Tailoring AEDP Interventions to Attachment Style (Page 5)
The following transcript is from two significant sessions about eight months apart, with a woman with whom I have worked for three years. In the first session the patient is facing a troubling experience with a current boyfriend that clearly has roots in her early life experience. Very briefly, when she started in treatment, while there was a known history of a childhood that was riddled with abuse and neglect, the emotional experience and connection between her current choices in romantic relationships was somewhat abstract. The mere mention of a younger self was met with a sense of disdain. In working with patients for whom emotional memory is dissociated, I often hold an image of some particularly poignant moment that seems to crystalize a traumatic memory. In this case, my patient had told me of an experience where she was caught between two very self-absorbed parents in quite a frightening situation, and yet there was no emotional access to what she might have actually experienced as the young girl at that time. We enter this session as she makes a statement that ties her current relationship experience into something from her history.
PT: …And it’s not like that’s a defect. That’s a wound that somebody left on me. So now the whole world gets to see…
TH: wait? Hold on for a second. That’s a wound that somebody left with you? [She is identified with the wound and feels vulnerable about being seen.]
TH: right… that just brings compassion to me… [I offer my compassion as antidote to shame.]
PT: it’s embarrassing to me.
TH: I understand… [Staying with her]
PT: how could you have compassion? It’s so humiliating. [She becomes curious about my response.]
TH: Look at me, how can I have compassion for you, really? [I want her to see me here with her.]
PT: well you could just feel bad for me [I hear this as speaking from shame… I mobilize to speak up on her behalf.]
TH: No, I feel mad on your behalf and I also understand that you were raised in a very unprotected way and your little heart was torn between two parents who were very self-absorbed and locked away in their own crazy worlds: Him desperate in his way and your mom desperate in her way…and you caught between them. [I bring awareness to a specific memory we have previously talked about – that epitomizes the very core of her struggle and relational trauma – a “model scene.”]
TH: being asked to help, so getting the message from early on – “You have to be the one to save me, you have to be the one to get mom to help me… I’m gonna like drown if its not you.” So I just have like a world of tender ache in my heart for how that little one was so unprotected and how that could get. …[Empathic elaboration]
PT: I feel like I’m really going away. It’s too much. [She recognizes she starts to dissociate. My explicitly drawing this scene forward to the extent that I did exceeded her window of tolerance.]
TH: Can you come back? Well, thank you for telling me. [Dyadic regulation: appreciating she was letting me know I had misattuned and went too far is also how I make repair.]
PT: yeah I just started being like, I hear your words but I don’t (eyes looking up and away)
TH: stay focused with me, what part could you hear, what part was too much. [I want to help her to notice what she can, to identify the anxiety that surged before the dissociation.]
PT: I hear your words in the beginning. Like that’s my chorus – caught between two self absorbed people, and sometimes I hear you say it and it feels just like – I mean its real – but it’s like numb. I know that happened. I know your seeing something … important. I know it’s a theme. I know it’s a template… but I don’t have like a sad feeling for that person…like I… [I am glad she can hold this much –the part where I bring in more affect on her behalf as I start to feel for her predicament was the part that evoked so much anxiety. Then she says she doesn’t have a sad feeling for “that person.”]
TH: so if we stop there, can we be with the numb… and like notice your present self. [Moment-to-moment, be in the moment with her and resource her in present time with present self.]
PT: I’ll watch you feeling sad and compassion for that – but it feels like I’m watching a show on TV
TH: Its like you’re a little depersonalized… so that’s where we need to stop. Like anything else I said after that (waves hand as if to push away) [My feeling for her is the moment that triggers her.]
PT: and I don’t remember [She goes away and starts to dissociate.]
TH: it doesn’t matter, right, cause that to me is – the place where there’s a recognition that I’m naming something that you know happened. I have feelings for it – and you don’t. [I platform by naming the process I am seeing that led to her dissociating – I don’t avoid it – I don’t move past it – we stay here to explore what is happening.]
PT: (shaking head) – yeah I just…
TH: I have feelings for you there… and you feel dissociated or disconnected. So that to me says – Okay… Can we somehow work together around helping you build a bridge into that part? [Ask permission to build collaboration]
PT: and then I get this angry disgusted feeling toward myself… about Why is this taking so long? Why does this take such hard work (hand scratching her hair – looks off to the side) what is wrong with me that… [She turns against herself.]
TH: so what if you directed that energy towards either of those parents who were pulling at you… [I want to redirect the energy outwards.]
PT: it’s the same feeling I have about getting mad at him right now – It feels pointless, I feel unimportant… it feels I don’t really matter. It’s just a bullshit pretend game. [She refers to the current situation we had been talking about before dropping down to the underlying pattern with her parents.]
TH: right, th… th…
PT: it’s just a game [Having her feelings is such a stretch.]
TH: right that’s the defensive place that you say ‘It doesn’t matter.” The “I” that doesn’t matter is stuck. Right cause they gave you so little recognition… that you can’t see yourself here. [I am reaching for her and wanting to make a link that she can’t quite give herself what she wasn’t given.]
PT: right. I’m not even sure there’s like an ‘I’ there.
In talking about a current relationship problem, she expressed that there is really no point to feel anger, there is just no way out, no way that her feelings matter. This is a classic situation in psychotherapy, how to convey to patients that indeed, feeling on your own behalf does matter, and is indeed a key to unlock being imprisoned in the past. What she began to notice was fascinating. She remembered how she felt love for her father, despite his rampant self-centeredness. She gave to him the love she craved. In a sadly ironic way, she is realizing that her focus on others is an adaptation to the lack of attention given to her. What was there for her was just plain empty. Herein lies another dilemma of working with someone who suffered from neglect: How to bring compassion for what was never received in the first place.
C: I sort of feel like I developed that part – may be being mean to myself – that that was a way to get him to love me. I saw that if I was ever going to get anything – I better feel for him and meet his needs [The maltreated one looks to understand the mind of the other for her own survival.]
TH: well then, how beautifully resilient of you. [Affirmation of self]
TH: to get yourself some care where there was nothing.
TH: SO how can we honor this little girl who gave of herself to protect herself? [I sense this is our opportunity to make a connection with her younger self.]
PT: Without completely merging and going under? [She fears dissociation and disorientation.]
TH: Right, can we do that? [I am checking for willingness.]
PT: Right, like have one foot in here and one foot there. [She identifies the way, by keeping one foot in present time and one in the past.]
TH; Right… Actually I love your question, how do I not merge with what – we still have a few minutes…
PT: Just the despair… and the sadness and the eech disgust – such a fixed experience a fixed template – so that’s one part of me – so not be overcome by that. [She wants to find the window of tolerance.]
TH: Right, what if we make an agreement that you don’t go there alone, that you don’t have to go there on your own. Can you do that? Can you contain that or compartmentalize that or put that in a loving – I see a loving padded box…[Making agreements to contain for safety]
PT: (one side of lip is curled up) right…
TH: those little fluffy cushioned boxes… [I want to extend cushy comfort to her.]
PT: like velvet inside
TH: I see like velvet…. [At first, I think she is with me in this.]
PT: okay put that like take that snapshot and put it in there – [Containing]
TH: and we can keep working with it cause the feelings that you’re describing need to be felt, but not alone for goodness sake – [Accompanied]
TH: and if anything to cultivate compassion… [Creating an imaginary caring place]
TH: kindness, like how you feel towards P [Resourcing with her feelings towards someone she knew at church]
TH: Like how you feel towards somebody that you care about… that you have an uncomplicated relationship with
PT: I was going to say I have such complicated relationships – Actually I don’t have one with P.
TH: what if you take that feeling (towards P) and surround that box with it – that little girl – even if you can’t connect to her, love her anyway
PT: I think what I can do is just put her in like a crate, like a wine crate or something and just stuff her in there and put it to the side. I can’t do all the surrounding and the velvet and the [As she feels into the imaginal picture, she summons the brakes.]
TH: oh you can’t [I inquire to be sure.]
PT: I can’t
TH: can I? [If there is a way for me to hold when the patient can’t yet, I want to try.]
PT: I could lie to you…
TH: no, I want you not to lie to me. I love your straight talk. You gotta be straight with me… [What is real and true matters more than compliance.]
PT: and I think am I just being contrary, am I just being difficult? How do I even know what’s real. I just know I was having trouble come up with an image… like velvet or fluffy or cute box, so that probably means that’s not going to work…
PT: So then the next thing that came is you know – just like a crate… just like a milk crate or something… And so that’s better than nothing.
TH: it is, especially if she is contained… [I accept that she is finding a way that works.]
PT: yeah and there is like air holes… for her to breathe
TH: I’m going to throw her a blanket
PT: (laughs out loud) you’re going to throw her graham crackers
TH: I’m just going to stuff a blanket [I am aiming now to provide some cushion.]
PT: a juice box
TH: just a blanket…in and around the edges so that…she’s got a little softness in there…
PT: she’s all like cold
TH: She’s cold okay so I give her a blanket [Now for warmth]
PT: that’s very nice… she likes that? And she has her thumb…
TH: and a juice box?
PT: yeah a juice box and graham crackers,
PT: … she’s set (waves her hand off) it’s very comfortable [Note the “it”]
TH: Okay…we’ll come back [We have co-constructed a contained place and a specific way to hold this young part until we meet again.]
PT: (chuckles) we’ll see you next week
TH: we’ll come back
PT: bye bye…(laughing) yeah we’ll just do that.
Over the next 6-9 months, we had periodic visits and explorations with this young part still in a crate. In the session following this one, we happened to call it the feral child, which stuck. PT. recognized the tenacity of this part who has been so banished, yet PT. realized that she has taken over at significant times and influenced choices PT. made that were harmful to PT.’s overall well-being. This has been a huge connection. After the following session PT. grows in her appreciation of the strength and grit of this young part and was able to reflect on how she had come to disconnect from her instincts. She also identifies how she is internalizing the care and compassion with which I have been holding her and how this is changing her relationship with herself.
Eight Months Later
PT: I was having a conversation – I was having a wondering, an aside, I think I was getting something back. I think I was having an empathy… an empathic exchange – it’s not like I remember the feral child “I’m hungry”. It was more like I was curious, getting that was really hard. It was more like I was understanding somebody is locked up they haven’t been taught anything. I don’t know if it was after I left here or the next day (sing song voice) I know – its cause I was talking about how hard it was for me to have contact…in between sessions and I realize I was having contact – and I was like – I’m having contact! [Vitality affects surge with the recognition that this is right action!]
TH: (Laughs delightedly)
PT: I’m having contact and even if it was just a few minutes [transformance glimmers]
TH: that’s fantastic
PT: it felt really alive, but it wasn’t…
TH: That’s what is important, that it felt really alive for you… [Affirm and validate]
PT: It was like I was mimicking what I see you do [She is internalizing our secure haven.]
PT: but it felt me – doing it but more like practicing or something. [Imitating me but feeling as herself. Wow!]
TH: And you wanted to tell me in person. That’s so sweet. [Authentic sharing in person]
PT: I know…I said that’s, be… no… it’s not urgent…and I’m starting to have a trust that I’ll remember things. Isn’t that a big deal? [Trusting herself to contain and remember]
Th: Yes, it is.
PT: even if I don’t have to remember it. But in the coming in, and the sharing, and the relating… that it will come out. [Trusting our process]
TH: it will be remembered…
PT: it will be remembered (stated affirmatively)
PT: maybe I can on my own…remember it… but that’s not really the point I don’t think…
TH: there’s a context that we’re containing…and bringing this into…
PT: and I knew not to stare at the sun for too long…like I knew okay that’s it… moving on. So…
TH: (nodding and smiling) hmmm
PT: that was just very sweet.
TH: very much, much, much
PT: yea… very cool…
TH: So how do you feel, right now?
PT: yeah some pride – maybe I can do more than I think even. [Transformance glimmer]. Maybe I get down on myself, and feel insecure – and you have faith in things and you have trust in the process… and I’m relying a lot on that I think… [She’s borrowed my faith and trust as she gathers experience from our work together to fill in what was missing.]
TH: and I have trust in tangible things… which is so much why I am trying to share with you what I am seeing – so that you can grab hold, not just of castles in the sky.
PT: Yes… wasn’t that a movie?
TH: (Smiles) I don’t know
PT: not castles in the sky, I like that. Tangible, concrete…and its so interesting cause you’ll say those things to me. And yet, my mom was home this time and she won’t say those things to me
TH: no one will say how they see you growing or changing?
PT: No, I’m trying to think. They don’t. [But I do, and she is sharing that her receptive capacity is serving her growth.]
Desirable Mobilization: Categorical Emotion Adaptive Action Tendencies
The desirable action tendency here is courage: the courage to face what has been lost, disconnected or cast off. Feeling into affective glimmers and the fractals of self experiences (Fosha, 2013a) that arise in small bits and allowing them into awareness and to move through is how to build capacity. It is this willingness to engage and bring back online dissociated affects and memories that can give rise to understanding and making sense and lead to developing the capacity for reflective functioning. I also want to support any action tendency that strengthens the patient’s capacity to relate to another, as in the disorganized state the patient can vacillate between seeking the other to feel safe and then rejecting the other’s response of contact and care. The most important handhold here is to remember the adage of both/and as opposed to either/or. The definition of disorganization is that two contradictory circuits cannot come online at the same time. Treatment needs to proceed slowly and with care to enable splintered selves to coexist, while building a large enough window of tolerance so that eventually it becomes a window of opportunity for corrective emotional and relational experiences.
In summary, I hope this presentation of my grids with detailed discussion and transcripts illustrate how to both conceptualize interventions as well as to apply them in practice. My intention is to emphasize that first, the way we care for ourselves, and our patients, is strengthened by our own capacity to operate from self-at-best, and second, self-at-best is strengthened by our understanding as clearly as possible, the mechanisms behind the challenges of our patients as well as ourselves. The more we can decipher what is going on in our patients, the closer we can attune to what they actually need from us and with us. The grids can be considered in combination as well as alone. Instead of being caught by blind spots when faced with the insecure attachment styles, they can help us to prepare for how to address our patients who have deeply entrenched attachment strategies and how we might respond when facing particular difficulties. Our presence can be an antidote to expectations based on earlier schemas. Interventions are offered to help with typical challenges of each attachment style, but also with a direction in mind of what is important to develop.
Ideally by cross-referencing the grids, we can build a bidirectional concentration. With an eye on the past, while stepping more fully into the present, we can help our patients to heal and grow into the most fully human beings possible, more capable of enjoying secure functioning within themselves and in relationships with others.
To Diana Fosha, I feel deep gratitude for the therapeutic integrity of AEDP, your inspiring view, your steadfast trust in transformance, and your unwavering recognition of the scope of this project. Thank you for your midwifery. To Victoria Beckner, thank you for being a true other to me in this process. Thank you for astute organizational suggestions, seeing the thru-line of this paper with your keen mind and your kind heart. To Gil Tunnell, true colleague and editor, I appreciate your boldness, your deep respect and the joy of working out the finer details with you. To David Mars, dear husband and colleague, thank you for edifying dialogues and clarifying ideas in this paper with me. Living the felt sense of earned secure attachment with you provides buoyancy to me beyond measure. To my patients who have courageously entered into new terrains in their psychotherapy and given permission for their work to be shared to further the growth and understanding of our field, my heart beams with gratitude, respect and admiration.