this?”   Similarly, if a man says it’s not safe to talk to his male partner without his flying off the handle, we may ask him, “How do you experience the lack of safety in the relationship?  How does your distrust of his reaction make you feel?”  And then back to the other man:  “Did you know this, that he experiences you as unsafe? What do you feel as he says that just now?”
In all the above, Couple AEDP, much like Emotionally Focused Therapy for Couples (EFT, Johnson, 2004), gently helps the couple explore what emotions are underneath the surface content of the fight, particularly what attachment-related emotions, are getting triggered:  Who’s feeling lonely or isolated?  Who’s feeling unsafe or insecure in the relationship?  In addition, I track the autonomy/connection dynamic:  Who’s seeking more emotional connection and greater intimacy?  Who’s seeking more autonomy and more space?

When deeper emotion begins to emerge in one individual, a major difficulty in couples experiencing conflict is that the therapist cannot count on the observing partner to be empathic.  In fact, as Mars (2011) has written, the AEDP Couple therapist must do moment-to-moment tracking of two people at the same time.  For a couple new to therapy and still in conflict, the observing partner may not be at all empathic, let alone be willing to encourage the other to go deeper into the feeling, as a trained AEDP therapist would.  Individual AEDP therapists are specifically trained in “dyadic regulation of affect,” and will help the individual “drop down” to the bottom of the triangle, sidestepping defenses and minimizing anxiety.  Once the individual patient begins to experience emotion in the body, the AEDP therapist actively helps the patient elaborate it to its full expression, going deeper and deeper into it.  While the ultimate goal is to have the couple themselves engage in some version of “dyadic regulation of affect” with one another, the Couple AEDP therapist, like an EFT therapist who serves as a “surrogate” attachment figure (Johnson, 2008), may need to do it first with each of them before they can do it with one another.

Specifically, what can happen as one partner begins to speak more “from the heart,” is that observing partner gets anxious or defensive rather than showing compassion.  The observing partner may then attempt to sabotage the process.  If the listening partner is still angry, he may minimize the speaker’s feelings or mount an argument against them.  If the listening partner is not so angry but not totally empathic either, he may offer premature reassurance (Don’t worry, everything will be ok), or even express disgust that his partner is so “emotionally needy” (Buck up! Be a man!), which also short-circuits the process.  (More than once in working with heterosexual couples, when the man does become softer and more vulnerable in session, the woman responds with disgust, shaming him that he is showing weakness, even though she claims to want a more intimate connection.)

The therapist must then actively modulate the observing partner’s anxiety, while helping the one experiencing core affect complete the experience.  It can be a juggling act to be present for both partners when one is not showing empathy or compassion.  What to do?

If the listener is getting anxious, we acknowledge and explore it (What is going on as you listen to her?)  To help reduce the partner’s anxiety, we may ask him to try to set aside his discomfort, simply listen in and stay engaged by looking at his partner, reminding him that his turn will come.  I ask the couple to maintain eye contact because mutual gaze is a right-brain to right-brain mechanism to increase connection and security (Beebe et al, 1997), even as the couple is discussing difficult issues and feelings.

Once a genuine breakthrough to core affect occurs, the partner almost always responds with compassion and empathy.  Just as structural therapy counts on healthier behaviors to emerge eventually, Couple AEDP counts on empathy to kick in, once the partner expresses deeper, from-the-heart, core affect.  If empathy doesn’t kick in, the therapist may self-disclose his own affirming, empathic reaction (I don’t know about you, but I was very moved by your partner’s courage in telling you how alone he feels in your relationship).  If said in a non-shaming way, not with a “this is how you do it” attitude, such statements by the therapist may help the partner develop more empathy, as well as providing much needed support on the spot to the person who has risked revealing himself.

When the process goes well—one person reaches core feeling and the other responds with empathy and compassion—it is crucially important that the therapist initiate relational metaprocessing back and forth between the two of them (With the empathic listener, we try to deepen the empathy: What is it like for you to hear your partner express his feeling?  To the one who received the empathy: What is it like to have your partner “get” you?)   This cognitive “left-brain” processing helps the emotional connection deepen and “sink in” and entrains more secure attachment.  Given that the experience of receiving empathy may be new, it is important to spend time here, helping that partner “take in the love, take in the attachment,” which in AEDP terms, is a receptive affective experience.  Metaprocessing is absolutely essential here.  The therapist can also affirm what she just witnessed (I am very touched by seeing both of you connect so deeply…. to take the risk that it’s ok to tell him what you really feel, and for you to respond with compassion.  It is very moving to me.)

Finally, although the above examples are about helping a couple create greater emotional connection in AEDP fashion, I am also interested in how they manage their needs for individual autonomy.  How do they regulate the needs for both closeness and distance, at any given moment as well as over time?  This task involves finding the right balance of autonomy and connection, experimenting with the right rhythm for them as a couple, and learning how to manage and respect each other’s preferences for autonomy and connection.  There usually must be a modicum of both connection and autonomy for each person to be satisfied, but individuals (and different cultures) vary enormously in what they desire on this continuum, and it is not up to the therapist to determine the right balance.

If closeness/distance regulation has become dysfunctional for the couple, it generally takes the form of “pursuer/distancer” dynamics, where the pursuer desires greater intimacy and connection.  A circular dynamic gets set up that as the pursuer pursues, the distancer distances, leading the pursuer to pursue more fervently, etc.    Structural therapists typically intervene by first challenging the pursuer to back off.

It is tempting to say that the pursuer has an insecure/anxious attachment style, and the distancer has an insecure/avoidant style.  Attachment therapists view severe closeness/distance problems as a sign of an insecure attachment bond (Solomon, 2008; Johnson, 2004).  That is, if the “pursuer” actually felt loved and was more securely bonded, i.e., that he felt he was in the heart and mind of his partner even when they were apart, the exaggerated pursuit of intimacy would diminish.  Instead of pathologizing distancing as a defense against closeness, or interpreting pursuing as a defense against being separate, I try to honor and explore both  stances.

It can be useful to directly ask the “pursuer” what he or she is seeking: Is it, when all is said and done, a simple reassurance that he is loved and cared about?   It helps to make this explicit.  If that’s the case, then the “distancer” can be coached to provide enough reassurance to calm the pursuer, and the “pursuer” can be helped to view his distancing as a simply a need for personal space or autonomy, rather than a relationship rupture.  What does the “distancer” want?  Men are often, but not always, distancers in both homosexual and heterosexual relationships.   Men may need more time alone to process emotional experience before they can reconnect or even be empathic (Fosha, 2013a).  So I may ask the distancing partner about how much “down time” or solitude he needs, and whether there is anything about the partner’s behavior that is making him seek more time alone.  Upon exploration, the “distancer” may well say he feels overwhelmed by the continually close interaction and just needs a break, just as infants avert their gaze from the mother when the connection becomes too intense (Beebe et al, 1997).  In attachment terms, just as an anxious mother who wants to bond with her infant gets upset when the infant refuses eye contact, the adult “pursuer” may feel that the relationship itself is in jeopardy when the “distancer” simply wants space.  Reacting as anxious mothers by trying to catch the infant’s eye yet again, the “pursuer” is, in essence, approaching the “distancer” for reassurance about their bond.

In short, I normalize the dance of closeness and distance.  One needs separation and distance to appreciate the connection.  One also needs connection to enjoy the distance and separation.  It is entirely natural to go in and out of states of separateness and connection, and, despite its goal of creating shared affective experiences in therapy sessions, we should be respectful of states of separateness.  The Couple AEDP therapist can provide psycho-education to the couple that (a) an ebb and flow exists between closeness and separateness, (b) most people cannot sustain a deep sense of close connection indefinitely, and (c) individuals vary in how much closeness they desire (when does intimacy become enmeshment?) and how much distance they want or can tolerate (when does distance/autonomy become “unbearable aloneness?”).  The task becomes one of encouraging the couple to respect their individual differences and to experiment with healthier ways of transitioning between the two states of being.

Case Example

When Maria and Stefan, both successful executives, met and began an affair at a professional conference, each was unhappily married to other people, each had a child entering college, and each was contemplating divorce.  Falling in love with one another was the catalyst to start the divorce process for each.  When I first saw them, they were already living together, and Maria had just completed her divorce, which had been fairly amicable.  However, Stefan’s divorce was much more protracted, with his wife resisting it, and overwhelming him with daily romantic phone calls, text messages and emails to come back to her, with pleas not to break up the family.

The initial problem the couple presented was that Maria thought that Stefan was “dragging his feet” on his divorce, not being firm with his wife that their marriage was over, and even more important, not taking a stand that all her romantic pleas needed to stop.  Stefan was afraid to be more assertive with his wife, primarily for fear she would triangulate their daughter and turn her against him.  Maria and Stefan fought regularly over this issue, and had established a fixed and rigid pattern:  Stefan would receive an intrusive email or voice message from his wife, Maria would learn about it (often by snooping), demand he take action, he would promise to handle it in his own way, with Maria persisting he take immediate and decisive action.  The fights had become extremely destructive and often lasted several hours into the night, with Maria escalating into an angry rage.  Stefan, trying to mollify her without success, would eventually become angry himself because she wouldn’t stop the fighting.  The fight would end by one or the other threatening to leave the relationship, which was traumatizing to each of them.  They would then re-constitute, but nothing ever changed in the dynamic.

Stefan said in session that he understood Maria’s impatience and anger, but the lengthy fighting exhausted him and was corroding their relationship, saying “he couldn’t take it anymore.”  Those very words stirred up Maria’s fears of abandonment.  Not only had she completed her divorce expecting to be with Stefan but who now seemed to be distancing from her, she had been subjected to extreme physical and emotional abuse and neglect in her childhood by both parents, leaving an imprint on her that she was, in the end, simply unlovable and unworthy of being connected to.

Early interventions focused on encouraging Stefan to provide explicitly much greater reassurance to Maria that he wanted to be with her, joining with Maria that Stefan did in fact need to be more assertive with his wife, and challenging Maria to shorten the fights.  She felt she couldn’t trust Stefan to share with her all  the intrusive messages from his wife, which led her to snoop through Stefan’s emails and voice messages.  Maria was becoming increasingly distressed, and at one point reported on a dream she had:  That Stefan and his wife were in the front seat of a car, with her in the back seat, monitoring their every move and feeling excluded.

Understanding the complementary dynamic from a structural point of view (Stefan hedging on showing Maria all the messages because she would only get upset, and Maria actually getting upset upon learning of messages she had not seen, causing Stefan to continue to withhold, etc.), I needed to disrupt the cycle.   I suggested a pact that he would show her all the messages, but only if she promised not to get upset.  That intervention worked almost immediately, insofar as helping Maria became more trusting of Stefan, and Stefan began to engage Maria more as a “team” in helping him manage his wife’s intrusions.  Together they instituted a policy of simply not responding to any of the wife’s romantic messages, and Stefan began using Maria as a sounding board for the financial negotiations of the divorce.

Yet the lengthy fighting continued in other instances when Maria felt unattended to.  I explored Stefan’s statements that he simply needed a break from the intense fighting:  What do the fights do to him?  How does he feel internally?  He reported being overly anxious and extremely stressed and just needed relief.  At one point he said in session, “I just need a break.  I’m willing to continue to talk with Maria about all this, but I need to do it in small doses.”  Hearing this as his desire for periodic separation and his need for some individual autonomy, I validated that and coached him to try ending the fights by saying to Maria at what time and place he would be willing to continue their discussions when it was less heated between them.  Although Maria did not understand at all his “need for a break” (which she heard as a break “from her” rather than a break from the fighting), he felt enormously understood and validated by me.

Over the next year, Stefan completed a very difficult divorce that left him financially in ruins.  Seemingly unable to enjoy the moment when the divorce was granted, within two months Maria began pressuring him to marry her.  Since he had just been put “through the ringer” financially and emotionally with his ex-wife, he was in no way prepared to give Maria a ring and marry her so quickly.  Moreover, since he was now wiped out financially, Maria was paying almost all their expenses, and he could not tolerate being that financially dependent on a wife.

That Stefan was not willing to proceed with marriage quickly was devastating for Maria, and the fights continued, leaving Maria with a familiar childhood feeling of being unloved and unlovable.    She explained that, although she was a feminist and had achieved remarkable business success entirely on her own, she was, in the end, a “traditionalist,” who needed the more secure commitment of marriage to feel safe.  Stefan was now questioning the whole institution of marriage and dug in his heels.

However, one evening after witnessing how sad and distressed Maria was, Stefan “spontaneously” proposed (he already had the ring and was preparing to propose in a few weeks on a planned vacation).  Six months later, the couple married.

Over the course of their therapy, I learned much about their traumatic childhoods and families of origin that helped inform their often difficult interactions.  (With the couple’s permission, I had a collaborative relationship with each of their individual therapists, and I encouraged the couple to share in session their childhood experiences).  Maria’s trauma history (both parents had physically and emotionally abused her, leaving her all alone with an imprint that she was unlovable) helped explain her extreme fears of abandonment when Stefan was earlier dragging his feet on his divorce and later being ambivalent about marrying her, as well as her need to be recognized, loved and tended to.  Stefan’s mother was extremely narcissistic; he felt she had never showed any real interest in him.  His father was prone to angry rages.   He grew up feeling completely isolated and alone, distrustful of others and believing that “no one will ever be able to meet my needs.”

As a couple, Maria and Stefan demonstrated extreme pursuer/distancer dynamics.    Maria wanted almost constant connection (with the slightest disconnect triggering deep fears that she was unlovable).  Stefan, although he was enjoying an intimacy he had never known previously and felt “here is finally someone who meets my needs,” nonetheless needed down time to disconnect and be separate.

The brief vignette below began with the couple describing an exchange from the previous evening, what for them was now a minor skirmish, but still familiar dynamic:  Stefan was reading the newspaper as Maria approached him, wanting to tell him about a new, creative idea she had for her business.  She was excited to talk but couldn’t get his attention, and she began to escalate.  He finally snapped at her.

Maria:   I was like a proud cat bringing a dead mouse to my owner.  I was excited with what I had done, and instead I got whacked.

Therapist (knowing about similar incidents with her Mother):  Just like what your Mother did to you.

Maria resonated with this, as did Stefan, who knew her childhood history and how mean-spirited her Mother was.  Without any prompting from me, something “clicked” for Stefan.  He suddenly began to apologize for being inattentive to her last evening… but he went further than a mere apology:

Stefan:  As you well know, I did not want to get married again, but I have to tell you, I am the happiest man alive married to you.  I adore you, Maria.  I treasure you.  You give me a love I’ve never had before, either from my first wife or from my parents.

He then embraced her, holding her tightly, now with tears in his eyes. 

Maria, however, pulled away from Stefan and began trembling and visibly shaking.

Therapist (tracking her trembling and taking a risk to explore it):   So Maria, how does it feel to be appreciated and treasured finally by someone you love? What’s it like to love and to be loved back, ……..and not to be hit or whacked like your Mother did when you only wanted recognition and appreciation?

Maria was unresponsive, seemingly paralyzed in fright mode, unable to talk, and looked like a deer in headlights.  She began to shake uncontrollably and began to cry.    Again without any prompting from me, Stefan elaborated on what he had already said.    

Stefan:  Maria, I so appreciate you, you give me so much.  Never have I experienced such love from anyone, you pay attention to me and to the details of my life, and never I have I loved someone so much.  I never thought any person could be there for me, but you are.  And I am there for you.  I am just so grateful to have you.  You are the love of my life.

Maria’s shaking stopped and she began to sob.

Therapist (softly):   Can you just sit with it and take in his love?

Stefan and I sat in silence as Maria slowly stopped crying in Stefan’s arms, and then sat up. 

Maria:  Wow,…..that was just so powerful.

Therapist (metaprocessing):  How so?

Maria:  I mean…… I have known in my brain Stefan loves me, and we’ve come a long way here working with you.  But just now his words got through to me in a really different way….like I can finally trust his love in my heart.  I’m not sure how all this just happened, but I thank you both.

Therapist  (affirming and witnessing their experience): I’m not sure exactly how it happened either, but it was beautiful.  Maria, you showed him your vulnerability, he saw it, connected the dots, and he was really, really there for you.  It was profound for me and very moving (all of us now with tears in our eyes).

This “breakthrough” session could not have occurred had I not known of Maria’s emotional abuse by her Mother and brought that into play.  Thankfully, Stefan, knowing her childhood history, also connected the dots.   His empathy “kicked in” when he saw her trembling, and he provided not only physical comfort, but his repeating softly over and over his loving words gave her a healing experience.  Stefan acted in this session in a way that empathically responded to his wife’s need for transformance, saying precisely  what would help her self-right and grow, i.e., that she is neither alone nor unlovable.  Thus, in this session, Maria had a receptive affective experience of Stefan’s love.  From my perspective, this session demonstrated a “couple at best.”   I now see the couple only periodically.   They refer to this session as pivotal.

By helping such couples build more secure attachment bonds, experiencing each other as secure bases and safe havens in the therapy sessions, they become more adept outside the therapy room at bridging and sustaining periods of distance, separation and relative autonomy.  Secure attachment ultimately is a felt knowledge that each person exists in the heart and mind of the other.  That seemed to happen for Maria in the session.  As a gay patient of mine once said about his partner, as if channeling John Bowlby:  “I can take on the world when I feel he has my back.”



In brief, the therapeutic processes in Couple AEDP are as follows:  a) in the first session,  affirming the couple and both individuals, forming a rudimentary attachment bond between the couple and the therapist, evoking positive memories from the couple, affirming the couple’s attachment to each other, and instilling hope; b) down-regulating anxiety, and bypassing defenses; c) helping each become more emotionally vulnerable, with the other remaining present and empathic; d) metaprocessing that experience, which strengthens the attachment bond;  and e) normalizing closeness/distance dynamics.

This article has compared Structural Therapy with Couple AEDP.  The similarities between the two models are as follows:  a) focus on the here-and-now; b) change happens within the session; c) once defenses are out of the way, healthier behavior will emerge; d) setting up enactments between the couple; e) clarifying complementary dynamics, and f) actively interrupting the couple’s exchanges.

The key differences between the models are as follows: a) while Minuchin believes change happens when individuals are made to feel anxious (with the therapist being an provocateur), Couple AEDP believes change occurs when individuals are made to feel safe (with the therapist being an affirming coach and facilitator); b) early in treatment, Minuchin challenges the couple, while AEDP affirms the couple; c) Minuchin raises the couple’s anxiety; AEDP lowers it; d) Minuchin focuses on behavioral change, AEDP focuses on positive emotional experience; and e) whereas in structural therapy there is no metaprocessing at all, in Couple AEDP there is extensive metaprocessing of the couple’s experience in the session.


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