Tailoring AEDP Interventions to Attachment Style (Page 2)

PORTRAITS OF ATTACHMENT STYLES

Turn It Off: Avoidant/dismissive

With avoidant attachment style or dismissive states of mind, (Main, Hesse, & Kaplan, 2005), the distinguishing feature of the procedural learning is self-reliance, which has an insulated quality, which is residual of a profound lack of connection between self and other. Early on, protective walls have been erected to protect the self from rejection, intrusion, and/or vulnerability. Withdrawal and shutting down have been sure ways to survive the agony of being hurt by disappointment, humiliation, and rejection. Pursuing, doing and accomplishing are ways of realizing success in the world, while often disconnecting from the loneliness within. While anxiety is definitely part of the picture (Ainsworth, 1978, describing the avoidant child’s behavior in the Strange Situation) it is often deeply held, concealed.  So much is internalized, and so little is expressed. This way of living, one that diminishes experience by suppressing arousal, becomes a kind of disappearing oneself, making it hard to be seen, much less known by another, also hard to find oneself or acknowledge one’s own needs. Facial expressions are masked, and words are withheld behind walls of silence. Energy conservation is the way and the how.

So often these successful-in-the-world people enter psychotherapy when their partners complain and struggle with lack of intimacy and want more satisfying connection. The partners’ approach behaviors and bids for deepening relationship have been met with hostility and dismissing words and gestures: the avoidants’ hands motion “stop right there,” their arms brush off contact, giving implicit and explicit messages that shout “leave me alone.” While underneath there can be a yearning for contact, the avoidant attachment strategy is a defensive prohibition against needing others in order to prevent the risk of being hurt. Early longing was disrupted.  Getting close to that again must be avoided at all costs. Cassidy and Kobak (1988) identified secondary attachment strategies, deactivating and hyper-activating, to describe what happens in affect regulation when one’s attachment figures are unavailable and seeking proximity is fraught. Avoidants are prone to use deactivating strategies, turning the attachment system off, to disconnect their need for others as a way to bear and cope with anticipated loss, frustration and rejection.

Turn It On, and On… : Ambivalent/preoccupied

With the ambivalent attachment style or preoccupied state of mind, (Main, Hesse, & Kaplan, 2005) the procedural learning revolves around clinging and protest, with an excessive focus on the other. These behaviors are actually strategies to counter the deeply ingrained fears of abandonment that arise in the wake of inconsistent caregiving. When caregivers are sometimes present, attentive and attuned, then at other times are not available, and are actually inaccessible or abandoning, their children suffer the insecurity of unpredictability. Uncertain whether mom will be available or absent, these children learn to keep a keen eye on her and often burst out with excessive displays of emotion to get her attention. Sadly, despite their clamor to be noticed and their longing for affection, they have a difficult time receiving soothing and calming, and letting it penetrate to their core. Even though the language of this attachment style appears to be one of attachment longing, this too is a defense. There is a high expenditure of energy and drama which actually obscures internal experience by externalizing discomfort, often with “walls of words” (Pando-Mars, 2013) that are tangential (Main, 2000) and ironically push others away in an effort to control the terror of abandonment.   In this style, the secondary attachment system, hyper-activating strategies, (Cassidy & Kobak, 1988) keep the attachment system turned on high alert, in attempts to get the help, love and support they need.

Disorganized: Unresolved/Fearful

With disorganization, the state of mind is unresolved, not representative of a particular attachment strategy in and of itself, but rather, a state that occurs when early attachment needs have been wired with trauma. When emotions in relationship are touched, this can generate enormous amounts of anxiety and distress in anticipation of what Mary Main calls “fear without solution.”  There can be rapidly oscillating shifts between dismissive avoidance, fearful preoccupation and dissociation or fragmentation.  The procedural learning is a response to longing and fear that co-arise; yet both of these neurological circuits cannot fire at the same time (Siegel, 2007). When the ones who are supposed to protect and care for you are frightening and terrorizing, or frightened themselves, it is quite the vicious circle when these loved ones are the ones who hurt you. Emotions are unsafe to feel and unsafe to express. Rather than feel emotions, someone in this state anticipates becoming overwhelmed, and dissociates to sever the connection. This both dissipates longing arising from inside, and disconnects fear about what is happening on the outside. Sometimes this dismantles the charge; other times it is acted out impulsively in threatening actions towards the self or others. When two contradictory circuits are activated at the same time, a fuse must blow out, and one of them gets extinguished. When this occurs, the therapist might notice a shift in posture, a clouding over or light gone from the patient’s eyes.

When a parent who has been traumatized raises children, disorganization can also result, especially when these parents behaved in unpredictable, fear invoking ways.  Their children develop role reversal strategies where the caretaking and controlling extend inversely from child to adult (Main & Hesse, 1990).  This too is protective, and such strategies enact “I can’t need you and be scared of you at the same time, so I will leave, take control or caretake you in the meantime.”

THE AEDP APPROACH

AEDP is an experiential, transformational treatment model whose theory, procedures and maps have deep foundations in attachment theory and interpersonal neurobiology, with a central focus on processing affective experience through to completion in close rapport with the psychotherapist. In AEDP, the heart of this transformational model is the relationship, as the therapist and patient foster the immense potential to become a healing partnership (Pando-Mars, 2011).  The AEDP therapist is engaged, attentive, caring, and explicitly empathic (Fosha, 2000), with the intention to foster security between therapist and patient. This is the backbone of the therapist stance in AEDP.  Establishing safety and undoing aloneness (Fosha, 2000) are the guiding principles of this model, to provide a safe haven and a secure base. Within the safe haven, we accompany our patients and facilitate their regulated affective experience, while we monitor their receptivity to our help and care. With this safe base, we support their exploration of their psychological issues, and we work experientially, moment-to-moment, to catalyze transformation in both their emotional and relational realms (Fosha, 2003; Lipton & Fosha, 2011; Prenn, 2011; Tunnell, 2011). Then, we process the change itself, i.e., we metaprocess the change that happens when people who have not been able to, indeed do so. This kind of metatherapeutic processing (described in more detail below) continues to deepen the self’s capacity for reflection, integration, and action on behalf of the self (Fosha, 2009b; Russell, 2015).

What AEDP strives to do is bring a secure attachment relationship to the fore, so that patients can develop a secure base within themselves. AEDP has a three-factor theory of change: It involves affect, relatedness, and transformation.[4]

Empathy, attunement, and the establishment of security and safety are essential, but not sufficient. The bond that gets created as a result of dyadic processes, the adult therapeutic relationship equivalent of secure attachment, serves as a matrix, a holding environment in which deep emotional processes, the kind mediated by the limbic system and right brain, can be experientially accessed, processed, and worked through, so that they can eventually be integrated within the individual’s autobiographical narrative (Fosha 2003, pp. 231-232)

The AEDP therapist focuses, first and foremost, on dyadic regulation of affect (helping the patient access, tolerate, and experience deeper feelings) to create a secure base for our patient’s explorations. We want to help them to make use of our presence, and genuine interest and caring. The AEDP therapist inhabits the relationship authentically, allowing his or herself to be impacted by the client and is looking to impact the patient in ways that serve up new experience—new in the sense of being corrective of previous attachment lapses. Diana Fosha expands upon Fonagy with her assertion of the importance of existing in the mind and heart of another. This incorporates “feeling felt” (Siegel, 2007) as well as feeling understood, which offers a depth of meeting that can profoundly impact the undoing of aloneness that besieges patients who were not seen and responded to reliably and with care.  Most importantly, this establishes the container for the deep emotional processing that is needed to restore the patient’s essential self.

The AEDP therapist also affirms signs of new relational and affective behavior in the patient, supports patients’ attempts to change old patterns, and is on the lookout for signs of distress that need a responsive touch. Seeking to undo aloneness and promote adaptive affect regulation, the AEDP therapist offers a) expressions of delight and judicious self-disclosure to build rapport and connection; b) explicit empathy and willingness to help, which may include providing psycho-education; and c) dyadic affect regulation for the accessing and processing of heretofore unbearable emotions. The AEDP therapist tends to the coordination of the attunement, disruption and repair cycle, stepping in when patients become dysregulated by anxiety or shame and lends a psychological hand (Fosha, 2000) to help patients regulate their arousal and affects.

In so many ways, the AEDP therapist occupies the right-brain–to-right-brain state sharing that Shore emphasizes, responding with sensitivity to what may be needed at any given moment. And at a point, we methodically shift from a right-brain exploration and accompaniment to a process using left-brain reflection. The AEDP therapist punctuates moments of meaningful experience with periods of reflection, referred to as metatherapeutic processing, or metaprocessing for short (Fosha, 2000). This alternation between experience and reflection gives patients opportunities to bring awareness into places that emerge freshly during the therapeutic encounter. Such reflection serves many functions: a) it initiates a pause that makes space for a new experience to be noticed, b) allows for deepening the experience and its integration, c) gives time for meaning making and “clicks of recognition” to arise, and d) helps the brain to encode new experiences so that, as Rick Hansen (2013) says, “new states become new neural traits.”

A specific intervention quintessential to AEDP is to check in with patient’s receptive affective capacity to inquire about how the therapist, their interventions, disclosures or other offerings are being received.  And I hope that you, dear reader, are seeing by now how important this is:  We as therapists need to know how our patients are feeling in our presence and how our intentions to be helpful are actually landing inside of their experience.  So we ask our patients directly: What is it like for you to hear me say that, when I self disclose something about myself, appreciate you, to have gone through such an emotional experience together? And more specifically, what happens in your body? When we can identify markers of arousal and activation and respond with what is needed relationally, we are offering qualitative accompaniment in the here and now. My intention in this paper is to provide inquiry as to what makes for just the precise relational dosing to be palatable and necessary for each patient to progress.

As patients feel met by their therapists, they are more likely and able to reveal unresolved traumas, losses, and disappointments and to show up in ways that allow themselves to be seen and to be known. Innate capacities and strengths begin to emerge naturally in such an environment, when what was sorely lacking is offered and now can soothe discomfort and ease pain. As the AEDP therapist encourages accessing and tolerating heretofore dreaded emotional experience and, with accompaniment, emotional processing to completion, this activates the specific adaptive actions that stimulate growth and well-being. Our assiduous systematic and consistent metaprocessing of each moment of growth and change serves our biological need to reflect on experience, to build understanding which deepens integration, and the capacity to know both our own mind and the mind of another (Fonagy & Target, 1997). This helps our patients move towards greater wholeness into a self that is transformed: secure, flexible and capable of being able to be in relationship while adapting to current life situations.

Thus, the patient transforms how they relate to their past, and by doing so can now thrive in the present. Transformation, the third factor in AEDP’s theory of change, is woven throughout the model of AEDP in multiple ways. First, AEDP is guided by the map of the phenomenology of transformation, which shows clear markers of affective change processes through the four states.[5] This includes transformance: the immense motivational force of growth and self-righting, the urge to actualize our intrinsic capacities, gifts and talents (Fosha, 2008). Transformation is enhanced by way of recognition processes: the “match” between something out there and something inside (Fosha, 2009a, 2013a). Recognition gives rise to realization affects that fuel discovery and understanding. In AEDP, the therapist is keen to recognize and foster such glimmers of health, self-awareness, and inner guidance.  Noticing and reflecting these aspects of the patient’s self taps a vital need to be seen and known, which further energizes the process of healing and growth (Fosha, 2009a, 2013b). We harness recognition and the sense of truth as motivation to guide necessary explorations. When knowing occurs and our patients begin to trust what springs from inside of their own experience, their “will” also comes online, as well as longing and intention.

This is the aim of AEDP, and we have ample evidence that despite histories of insecurity and disorganization, there are many patients who are able to move session after session along this transformance path, where their relationship with their therapist stays secure even as they explore difficult issues. Transformance allows the capacity for secure attachment to come to the fore in safety-inspiring relational environments and give rise to corrective emotional and relational experiences.

            Main and her colleagues discovered that a child’s attachment style is most often tied into the parent’s attachment style.  This has enormous implications for treatment. Mario Mikulincer of Israel has done much research on secure priming, to show how people can intentionally evoke a sense of security (Mikulincer, 2015). As the field of attachment theory grows, and its application to clinical practice (Bowlby, 1988) it continues to reinforce the AEDP principle for therapists to foster secure attachment during treatment so we can best help our patients face and explore what troubles them with maximum openness, curiosity and compassion. One of the constructs that AEDP has found particularly of use is that of “self-at-best” and “self-at-worst” (Fosha, 2000). Self-at best is a state in which a person is able to access their emotions and be present with their own experience while also able to accurately register the experience of others.   They feel capable and effective in themselves and have a realistic view and understanding of others. Self-at-worst is a compromised state in which a person has difficulty accessing their emotions and staying present. They may be experiencing heightened anxiety, defense or dysregulated emotion which distorts their perception of others. In the way that self-at-best and self-at-worst are representations how the self perceives the self and other, attachment styles can be viewed as self-at-best and self-at-worst configurations.[6]

AEDP on Attachment Styles

AEDP understands attachment styles as inner representations that depict how early relationships formed the neurological basis for how the self functions with emotions and relatedness in the context of relationships. Thus the contribution and terminology Diana Fosha introduced in her 2000 book, The Transforming Power of Affect, ties security of attachment with the capacity to regulate and experience all emotions, and insecurity of attachment with defenses that develop when the relationship is not able to hold the individual, and whereby the experience and expression of certain emotions cannot be tolerated.

Fosha (2000) thus describes attachment styles in the following ways:

Secure attachment: “Feeling and dealing while relating”(p.42): The capacity to simultaneously be with self and to be with another, to be with and process emotion while engaged in relationship; it also speaks to the capacity to be with and process emotion on one’s own without needing to heavily rely on defensive processes.

(Organized but) Insecure attachment:  Avoidant: “Not feeling but dealing” (p.43): A defensive stance of favoring self-regulation over dyadic regulation, self-reliance above shared experience. Emotion is defended against; it is contained, denied, internalized, often below surface awareness.  Avoidant defenses are powerful in keeping emotional and relational strivings offline, but functionality at any cost is privileged. Along with closeness, what is often sacrificed is vitality and energy for life.

(Organized but) Insecure attachment: Ambivalent: “Feeling (but reeling) and not dealing” (p.43): There is a defensive focus on the other and compromised contact with oneself.  Emotionality is pronounced, rather than emotion, and is attention-seeking rather than relieving or informing the self. Here, emotionality, which often gets confused with emotion, is really the by-product of defenses against emotion. Relationship at all costs is privileged over autonomy and functionality, which is where the cost shows up. These patients often present as “reeling” in response to the pressures of daily life, and often come across as hanging on by their fingernails.

Disorganized attachment: “Not feeling and not dealing”(p. 44): Difficulty being with self, difficulty being with other and the inability to experience core emotion without being overwhelmed, which is why emotions are dissociated. This leads to fragmentation in self to deal in relationship, and emotion that is dysregulated, dissociated or somaticized. Functionality is either compromised and/or painfully achieved at the cost of feeling real or present.

Therapy: When the Way Seems Blocked

For some patients the relational stance of the AEDP therapist is welcomed and received as a parched plant absorbs water. For these patients, counter to what one might expect based on their relational attachment traumas, treatment flows along the transformational pathway through the four states that characterize the process of change (Fosha, 2009a).  Yet, for other patients—and they are the focus of this paper—these behavioral attempts to establish self-at-best instead challenge or even threaten the patient, as their nervous system is activated at the level of the attachment wounding. They are baffled by the invitation to be seen and cared for, and with them, the work can lack a sense of flow and connection. These patients with more entrenched patterns of attachment insecurity are wary to give up their protective barriers to let such accompaniment permeate to their core.

Defenses come into play for a child when their distress is not mitigated by caregiver’s responsiveness to help and provide the care that is needed. From an early age, children will adapt to the absence of such response by doing what is needed to cope. By the time they arrive at our offices, those with insecure attachment will have become quite accustomed to living in their preferred defensive adaptations.  Of course, defenses are an integral aspect of our functioning in the world.   I am talking here about when defenses interfere and become an impediment to living life in a meaningful and engaged way.

The more a patient rigidly relies on habituated, defensive pathways of interaction, the more likely the therapist will be challenged to be effective (Schoettle, 2009). This is what can make engaging patients with significant histories of relational trauma so difficult.

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