How to Set Transformance Into Action

 The AEDP Protocol

By Natasha Prenn

“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).

This quotation captures the dual focus of AEDP: it is a profoundly relational model requiring attunement to the attachment needs of the patient in each moment, and it is simultaneously a powerfully intrapsychic emotion-centered psychotherapy focusing on the biologically-driven adaptive action tendencies contained within us all. This article and transcript will illustrate how to set transformance, our innate urge to heal, into action. I will lay out a protocol with special attention to the language of actual interventions as a guide to facilitating the kind of experiential, transformative, therapeutic work that AEDP seeks to bring about. In keeping with AEDP’s attention to moment-to-moment phenomenology, throughout the transcript I will pinpoint the specific in-session signposts that guide my interventions.

The following transcript of a session with a new patient illustrates many of the fundamental principles and hallmarks of AEDP. These include the therapist’s working to establish safety from the very beginning, focusing on the physical experience of emotion that ‘comes up’ inside the patient, and educating the patient to notice and stay with her affective experience. Two affectively laden portrayals are central to this session; they mobilize waves of healing and energy release associated with the healing affects (Fosha 2000, 2004; Russell and Fosha, 2008). These are then followed by the mastery affects: the pride of “I did it!” and with the bubbling up of healing affects comes the emotional pain of a real mourning of the self (Fosha, 2000, 2005, 2007) with the haunting realization that she cannot go back in time and redo what has been done: “I can never be before that again.” The healing affects, the mastery affects and the emotional pain associated with mourning the self are all transformational affects that arise during the Metatherapeutic processing of transformational experience. As I recognize this patient, she recognizes her self (Fosha, 2009); in these first moments of meeting I am a True Other to her True Self (Fosha, 2005). And finally we arrive at core state, where she declares her dynamics and dilemmas. She ends by saying: “That is pretty much everything I need to acknowledge and understand.”

The AEDP PROTOCOL

In my grappling with how to learn, and now how to teach, AEDP, I have translated AEDP’s phenomenological map (the four states and three state transformations, see Fosha, 2009) into a six step sequence or protocol with suggestions of actual words for each step of the way. Its basic structure is:

1. notice and seize (moment-to-moment tracking) (Frederick, 2005)

2. stay

3. ask the body to help, ask permission, invite to collaborate

4. affirm, explore and expand (Lipton, 2005)

5. let it be

6. Metatherapeutic processing/metaprocessing

Table 1: The AEDP Protocol

	AEDP Protocol	Typical interventions
1.	Notice and seize, moment-to-moment tracking	What’s coming up? I am noticing…
2.	Stay	Can we stay? Stay with it.
3.	Ask the body to help, ask permission, invite to collaborate	What are you experiencing physically? Can we look at this together? Let’s make a lot of space for this…
4.	Affirm/explore and expand	You are doing a good job. Is there more? Uhuh…and what is that like?
5.	Let it be	Mmm. Say more…
6.	Metatherapeutic processing/metaprocessing	What is it like to do this with me?

 

By translating theory into a user-friendly format, this protocol lays out a roadmap for “how to…” work experientially. Each step of the protocol aims to help the AEDP therapist facilitate the patient’s experience. Notice and seize alerts the therapist to be unobtrusively tracking the patient and, where there is a shift or a glimmer of feeling, to gently focus attention there. This shift or emergent feeling becomes the immediate target of both the therapist’s and patient’s attention. Next, we try to help the patient Stay with the emerging affect or attend to what happened in the shift.

Once we have a focus or target, steps three and four identify some of the ways to help the patient Stay with whatever it is. Step three contains different interventions to try to assist the patient and offer our collaborative help. Anchoring the work in the somatic experience of the patient and undoing the unbearable aloneness (Fosha, 2000) that may have accounted for the defensive exclusion of the affect in the first place, step three explicitly draws attention to the relationship with the therapist and works to increase the awareness of somatic sensation. Step four draws attention to the fundamental stance of the AEDP therapist: we are affirming and encouraging of all the patient is able to do, and always building on that by exploring and expanding what they are aware of as it emerges. Useful interventions include: What is that like…uhuh and what is that like? Is there more? Say more… Tell me more. Staying with the core feeling, patients enter core state. Here they reflect on their experience and are in touch with their coherent narrative. We do not want to interrupt this: Let it be. Nonverbals of affirmation, understanding and connection work well here: mmm and uhuh.

Step six is metaprocessing. Metaprocessing or Metatherapeutic processing is exploring the experience of having the experience: it is the place where right brain experience is uploaded into left brain language; where previously unformulated experience is formulated and symbolized. In AEDP we use metaprocessing as a way to constantly titrate our therapeutic interventions and the ongoing texture of the relationship itself: the language of the intervention: What is it like to…?: helps both patient and therapist alike make the implicit of our work explicit.

The Patient

The patient, “Amy,” is a twenty-seven year-old young woman. She has recently moved to New York. After the separation and divorce of her parents when she was five years old, her mother remarried and raised her. Amy had limited contact with her father. Then at the age of fifteen, Amy and her father had a big argument and they have not spoken since. She was sexually assaulted by a trusted friend in high school, and saw a school counselor for almost a year after that. Amy came into treatment suffering from depression and panic attacks. She had been isolating since her move to New York.

Our sessions are sixty minutes and videotaped; the patient receives a DVD copy of the session. The transcript below is the second session. The precipitating event that brings Amy into therapy is that her best friend has inexplicably stopped talking to her. This leads to her isolating behavior, a depressive episode and a series of panic attacks.

As we work together in this session, it becomes clear that the recent abandonment by her friend is bringing up her previous abandonment by her father, both at five, when he left the family, and at fifteen, when they stopped talking. It is also triggering feelings about the sexual assault that took place in high school. As we work through more and more emotionally laden material through the vehicle of affectively charged portrayals in this first session, Amy moves from addressing her father, to her current friend and finally to expressing her anger at the young man who assaulted her in high school. At times it is not clear to or about whom she is talking, illustrating the degree to which freshly emerging intense emotional experience is mediated by the right brain.

Right from the very beginning of the session, I orient her to the dual focus of my attention so that it can also become the dual focus of her attention: on her experience both cognitively as she tells her story, and physically as her body tells its story via somatic markers of emotion. To build the attachment, the ‘we’ from the very beginning, I specifically ask her if ‘we’ can look at things ‘together.’ In doing this explicitly, we are working to undo and repair the “unbearable aloneness” (Fosha, 2000) that has prompted defensive exclusion (Bowlby, 1982) of vital emotions, without which she is compromised in her dealings with the world. Finally, after each round of work, we metaprocess whatever has come up; we also metaprocess Amy’s relationship with me, her therapist. I do this by checking in on how she is experiencing herself throughout the session and how she experiences this new experience of herself with me.

This session is illustrative of the experiential-dynamic focus of AEDP, and how this specific, embodied focus catalyzes a deep, intimate experience of being known. As we launch into the work together, I do not know what had happened to her, nor do I know exactly why she was seeking treatment. Yet through a series of simple questions, Amy starts to feel deeply known and becomes able to focus on her somatovisceral experience. As she does, layer after layer of experience unfolds, and revelation (to herself, and to me) follows revelation. The work with Amy was set in motion and proceeded out of the profound way in which she felt seen, recognized and understood by my asking her about her experience of and in her body.

The Transcript/Three attempts at getting started

We begin the session with three attempts at focusing on her somatic experience. Notice the repeated question: ‘what are you experiencing physically?’ and the sequence and content of Amy’s answers. At first she does not describe what she feels in her body, physically, but rather uses more abstract words that, although emotional, are not somatically based. Then in answer to the question a fourth time, she makes the connection, and describes what she is feeling physically. In terms of dyadic regulation: we are nodding and matching each other in tone, pacing and intonation. We are getting in sync. By lowering my voice and slowing my pace a little, I am pulling to help Amy slow down and drop down into her somatic experience.

The transcript that follows is verbatim: author comments and descriptions of interventions are in bold, descriptions of tone and body language, etc. are in italics and AEDP interventions from the above protocol are underlined.

Pt: All my personal power comes from my… my speech and my ability to figure things out and to talk about them and to ya…so like to literally to protect it, you know, I guess (notice cognitive disruption)

Th: And as you are saying that, what are you experiencing physically? (focusing on the physical experience of emotion; asking the body to help)

Pt: Well, I am always a little embarrassed to talk about something that I am proud of in a way. Like I am proud that I am really smart (big laugh), you know. And um I’m also embarrassed that that is something that I would have problems admitting (patient tears up).

Th: That brings tears to your eyes to say that you are embarrassed of something that you are proud of (moment-to-moment tracking; noticing and reflecting back)

Pt: Ya. ‘Cause I am not as embarrassed as I am that I am embarrassed that I am embarrassed.

Th: It is like it is layered.

Pt: Ya.

A minute later:

Pt: (her mother and step-father)… they just like laughed a lot and…

Th: And this touches something? (tracking her experience; letting her know I see her feeling here)

Pt: Ya…

Th: Ya. Stay with what is happening physically. I see so much feeling coming up around this. What do you notice inside? (starting to entrain somatic focusing)

Pt: It is just…(she calms and gently smiles). It is so much in my childhood…(not quite getting to the physical, but it is emotional)

Th: And where do you feel it? Physically, if you just describe…just notice. Physically, right…(I keep asking about the somatic piece)

Pt: Physically…Well, it is like, I don’t know how to explain it, when I get nostalgic, when I get homesick or whenever it is like hard to be in New York City, and, I just, I think about that as such a great time in my life…yeah.

Th: And so much came up, right? (again educating that feelings come up inside, and letting her know I notice)

Pt: (laughs) Ya. It was a really wonderful way to grow up and at the same time difficult because it’s not common to be. It’s not as common, I should say, to be confident about how you look because you don’t care as much and then to realize that everyone else cares a lot, and to sort of bring that into your sense of self, you know what I mean?

Th: I think I know.

Pt: …I was never one of those little girls that the mother was like, “Let’s brush your hair, put you in a dress. You’re really cute. Don’t you look pretty today?” It just wasn’t in our vocabulary. From my dad it was really not in our vocabulary ‘cause he would never say, “You look pretty.” He was always saying, “You should look prettier.” (makes a fist and bangs armrest of chair). So I just…

Th: Mmm…and something shifted when you said that: a lot of feeling about that. (noticing a shift, and seizing upon it as a target of our attention and work)

Pt: Ya.

Th: Again what do you notice just physically, you know, because I…(asking her to focus on her somatic experience)

Pt: Clench up a little bit…(the therapeutic focus takes hold here)

Th: Ya.

Pt: Get a tighter throat . . . I have a hard time breathing sometimes. (the patient ‘gets it’ and begins to describe what she feels physically)

Th: Mmm… and if you just stay with that: that a lot of feelings comes up around this. What do you ? If you just let it be.

Pt: Be there (quietly and seriously)…(she makes it more specific; she gets it)

Th: Ya. What is that feeling inside? ….Tightness and…?

Pt: Well, it is funny that you should ask me because it’s…This is the stuff that bothers me so much that um physical tightness that leads to anxiety attacks and stuff like that. (this is a pivotal moment: the ‘click’ of recognition (see Fosha, 2009, p. 179))

Th: Mmm.

Pt: And it always seems to come from someone just being mean (laughs), you know?

Th: And you laugh, right? When you say someone just being mean.

Pt: Yeah.

Th: Yeah.

Pt: And I’ve noticed at work sometimes even… when someone in the line will speak to me like I am an idiot or like, you know, because there are some very, very ritzy people calling in.

Th: What happens inside, ya?

Pt: It really makes me tighten up ….feel really like I want to defend myself, but I am not supposed to.

Th: Mmm…

Pt: You know? Which is how I felt at my Dad’s house…all the time (Again she bangs her hand down on the armrest of the chair). He would always say, “You should be prettier.” (she makes the connection between past and present)

Th: And when you say that you make a very strong hand gesture. (Tracking her physical movements; asking the body to help: drawing attention to the somatic manifestation of an impulse; helping patient overcome the habitual exclusion of this somatic information from her mind)

Pt: Ya.

Th: You get this tightness. And, if you stay with that.

Pt: It was just such a mean thing to say to a kid.

In these very first minutes (we are 12 minutes into the session), my focus on the somatic component of emotions brings important, affectively-charged memory to the fore, complete with a somatic impulse. As the session progresses, we will find together that this tightness in her throat and panic attacks presage the affectively-charged memories associated with several relational traumas: the multiple experiences of abandonment with her father, the sexual assault in high school, and the event that brought her into treatment: the abandonment by a close friend. By using simple, repetitive language, a soft, gentle holding tone of voice, and focusing our attention on her physical experience as well as staying with her experience, we learn a significant amount about her past dynamics from her experience of the present moment with me.

After the patient bangs the armrest with her hand, I notice this, and we move into an awareness of the feelings that talking about her father has aroused. These feelings are processed via a portrayal (Fosha, 2000). Portrayals can be real or imagined scenes from the past, present or future in which the patient is invited to have a reparative, or a feared and avoided or a wished-for experience, through the vehicle of imagination. The brain processes imagined experience with very similar circuitry to that used in actual experience; the imagery and metaphor of portrayals activate many different areas of the brain (Pally, 2000, p. 33; p. 132). In this way, portrayal experiences in session assist in the processing of unsymbolized, dissociated, and traumatic material. Moreover, the more vivid and specific the imagery, the more connections there are to affective experiencing. With the therapist facilitating and working to enhance the vividness and visceral quality of the imagined scene, patients come to have a physically rooted, symbolized entity of their own. This expands the patient’s experiential, emotional repertoire. (Piliero, 2009). Although one always emphasizes (implicitly and explicitly) that these imagined scenes are not rehearsals for action, in fact, in many ways they are (though, of course, not the exact action portrayed in the portrayal). As patients gradually face—intrapsychically—people, affects and situations that have been avoided because of their painful/frightening/longed for content, patients scaffold up their capacity to connect with or confront people in their lives. Portrayals do in fact gradually open up possibilities for patients to become more assertive, confident, and emotionally connected, and to engage in adaptive actions on behalf of themselves.

Portrayal “DAD.”

As the patient begins to address her father, I work to make the portrayal as vivid and detailed as possible: I ask her to speak to him directly. I ask her what she calls him and then repeat his name. She repeats what she calls him, “Dad,” and in that moment she drops down into the seriousness of her core affective sadness and then moves swiftly into a core state declarative statement. The emotional breakthrough is fleeting, but is a heralding affect marking the transition into a core affective moment before she moves into a declaration of self. I metaprocess with her what it was like for her to do this piece of work with me; I am explicitly affirming throughout. Notice how I ask, “What is it like telling me…?” and she focuses on the dynamic work: “…it is nice to know that you understand where that tightness is coming from.” As I ask if there is more she needs to say to her father, she continues. This leads to another wave of sadness and a big sigh as that wave ends. Ultimately she lays out her dynamics: because of the patterns she developed in her relationship with her father as well as the sexual assault, she is fearful of and avoids emotional closeness with men.

 

Th: So what would you want to say to him if you just let yourself?

Pt: I would say to him, I would say: “I wish that he would have acknowledged the other stuff about me and realized that I was really a very beautiful kid.” …And that other people in my life…other adults… were always saying to me you know it’s his loss.

Th: Mmmm…And if you said it to him directly. What do you call him? What do you call your Dad?

Pt: I call him, “Dad.”

Th: “Dad,” you’d say…

Pt: I’d say, “Dad.” ( she tears up and her voice cracks)

Th: Mmm… What happened? It brought up a lot…just saying his name.

Pt: It’s just I stopped calling him, “Dad.” I…his name, “Dad;” when he left. I would say, “Dad, I am a very beautiful person and you are not a very beautiful person for saying that to me.”

Th: Mmmm…And what is it like to say that out loud? (metaprocessing this round of work)

Pt: Really justified. (beaming)

Th: Yeah, yeah and… What does that feel like inside to feel justified?

Pt: A bit more solid in a way…

Th: Tell me a bit more…ya… because…

Pt: I have never acknowledged him as an adult, you know?

Th: Ya…I think I do.

Th: Say more.

Pt: It’s very much like sometimes I think that I know I was a kid so I wasn’t really trying very hard like it wasn’t my job to be an adult but sometimes I feel like I was never really honest with him in pretty much the whole relationship and it feels good to be honest. (this is new: coherent narrative emerges)

Th: And to say what you just said really directly out loud. (explicitly naming and affirming all that she has already done)

Pt: Ya.

Th: Ya…sounds right and how is it? How are we doing? It is really our first, in a way, it is our second meeting, but in a way… (metaprocessing)

Pt: Pretty good.

Th: Yeah. What is it like telling me and seeing that I am getting it and hearing it? (metaprocessing the experience of recognition)

Pt: It feels good. I mean it is nice to know that you understand where that tightness is coming from. (patient refocuses me in the physical experience: her right brain is engaged and is keeping us on track)

Th: And how is that tightness now as you just sit with it?

Pt: It is a little less.

Th: Yeah. Mmm.

Pt: A little less, less pangy.

Th: It is still there a bit … Is there more you want to say to him directly?

Pt: Well….(sigh)…The thing I really want to say to him is, “Dad, how could you just pick up and leave your daughter… I just I can’t even understand any part of it.” That’s the main one…

Th: It’s a lot. (affirming)

Pt: Ya.

Th: And what do you notice, as you say that? the feelings inside? You let out a big sigh before you started. (tracking her experience)

Pt: (sigh)

Th: A big sigh. (noticing theend of wave of feeling)

Pt: It’s just very…it’s kind of lonely, I mean. I understand that I can’t control other people, but I feel this huge urge to do that…(self declarative statement)

Th: So, if you stay with what is coming up and just let it be, what do you want to say or do?

Pt: I would love to say, “If I were a father, I would fight for my daughter, if I thought that…” because he thought that my mom was, you know, corrupting me against him… “and I would fight. I would try to see me as often as possible and the fact that he didn’t says to me that he was not a strong enough person to love someone who was not just going to cater to his every whim.

Th: Mmm….Wow…that’s a lot. (expanding;affirming; empathic)

Pt: Ya…

Th: Is there more?

Pt: I am worried that I am like that…

Th: Mmm…Say more…

Pt: When I am dating people I am always, always breaking up with everybody and sometimes I just stop calling and I just it’s out of like sheer panic and I feel bad for the other person and I don’t want to deal with that situation and how do you tell someone you just don’t…

Th: You just don’t…

Pt: You just don’t love them. And at the same time you…it is not my responsibility to stay with people the same way your family is, but I am worried that that is something that I would do.

Th: You are afraid you are like him in this way. Mmm.

Amy jumps right into the portrayal with a little help from me, and she gets an immediate result: a declaration of her self to her father and a deep, visceral connection between her physical experience and her presenting symptom. As the session moves forward, both our connection and her affective experience is deepening: “The directional flow of AEDP treatment is to always be moving down…” (Russell and Fosha, 2008). We are. Amy is having a new and positive experience from the very beginning.

In the intervening sections of this tape, we go into an exploration of good feelings around her mother and step-father; we metaprocess those good feelings. She describes her assault in high school and how she blames herself for making friends with the wrong people, including the young man who sexually assaulted her. She reports how she froze during the assault, and blames herself for that. I spend a few minutes educating her about the biological freeze response, and explain how it is adaptive and wired in for our survival. We then move into a portrayal of anger and revenge against the perpetrator.

Portrayal of anger towards perpetrator/GETTING UN-STUCK:

In this next section, immediately after Amy has described the sexual assault in high school, she complains about her feeling of stuckness: “I’m still stuck.” This “stuck” state and the cognitive disruption that follows are a manifestation of anxiety and the frozenness from the past. Note that this anxiety will abate when the patient and therapist, anchored in the safety of the current relationship, move to explore her deeper feelings. Her imagined impulse in the portrayal will overcome her anxiety and provide movement and relief. Amy connects her feelings for the young man who assaulted her with feelings about her father who abandoned her. She is making the connections with emotional threads. This final portrayal leads to a breakthrough of grief for her former self, before her father left her and before she was sexually assaulted. This portrayal is effective in that it leads to a sense of mastery and then a breakthrough of feeling. It is like a release valve for her sadness and leads to a beautiful example of healing affects in the transition to core state. It is noteworthy that the patient is doing all the work: she is telling me that the tightness in her throat is happening right now, and that feelings are coming up in the moment.

Pt: I haven’t had sex. I’m so mad at him ‘cause I want to (hands clenching up). I am so frigging terrified of it.

Th: And I see that you are really mad at him.

Pt: Ya.

Th: You are very mad.

Pt: Ya, and it affects my normal relationships even further because I want to date people, and I know that you don’t have to have sex to be dating, but at twenty-seven most people have and I don’t want to have to have this conversation with everybody that I date.

Th: Right. Right. Mmm.

Pt: Yeah. That is the biggest.

Th: Ya, that is huge.

Pt: Because I, like, I can work through what happened.

Th: Ya.

Pt: And I think it is important to at least go back and acknowledge the fact that I am

ashamed, and to understand why. Not that I shouldn’t be, but that it isn’t the case, but ultimately the result is that I’m still stuck and that is what bothers me the most with my father and with this and with anything that’s just… and that’s where the…the tightness comes from that’s coming up right now. That stuck feeling. (notice cognitive disruption)

Th: So if that boy was here what would you want to do to him to get rid of that stuck feeling?

Pt: (laughs) I have two answers.

Th: Do you want to tell me? (inviting)

Pt: I mean I want to cut off his penis…

Th: What do you imagine?

Pt: Sorry? (a little bit of a surprise; unexpected)

Th: What do you imagine? You want to cut it off. What would you use? Where would you be? How would he look? (explicit invitation: details are essential)

Pt: I imagine him being wild and drunk, but then I start to think about actually cutting off someone’s penis or even hurting anybody. I always have the opposite reaction which is to not, you know, and to let it go and to not let it go not in the sense of whatever, but to be able to realize that he was lashing out of whatever the hell he was lashing out of and it is a horrible thing, but that by still hurting myself about this I am carrying it around.

Th: So I am saying: I’m not saying that you’re going to go do this to him or to anybody.

I am saying, if you let yourself in your mind’s eye imagine it, my guess is you would get some relief from this tightness that is kind of choking you. (offering hope: we can do this together: inviting the patient to overcome her anxiety by experiencing her strong emotion with me)

Pt: (sigh) Ya…

Th: And I just, you know, just for a minute just to let yourself imagine what it would be like, if that feels like an okay thing to do with me (specifically undoing aloneness)

Pt: Yeah.

Th: Now just for a minute (offering a time limit creates containment and lets the patient know that I will help titrate the feelings and that we won’t allow the feeling to go on indefinitely or become overwhelming) you know not to do the civilized route, which is what we all do, right? (bypass defense)

Pt: Ya.

Th: It is not a rehearsal for action. It is just to let yourself know.

Pt: Then I’d like to punch him.

Th: Yeah. Where would you like to punch him? (details are very important)

Pt: In the face. Ya. Really hard.

Th: Which hand would you use?

Pt: Right hand. I am right handed, and um take him by the hair… this feels really weird. (a last gasp of defense; heralding affect)

Th: Just go with it. Just go with it. (explicitlyencouraging)

Pt: Take him by the hair and slam his face into a wall. Kick him in the crotch and below the kneecap. In karate it is the most painful place to kick someone.

Th: Which foot do you kick with?

Pt: Right foot.

Th: Ya. Ya (firm, serious, increasing tempo to match her increase in intensity and tempo)

Pt: And um I would I think I would cut off his penis.

Th: What would you use?

Pt: A saw.

Th: Aha. Mmm.

Pt: I heard that he had done that to other people through talking to people as well…and that…

Th: What he did to you?

Pt: Some people shouldn’t be allowed to have penises.

Th: Um. So he shouldn’t be allowed and what does he look like as you punch him and kick him and get out a saw?

Pt: Totally shocked and surprised just doubled over in pain.

Th: And what do you say?

Pt: Fuck you.

Th: Right.

Pt: Fuck you.

Th: Yeah.

Pt: Shithead. (verbal discharge indicating an intensification of feeling)

Th: Ya. Fuck you. Shithead.

Pt: Yeah.

Th: What is it like to say this out loud? (metaprocessing of the experience)

Pt: (laughs)

Th: Mmm. (low; trying to regulate her anxiety)

Pt: It’s, it’s, it’s both, uh. (laughs) It feels kind of good and I feel embarrassed a little for feeling good.

Th: And if you put the embarrassment to the side? (bypass defense)

Pt: Ya.

Th: And let yourself feel the good feeling. I mean you sat up really straight and your eyes are bright and you just did this huge big thing with me where you really let me know: that’s how angry you are. What’s that like? (metaprocessing)

Pt: It’s good.

Th: And what is it like to see that I am, like, right, that I’m moved, right? (metaprocessing explicit reference to me as her True Other in this particular moment; self-disclosure to complete new experience with affective response)

Pt: It’s great. It’s nice. It’s nice to know that that’s an acceptable thing.

Th: Mmm. Mmm. And I’m moved you trusted me with this huge big thing, right? All these feelings: what he did to you and what you’d like to do back. (using my self-disclosure of my emotions here to let her know she is having an impact) And I feel like and I don’t know if I am right but you are like, “Yeah!” (inviting her to feel mastery and accomplishment)

Pt: Ya, I did get a little bit more poised. I think of it sometimes you know the ways of like you try to not do things that are illegal, but he did something illegal to me and it’s nice to have that fantasy for just a second. Like in those old western movies: someone raped someone’s sister and then like five cowboys go out and like butcher the guy (my affirming her portrayal gives her permission to imagine even more release for this angry impulse and to take it further)

Th: Right. (affirming)

Pt: Yeah.

Th: Right, yeah. That is right.

Pt: Yeah.

Th: That’s right. (affirming: strong tone to match hers)

Pt: And in this situation nothing ever happened you know (reparative portrayal; something new has happened here together)

Th: Right, right, and I think that you’ve always tried to, you know, he did that and I am going to take the high road or I’m not going to feel that and, you know, I think to get through things we need to go through and allow ourselves to go through the feelings.

Pt: Yes.

Th: And I think you did a really good job today of going through the feelings, Ya. (Explicitly affirming)

Pt: Thank you.

Th: Ya.

The portrayal and Meta-therapeutic processing of my emotional reaction to the portrayal lead to a breakthrough of healing affects. We are now riding the wave of the change process itself. Amy has had an emotional experience with me, and sees that I get it. This is new and transformative for her. Metatherapeutic processing — talking about and reflecting on the experience — is as important as the experience itself, and is an integral part of AEDP and healing: “by focusing explicitly on meta-therapeutic experiences, rather than allowing therapeutic processes to operate silently, we give patients the opportunity to process, and thus learn about, the nature of helpful experiences in which they already have been successful.” (Fosha, 2000, p.163).

 

Healing affects/Post-affective breakthrough affects

The following section shows clearly why we do what we do in AEDP. After the portrayal, our brief but intensely emotional Metatherapeutic processing makes room for another round of work heralded by healing affects: these begin with a sort of hiccup; she describes a lot of air bubbling up, and feelings of feeling physically lighter and brighter. These healing affects are markers of the transformation and “heal in and of themselves.” (Fosha, 2000, p.163).

Pt: Mmm. Hiccup!

Th: Mmm. So what’s that feeling like that tightness now?

Pt: Um. It’s not tight right now. (anxiety diminished now by connection with core emotion)

Th: It’s not tight right now?

Pt: No. Um. That’s weird. A lot of air bubbling up (the release ofhealing affects)

Th: Tell me more.

Pt: (laughs) I don’t even know (laughs). Physically just lighter; a little bit brighter. (post-affective breakthrough affects)

Th: Mmm.

Pt: You know when um everything gets sort of closed in and you can hardly see outside your face…

Th: I think I know.

Pt: And then it sort of opens up a bit?

Th: Yup.

Pt: That’s what I feel like…

Th: You feel like…

Pt: …physically. (she is using my language and intonation from the beginning: she says this with some emphasis)

Th: Yeah. Wow. That’s great.

Pt: Yes.

Th: Ya.

Pt: I felt like this a while ago when I was so upset about my friend and we were at work together and I was so tight and I just could see like this much (she gestures with her hands on each side of her head as if showing blinkers covering her eyes) of the world and I was choking…(here she describes an experience of figuring out and expressing what she was feeling)…suddenly I could like see the world and that is what I just felt like right now.

Th: Right. Right.

Pt: It is so funny when that happens.

Th: Ya, that fits so perfectly, right?

Pt: Ya.

Th: And that it is about having feelings and letting them go where they need to go, right? As you just did in your mind’s eye. (leading; psychoeducational)

Pt: Allowing it.

Th: Allowing it, right? Because you are having the feeling whether you want to have it or not, right?

Pt: (Laughs) That’s true.

Th: And letting feelings kind of do what they need to do. I think nearly always… What is going on? Your leg is going. (This is an example of a hugely useful AEDP intervention: the interruption (Prenn, in press) when we start to talk, and notice that something else is happening with the patient. I “interrupt” myself here to notice and seize something coming up physically that needs to be tended to).

Pt: (laughs)

Th: What are you feeling inside as I am saying this?

Pt: No, I mean it is exciting…I am thinking about all the times that I like will have a feeling and then think I am feeling through it but then it is still tight (sigh).

Th: Yup. Yup. And so maybe, I think, in a way you learned something about feelings today…That was a big sigh, and, again, just notice, you know, because we just did a lot.

Pt: I think it is cool how physically you are very aware of everything that I am doing by the way. Very interesting. (moving away from “right brain” to “left brain:” linear, logical processing)

Th: I think the body tells a story, right?

Pt: Ya.

Th: And when you were feeling the anger, right? It comes up.

Pt: Ya.

Th: And so emotion needs to go somewhere, right?

Pt: Otherwise it’s like aaaahhhh!!

Th: That is right and then you feel it, right, it is like this thing, and what are you going to do with it? (We are both quite excited in our tone and pacing. I am leading: I want her to have a good experience, to know she has had a good experience)

Pt: Ya.

Th: Ya… So we are really pretty much at the end and I want to check in how really again this was to do this piece of work with me today. (Metatherapeutic processing)

Pt: It feels good.

Th: Say more.

Pt: I am really surprised. (healing affect; something new) I… usually when I tell that story I am really upset at the end. (“upset” is the feeling of constricted emotion coupled with anxiety; Amy is noting having the positive experience of core emotion without anxiety)

Th: Ya. And today?

Pt: I just. I’m not. I feel like I can really kick some ass. (mastery affect) I don’t know in what context.

Th: You did in every way, right? Not only his, but sort of internally for yourself. (Highlight, celebrating and cementing all that she did)

Pt: That is the most important thing that I feel, I think. (she tears up)

Th: And there are tears in your eyes. I think you feel some emotion.

Pt: I do. I mean in a weird way. I am sure you know what I am talking about. (she feels deeply understood; True Self/True Other relating in this moment). Even the smallest letting go of things is sort of sad.

Th: Say. Say… about the sad.

Pt: Both that you had it in the first place…that you sort of forgive yourself for having it and that you are not that person anymore…(mourning the self)

Th: Tell me about that …that at the end that you are not that person.

Pt: I’ll never . . . be . . . before . . . that . . . again. (She says this slowly and deliberately, pausing between each word as she spells it out)…And letting go of that is the same as letting go of that person a little bit and it’s not a bad thing. It’s just a little bit sad, you know?

Th: Uhuh. It’s a lot. Ya. Totally.

Pt: Woosh. (a release;transformational affect)

Th: What just happened?

Pt: It does. It made me a little sad to have been that young and that happy and excited and hopeful and really a very gentle person. And to grow up through something.

Th: Mmm.

Pt: Yeah. Sorry, I know we are right at the end. (yes, but we need to complete this)

Th: We are. I just feel. Is there more that you need to say because this feels like another wave of feeling coming up…(educating that feelings come in waves and need to be completed)

Pt: That was the biggest.

Th: About feelings…about.

Pt: I forget that I feel like this sometimes… occasionally that I get to feel like this sometimes.

Th: So, tell me what you’re feeling. This is important.

Pt: Very young and sometimes I wish I could go back in time and change what I would have done.

Th: Mmm.

Pt: Not just necessarily that, but everything: who I chose to be friends with, how I chose to treat myself, and to act but I was young at the time. So I am just sad for that part of myself…(increasing coherency; notice beginning of ‘parts’ language as a previously excluded self-state no longer defended against after her contact with core affect enters her conscious awareness)

Th: That part of your self, right, in fact, that he really took away.

Pt: Ya.

Th: I think some of these tears are that: that you are not that person anymore.

Pt: No. Exactly.

Th: Ya.

Pt: Ya.

Pt: Mmm…oy.

Th: But if you don’t “oy” it, right? And you just let it be, you know, there is a lot of sadness for yourself (bypass defense; stay)

Pt: Ya.

Th: If you just let it be. I feel like there is a lot more tears and you are doing such a good job of holding them back, but if you do a good job of letting them go? (inviting; tracking)

Pt: You are right. (laughs)

Th: Why are you laughing? Because that is what you are doing, right? (I see her defending against this wave of sadness)

Pt: Ya, I’m very sad.

Th: Yup. You are very sad.

Pt: (sigh)

Th: Don’t fight them. Don’t fight them. These are important tears.

Pt: Ya…(laugh) I can’t see anything aahh…(sigh) (laughs/cries)

Th: Mmm. We have time (slowing down and lowering my voice; making space for her) You don’t need to be so brave. Just let it be. I see you fighting…(tracking: inviting to stay)

Pt: (laughs/cries) (state transformation)

Th: Mmm…mmm. So much pain here…

Amy is struggling to contain her feelings; we are at the end of the session. As I notice another wave of emotion coming up, I take the lead and firmly let Amy know that what we are doing together takes precedence over time constraints. As I explicitly give her permission, she holds my gaze and says, “I am sure you know what I mean.” This is True Self- True Other relating, an I-Thou encounter (Buber, 1965) in this moment. I am what she needs right now (Fosha, 2005). As the healing affects bubble up in her and she feels an upsurge in vitality, she moves into mourning the self (Fosha, 2000). Through the abandonments by her father and the sexual assault in high school, she is not the same person that she was, but she can acknowledge that and the defenses she has put in place to protect that part of herself.

Grief for the self/core state/declaration of self/integration of dissociated self-state

Deeply connected with me, Amy is able now to contact this part of herself. Through our processing of emotion facilitated by increasingly affectively charged portrayals, and the Metatherapeutic processing both of this work and our connection in the moment, Amy comes into deep contact with a previously excluded self-state with its emotional components. This dissociated self-state, frozen in the past, is now present and Amy is able to both embody it with all its feelings and reflect and integrate it into her sense of her self. She is feeling this part of herself and able to connect to it. She also sees clearly how her defensive system came into existence and the part of her self it was designed to protect. In terms of transformance, what is remarkable is that although this is new to Amy, it is also deeply familiar, she comments, “I forget that I feel this way sometimes.” This feeling-state was there all along.

In core state: a place of coherence, clarity, openness, and compassion (Fosha, 2000, 2003), Amy is deeply in touch with her “emotional truth.” Structurally she describes how through traumatic experience she divided herself and put her defensive self in place. She sees her emotional self standing behind and protected by her defensive self. Her defensive self is ready with fists up. It is protecting a part of her that is just coming back into her awareness. She has lived an emotionally constricted symptomatic life for over ten years with her more vulnerable self dissociated and outside of her awareness. The imagery of Jesus and Judas come to her spontaneously: although she is not religious, they vividly portray these two separate parts of herself. Notice the amazing language she uses to describe the Judas part of herself. And how spontaneously the idea of forgiveness of herself comes.

Pt: I was such a good kid. I was a really decent person. I didn’t really look at the bad in everybody you know when in situations where everybody saw the bad I was always fighting with people, but I didn’t think they were bad people. I was fighting with them because I wanted them to be good people. (core state)…And I kind of gave up.

Th: Mmm.

Pt: (sigh) Yeah. It makes me sad…

Th: And what else is coming up? There is a ton coming up. If you just let it be. Don’t hold it back.

Pt: I don’t know why it’s so hard.

Th: Well, ‘cause I think you are saying, “We are at the end, and I can’t do this now,” but I am saying, “Look. This is really important: I see a ton coming up… all feelings that you are doing… you’re holding on to.” What do you notice in your body, if you describe it? (working to completion; my tone is firm and leading; the intervention is giving permission)

Pt: It’s just so funny that I can physically feel like I am like fifteen years old. (she is now viscerally embodying this dissociated part of herself)

Th: Mmm.

Pt: You know and all this time, and I feel like I never talk honestly any more and I don’t react honestly because I am trying to be both pleasing to other people and not in that situation again. And it is so hard to be close to anybody if you can’t allow yourself to be yourself or to ever be in any danger. And I was so impulsive and I was that person… I was so young. I was so hopeful. I was so open to everything. Everything hurt me and everything was wonderful, you know? (declaration of self and with it a coherent narrative of what her defensive strategies have been)

Th: I think I know.

Pt: And everyone would always say to me, “You need to get a thicker skin. (laughs) What are you? You can’t.” And I would always cry for like you know like hours and be like bawling hysterically and my Mom would be like, “What is going on?” and I would be like, “I have no idea. I just know that that hurt me or this is wonderful or …” And I miss being that person and that makes me really, really high-pitched apparently.

Th: ‘Cause you are feeling a lot.

Pt: Ya.

Th: You miss being that person. And he really took…really took…that person away.

Pt: Ya. He really did.

Th: Ya. He really did. (affirming; affect regulating: matching her)

Pt: Shithead.

Th: Shithead. Right. Right. And, physically, what are you feeling, right, as you say that, right?

Pt: Violent.

Th: Ya, ya. And what comes to mind?

Pt: Like two person like the person that was gentle and the person that’s gonna defend…the person…

Th: And what do you see?

Pt: I literally have this duality of like seeing myself standing in front of myself, you know, and literally having my self this self be somewhere like lost in the dark, kind of because of that, and to have this person out in front, you know, ready (she makes fists) (laughs) (she is describing her defense and what had to be kept out of her awareness or dissociated)

Th: (I make fists) Ready.

Pt: Exactly. And that is the part that is sad. I read this great play um The Last Days of Judas Escariot, and I don’t know if you know it?

Th: Uh oh.

Pt: There is this image of Judas in hell basically just in a coma comatose sitting there like a single tear running down his face and no one can reach him anymore because he doesn’t exist. And, um, and Jesus just sitting there trying to get him to come out of it and I am not religious at all. I just related to that. (vivid imagery in core state)

Th: Ya…It touches something. It touches you.

Pt: That Judas can’t feel that love and that Jesus will always forgive Judas, but Judas will never forgive himself and it’s not a forgiving myself thing but it’s…it is the same feeling and it kind of is forgiving myself.

Th: It is. I was going to say.

Pt: And I was going to say that too. (we laugh: this is a very tender moment and yet as we both laugh about this truth we are making this very new intersubjective experience stronger: “it is important to emphasize that dyadic means dyadic: The caregiver’s affects are part and parcel of the process of dyadic regulation…” (Fosha, 2004, p. 36-37).

Th: I think it is very hard to forgive yourself for being young.

Pt: So young.

Th: Ya

Pt: It is the Catch 22…

Th: Go on.

Pt: …of that situation because I can’t be that person again like I’m not anymore. So it’s hard to forgive that person for being naive because that person isn’t there. (laughs) (Amy rather amazingly describes clearly the phenomenon of living with a dissociated self-state)

Th: But you are saying in a way that you can imagine that part of you. (imagining can be an important first step in connecting with a feeling/part/self-state)

Pt: Ya. And I can imagine that part of me and if that part of me would only wake up and become a part again then I would be able to forgive myself and bring the two together so that I could be both a little naive and a little street-smart and a little gentle and a little tough. (declaration of self and how she can imagine what needs to happen and is happening as she speaks: this part of her self is entering her conscious awareness and becoming integrated)

Th: And you keep like you have this precious (her hands are holding something in the air; encouraging her to make contact with this vulnerable, younger part of herself)

Pt: That’s funny. It feels literally like that: I do have this beautiful thing inside of me that is just too painful, too too raw to bring to the surface and it’s so sad…

Th: There is so much sadness in that part of you, I think…mmm. This is this huge big thing.

Pt: It is really pretty big.

Th: Pretty big.

Pt: Ya.

Th: Ya.. and I feel so moved that you shared it all with me.

Pt: Thank you for letting me.

Th: (sigh)

Pt: (sigh) I mean that pretty much is the whole, I think.

Th: The whole?

Pt: The whole thing I need to acknowledge and to understand.

The True Self/True Other, I –thou relating interpersonally facilitates a self-self intrapsychic experience: Amy is integrating her more vulnerable fifteen year-old self into her sense of self. She will report a greater openness and vitality in all her interactions and more willingness to take risks in trying to make friends.

Immediate Follow up

After this session, Amy stopped isolating. She felt less cynical about New York City, and reported feeling softer and more tender in all her interactions. This transformative session was the beginning of her allowing herself to feel complex feelings towards her parents and friends, and for herself. Later, in discussing the session transcribed above, the patient reflected that, “It was like a super power at work: like I had the power to heal myself, my whole body was just like a… healing all my illnesses.” In AEDP “…we are primed to be on the lookout for evidence of the patient’s profound adaptive strivings, reflected in his reparative drive and self-righting capacities…” (Fosha, 2000, p. 68).

This is transformance at work.

References:

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Buber, M. (1965). The knowledge of man: Selected essays. New York: Harper Torchbooks.

Fosha, D. (2000b). Meta-therapeutic processes and the affects of transformation: affirmation and the healing affects. Journal of Psychotherapy Integration, 10, 71-97.

Fosha, D. (2001). The dyadic regulation of affect. Journal of Clinical Psychology/In Session, 57(2), 227-242.

Fosha, D. (2002). The activation of affective change processes in AEDP (Accelerated Experiential-Dynamic Psychotherapy). In J. J. Magnavita (Ed.). Comprehensive Handbook of Psychotherapy. Vol. 1: Psychodynamic and Object Relations Psychotherapies, (pp. 309-344). New York: John Wiley & Sons.

Fosha, D. (2003). Dyadic regulation and experiential work with emotion and relatedness in trauma and disordered attachment. In M. F. Solomon & D. J. Siegel (Eds.), Healing trauma: attachment, mind, body, and brain (pp. 221-281). New York: W.W. Norton.

Fosha, D. (2005). Emotion, true self, true other, core state: toward a clinical theory of affective change process. Psychoanalytic Review, 92(4), 513-552.

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Fosha, D. (2009). Emotion and Recognition at Work: Energy, Vitality, Pleasure, Truth, Desire, and the Emergent Phenomenology of Transformational Experience. In Fosha, D., Siegel, D.J. & Solomon, M.F. (Eds.). The healing power of emotion: affective neuroscience, development, & clinical practice (pp. 173-203). New York: W.W. Norton.

Frederick, R. (2005). AEDP Core Training Presentation, San Francisco, CA.

Lipton, B. (2005). Personal Communication.

Pally, R. (2000). The mind-brain relationship. London: Karnac.

Piliero, S. (2009). Presentation at the AEDP New York Seminar Series.

Prenn, N. (in press). Mind the Gap: AEDP interventions translating attachment theory into clinical practice. Journal of Psychotherapy Integration. Special Issue on Attachment.

Prenn, N. (2009). “I second that emotion! Self-disclosure and its metaprocessing.” In A. Bloomgarden & R. B. Mennuti. (Eds.), Psychotherapist Revealed: Psychotherapists speak about self-disclosure in psychotherapy (pp. 85-99). New York: Routledge.

Russell, E. & Fosha, D. (2008). Transformational affects and core state in AEDP: the emergence and consolidation of joy, hope, gratitude and confidence in the (solid goodness of the) self. Journal of Psychotherapy Integration. 18(2), 167-190.