The Work of AEDP
Repair, Growth, & Celebration
By Jennifer L. Imming
Repair is an essential ingredient in the patient/therapist dyad, since ruptures are a naturally occurring part of all relationships. Through the process of repair, patients can heal within the context of therapy, in addition to extending this healing throughout other relationships in their lives, both past and present. Therapists can attend to ruptures that occur within the therapeutic relationship and actively facilitate repair of such ruptures, appreciating the patient’s experience, acknowledging their own part in the rupture, appropriately sharing their personal experience of the interaction, and providing a corrective emotional experience. This paper presents a detailed transcript of a patient’s videotaped session in which the process of rupture, repair, growth, and celebration takes place. The dynamics and moment-to-moment processing of Accelerated Experiential Dynamic Psychotherapy (AEDP) are delineated throughout the manuscript, including concepts such as red-signal affects, green-signal affects, mastery affects, healing affects, heralding affects, emotional engagement, intersubjectivity, deepening positive affect, and the therapeutic interventions which facilitate this process. The manuscript also illustrates the significance of attending to the celebration phase of the session, in many ways the ethos of the AEDP model. Through privileging the positive, transformation takes place.
“The bonds of intimacy bring up the very same needs, yearnings, disappointments, and protective defenses that occurred in the primary bonds of infancy and childhood” (Solomon & Tatkin, 2011, p. 4). For this reason, adult attachment relationships have “a unique power to hurt or to heal” the other (Tatkin, 2011, p. 4). The intimacy of the therapy relationship has just that unique power to hurt or heal … or both. In fact, the process of attunement, disruption, and repair can lead to both members of the dyad changing and growing (Fosha, 2008).
Ruptures: hurt and heal
Ruptures are a naturally occurring element of any relationship. Therefore, it’s not that we can avoid ruptures altogether over the course of therapy (which would be impossible), but we want to catch them as quickly as possible and initiate the repair process. Interestingly, disrupted communication and lack of responsiveness between adults may lead to many of the same emotional responses that are evidenced in children’s reactions to separations (Cassidy & Shaver, 2008). Through the process of tracking the patient, the therapist can observe the patient’s response to a disruption in attunement. For example, the patient may display any of the following when a disruption occurs: looking away, changing their tone of voice, crossing their arms, speaking more rapidly, speaking nonproductively about a topic, or glazed over eyes. Exactly what behaviors are displayed in the session depend on the patient’s attachment status and the patient-therapist relationship. By tracking what happens in the therapy room, we can work to heal both the present misalignments which have occurred, as well as further the healing of ruptures from the past, which haven’t yet been resolved.
The therapist as an attachment figure
As a therapist, we develop an important attachment with our patients, eventually becoming an attachment figure for them. Simply stated, at its core, the moment-to-moment experience of attachment is based on sensitivity and responsivity to the other’s signals, which allow for collaborative communication (Siegel, 1999). As Siegel writes, “contingent communication relies on the alignment of internal experiences, or states of mind” between the dyad; “this mutually sharing, mutually influencing set of interactions-this emotional attainment or mental state resonance-is the essence of healthy, secure attachment” (Siegel, 1999, p. 117).
A great deal has been written about attachment figures and the role they play in relationships. According to Bowlby (1973), two essential features of attachment figures are accessibility (or “availability” to use Bowlby’s exact term) and responsivity. Bowlby asserted that the availability of the attachment figure will “turn on” the cognitive processes. He defines this turning on of the cognitive processes as including (1) the belief that lines of communication with the attachment figure are open, (2) that physical accessibility exists, and finally (3) that the attachment figure will respond if called upon for help (Ainsworth, 1990). Additionally, as Tatkin (2011) adds: the attachment figure will offer help without consequences, so that the individual doesn’t “pay for it” later. In the following transcript, the reader will see that the patient’s cognitive processes (according to Bowlby’s definition) have been turned on. She comes to the session expressing her unsettled feelings from the prior session, and in the session, the therapist is responsive to her need to process, understand, and repair the rupture. For this undertaking to be successful, the actions of engagement, disengagement, and re-engagement in the repair process must be coordinated within the dyad (Fosha, 2008). It is very much like a dance where both members of the dyad are tending to the relationship and working to move back to a coordinated, attuned state.
Characteristics of a transformational relationship
A disruption within a therapy setting is an opportunity for healing and transformation. Fortunately, people have a fundamental drive towards transformation which facilitates this process (Fosha, 2000). Fosha defines transformance as “the overarching motivational force, operating both in development and therapy, that strives toward maximal vitality, authenticity, and genuine contact” (Fosha, 2008, p. 3). Siegel asserts that for a relationship to be transforming several fundamental elements are involved, which include (Siegel, 1999, p. 3):
1. contingent, collaborative communication (e.g., in the transcribed session this is evidenced when I state, with my intonation indicating a question: “I insulted you,” and the patient responds, “no, not insulted…”)
2. psychobiological state attunement (e.g., session pacing-matching where the patient is and slightly altering it as necessary to be therapeutic, such as slowing down or amplifying affect without going over-board)
3. mutually shared interactions that involve the amplification of positive affective states (e.g., in the transcript, I say to the patient, “What growth–wow!”)
4. the reduction of negative states (e.g. soothing anxiety when therapeutic; delighting in a patient’s actions to counteract feelings of shame)
5. reflection on mental states-for example, mentalizing, defined by Fonagy et al., (2004, p. 3) is “the process by which we realize that having a mind mediates our experience of the world.” (In the transcribed session, the patient recognizes one of her defenses as people pleasing.)
6. and the ensuing development of mental models of security that enable emotional modulation and positive expectancies for future interactions (in other words, as the result of building the therapeutic attachment, including making necessary repairs of ruptures throughout the course of therapy, new mental models are created which an individual can later reference).
Basically, the repair of a rupture becomes a corrective experience which transforms a patient’s ability to metabolize past experiences and facilitates healthier future experiences.
Repair is interactive
Through contingent communication and moment-to-moment tracking, repair becomes an interactive process. For so many people, there was no possibility of repair with their parents during childhood; consequently, moments of misattunement and repair within the therapy relationship are healing and facilitate the development of secure attachment (Safran & Muran, 2000). As Solomon and Tatkin (2011) describe, repairs take place over a period of time, peeling off layers of defenses that are erected to protect against deep injuries from long ago. Often, we are trying to help patients who have suffered from multiple, un-repaired ruptures which have been toxic to both the individual and their relationships (Siegel & Hurtle, 2003). When ruptures and subsequent despair from the failure to re-establish connection are prolonged, individuals are left in a painful state. Early in life, defensive coping strategies emerge as an attempt to reduce such painful states so individuals are able to survive and function (Cassidy & Shaver, 2008). These defenses serve the purpose of maintaining balance in the face of these disorganizing emotional states (Siegel and Hurtle, 2003). It is important to note that the following transcribed session takes place after the patient has spent quite some time in therapy, focusing on defense identification and defense restructuring, which greatly facilitates the repair process.
Tracking signaling behaviors
Stouffer and Waters (1977) also write of attachment as an organizational construct and speak of individuals having “signaling behaviors” to access the attachment figure. Through moment-to-moment tracking, the therapist can attend to the patient’s signaling behaviors as they occur and sensitively respond as is necessary for healing to take place. These coordinated interactions bring about change, taking place nonverbally and verbally, and are communicated in milliseconds by the face, voice, gaze, posture, and gesture (Prenn, 2011; Tronick, 1998). The reader will see in this transcript how very receptive the patient is to the repair, signaling for it when she arrives to the session, and then seizing the repair as soon as it is offered. To further capitalize on the opportunity that has arisen from the present rupture, the therapist slows the session down to deepen the work to access past injuries that lie beneath the surface. In this way, the therapist is targeting healing beyond the present rupture and actively attends to the triangle of comparisons. The triangle of comparisons references three sources of transformational influence: current relationships, the moment-to-moment therapeutic relationship, and past relationships where patterns were originally formed (Fosha, 2000).
Understanding the other’s experience
For a repair to be truly successful, it is important to fully understand the other’s experience. With a peer relationship, each person will be striving to understand the other’s experience. However, in a relationship involving an attachment figure, such as the therapist-patient and parent-child, it becomes the attachment figure’s responsibility to initiate the repair when a rupture becomes evident and work to restore the relationship if at all possible. Hence, the therapist begins by striving to help the patient feel understood. The therapist does this by working hard to truly understand the patient’s experience-staying in the moment of processing-and suspending hypotheses or at least checking them out with the patient. Relationships which have an overall secure foundation will be open to the process of repair. Fosha writes, “optimally interactive patient-therapist dyads are effective in restoring mutual coordination and positive affects between them…the therapist in such dyads has the capacity to respond in an attuned manner, correct her responses, and be sensitive and responsive to the patient’s reparative initiatives. Between them, interactive errors-and the accompanying negative affect-spur reparative efforts that succeed…focusing on the healing affects, the positive affects attendant on reparation, further solidifies the bond and deepens the therapeutic work” (Fosha, 2000, p. 66).
What characterizes a secure functioning relationship?
Tatkin (2011) speaks of secure functioning relationships as being mutual. As Prenn (2009, p. 93) so nicely remarks, when we consider “the framework of attachment, attunement, disruption, and repair, we are in the land of dyadic regulation of affect.” In the following transcript, the reader will see the attachment that exists between the therapist-patient is indeed mutually caring. When the patient signals to the therapist that a rupture occurred in the previous session, an opportunity arises for healing the rupture in the present relationship as well as healing ruptures which occurred in past relationships. Again, this is referring to work that addresses the triangle of comparisons (Fosha, 2002).
The following transcript demonstrates the occurrence of disruption and repair in a therapy session. As the reader follows the unfolding session, the transformational process, as described by Fosha (2008) also unfolds alongside the repair. The transformational process is not linear, but rather occurs in a more spiraling manner. In other words, the patient may flow into a core affective state, but stumble upon a trigger that brings her back to using defenses. Implementing moment-to-moment tracking, the therapist can work with the patient exactly where she is at that time, honoring the practice of “take the time it takes and it will take less time” (Parelli, 2009). In this case, “it” refers to developing a healthy attachment, creating corrective experiences, melting and restructuring defenses, and ultimately healing old ruptures and wounds, seeing opportunities when they present themselves to do this important work.
Privileging the positive
Addressing and amplifying positive affects is central to the theory and practice of AEDP (Fosha, 2000). It has been shown that, “… the regulation of painful emotion in the context of a positive dyadic therapeutic relationship naturally culminates in the emergence of positive affects and positive emotional states, which in turn are vehicles for accessing emotional resources and resilience associated with resilient functioning and emotional flourishing” (Russell & Fosha, 2008, p. 2). Further, as Schore states (2003, p. 143-144), “attachment is not just the re-establishment of security after a dysregulating experience and a stressful negative state; it is also the interactive amplification of positive affects.” The following transcript illustrates the process of repairing a rupture in the therapeutic relationship and taking this healing to the next step of privileging the positive emerging from this repair, which further results in a transformational wave of growth, and finally the celebration of the work that has been accomplished.
The Work of AEDP: Repair, Growth, & Celebration
“Haley” is a 35-year-old woman who initially presented with anxiety and trichotillomania in addition to grief over a recent miscarriage (first pregnancy). While the pregnancy was a “surprise,” she and her husband were excited to begin their family. They had been married for two years. She further described issues of “holding in” her anger and experiencing shame when she cries in front of anyone, including her family. She had no previous therapy, and her history was relatively unremarkable. Her father was in the ministry, and she reported a stable childhood aside from two significant moves—one in elementary school and another late in high school, moving from the Northeast U.S. to Texas. She has one younger sibling.
Haley had attended bi-weekly therapy for approximately four years at the time of this transcript. She and her husband now have three children. The second child was born with an uncommon syndrome that falls on the autistic spectrum. Haley has chosen to be a stay-at-home mom, though this creates some marital tension due to financial stress.
During the course of therapy, Haley has grown accustomed to regularly shedding tears without being triggered into shame. She has moved to having appropriate anger and adaptive action tendencies that go along with that. Her anxiety has lessened and she rarely engages in hair-pulling behaviors, having learned to get curious about her feelings beneath such behaviors, which in turn guides healthy actions. The relationship to her therapist has developed into a strong attachment.
The Repair and Celebration Session
The patient, Haley, has been working in recent sessions on expressing her feelings about her parents. In the session preceding this transcript, she came to a place of deciding that she wanted to have a conversation with her parents, in particular with her mother. At one point, I grew concerned that she was saying that she wanted to take this action due to a belief that this is what she “should” do, and I asked her if that was the case. She assured me, during that session, that this wasn’t the case. I learn in the transcribed session below, that she experienced my asking her, even though it was only one simple question, as misattuned on my part, which results in a rupture to our therapeutic relationship. Haley is very conflict avoidant, so bringing this upset back to very next session was a significant and vulnerable step for her to take. Throughout this session, I am holding in mind the AEDP belief that even in adults “the capacity for secure attachment is there for the activating–in the right environment–from the get-go” (Lipton & Fosha, 2010, p. 3). My intent is to provide the right environment so that she can have a corrective, reparative experience and further develop a secure attachment status. Haley starts the session off by addressing the rupture.
P: Um, and um, there’s one thing that’s kind of been on my mind that I did want to talk to you about … (patient experiences some anxiety, red signal affect, in bringing this topic up; she has a history of family rejection when topics around any type of disagreement/upset are discussed)
P: And that was in our last session…
T: Mm-hmm? (facilitating, curious, and open to patient)
P: Um, it had kind of, it’s been sitting with me, so that’s why I kind of wanted to bring it up…. There was a moment in our last session where I believe we were talking about, like, talking to my parents about my feelings about wanting a deep relationship with them, and you had asked me, you wanted to check in with me… I’m not sure what you asked me, but you checked in…
T: Oh, I remember exactly what you’re talking about. (therapist helps facilitate the communication, seeing the patient’s difficulty in broaching this subject)
P: You remember that? (patient expresses pleasant surprise and relief that the therapist recalls) Yes, yes, but like it sat with me because I was (patient slows down and becomes reflective, she appears relaxed and open)–why did you, I didn’t know, like, why did she ask me that? Because…my feeling was…this was a place where I never have felt like I had to…say something because…I was prompted… (patient is referring to being asked if her plan to talk with her parents was what SHE wanted to do; she starts with a direct question of why I asked, but interrupts and rephrases the question in the third person “why did she…;” this subtle use of defense is triggered by red signal affect)
P: Or maybe I was prompted, but I didn’t feel like I was prompted.
P: Or it was, um, it was a….a genuine feeling that I was having. (she has become better able to see the importance of her own feelings)
T: Mmm-hmm (therapist stays with patient’s experience, allowing for her words to unfold, continuing to facilitate and not guess where the patient is going, regulating the patient’s anxiety with a soft focus and warm expression)
P: So a part of me was like, was I giving off something? Because I was kind of struck by it, like…like it didn’t sit, like it felt kind of like a, almost like a defense went up, like a “really? Like, Why are you asking me that?” (in this last exchange, the patient reveals that experiencing anger is still “bad” by labeling it as a defense, which in this case it’s not; the therapist makes a mental note that they still have work in two important areas: (1) learning when anger is core affect and the subsequent adaptive actions, and (2) moving to the driver’s seat of the defenses, choosing when it’s adaptive to use them versus an automatic mode where unconsciously the “defenses choose” when they come into play, so-to-speak).
P: That’s the thing that I kind of took with me.
T: Mm-hmm, mm-hmm, yeah, help me understand this feeling, there’s something important about it. (the therapist waits and facilitates, allowing the patient to come to her own understanding of her feelings first; the objective is to deepen and explore vs. lead as the therapist would do when a patient is solidly at the top of the triangle)
P: Yeah. Well it was kind of having to feel like…well, uh, almost like a, like…uh…a defensive feeling. (she continues to struggle in identifying the core affect, as she is somewhere floating between core affect and being at the top of the triangle in red signal affect and defense)
P: Like a wha… Why? Why?
T: Mmmm…I insulted you, or what do you mean a “defensive feeling?” (therapist attempts to understand-this is an example of their contingent, collaborative communication)
P: No, not insulted, not insulted like um…. I’m trying to put my finger on it, more like a… do you think I would not? Or… almost like… do you think I would say something to you because I just wanted to get a positive response from you? (patient’s voice sounds very young)
P: Almost like, I don’t feel like I would do that. Do you think I would do that?
T: Mmmm. Did I hurt your feelings by asking? (therapist doesn’t directly answer her question yet—waiting first to get to the feelings beneath her asking; therapist uses a kind, empathic tone, still working to understand what patient is calling a defensive feeling)
P: Maybe, almost like a, almost like….yes, I guess so. (there are soft tears in her eyes; she accepts therapist’s empathic facilitating; even if the communication is not perfect, she is able to take in the therapist’s attempts to understand)
Throughout every therapy session there are choice points of which direction to take or what to pursue at any given moment, such as which emotion to follow when more than one is expressed. We cannot do all the options all the time, so we make decisions based on a myriad of factors (e.g., patient issues, previous sessions, if it’s a rare opportunity that has not previously presented itself) as to which direction to take at each fork in the road. In this session, the therapist takes the route of facilitating a repair experience because she knows that the patient has many wounds from her childhood due to non-repaired ruptures with her parents.
Another choice in this session could have been to work with the patient to explore the anger she’s not fully expressing or aware of. In this case, the therapist has worked with this patient’s anger previously, using portrayals when the patient accessed anger at her parents. The therapist could have pursued anger again in this session, but mentally notes that it’s unfinished work to be done and opts to pursue the repair instead as the opportunity is an uncommon one in this dyad.
P: I don’t have that kind of relationship with you, I wouldn’t…
P: I wouldn’t – that’s how I feel, like I wouldn’t tell you something just because you wanted to hear it. So I was like, “Why would you ask me that? It kind of made me sad. (she again speaks in a young voice as she identifies the underlying feeling)
T: Mmm-hmm… yeah, I really hurt your feelings. (therapist begins to acknowledge the misattunement, showing vulnerability and own limitations, beginning the repair process through taking responsibility for the rupture in an open manner)
P: It did hurt a little. (her face is soft, open, and appears touched; however, she minimizes the upset)
T: And I insulted our relationship by asking. (therapist refocuses patient)
P: Yeah, a little bit.
T: Yeah….oh….I’m so sorry. (therapist continues the repair, speaking quietly and sincerely)
P: No, I’m not, I just wanted to, I was just holding it. (patient minimizes again–a defense–as therapist shows her own feelings of sorrow for the misattunement)
T: I’m so glad you brought it up, I’m so glad. (therapist supports patient’s feelings rather than focus on her defenses of minimizing her own experience too quickly)
P: Yeah, because I was like…
T: Particularly since you were holding it, and any time I have hurt your feelings…(therapist remains open and inviting, affirming patient’s experience)
P: Yeah (she nods and smiles, accepting therapist’s care: green-signal affects of openness and receptivity)
T: I would want you to bring it up (encouraging patient and reinforcing her courage to address her concerns with therapist)
P: Yeah. Okay. Yeah. Thanks. It just was, I just felt weird. (red signal affect)
T: Of course. (validating patient’s experience)
P: Like I don’t know what happened. (her voice is young again)
P: I was thinking all these things, like well maybe something I said, or maybe my gesture, or a tone of my voice. (she goes to blaming herself as she tries to figure out the misaligned communication between us)
T: Mm-hmm, mm-hmm.
P: You know, but I was like, I don’t want – that’s not how I want to be with you.
T: Yeah. Well maybe I can clarify, because I do remember that whole piece, if you’re interested I can clarify where the question came from. (therapist offers to disclose personal experience of that interaction)
P: Yeah, yeah I would love to know. (patient appears open and interested, sitting forward: more green-signal affects)
T: Because I don’t remember it being anything about how you said it or what you said. I think it was more out of…I know you can say something that…in that moment seems like the right thing to do.
T: And so I didn’t get that you-that it was anything that I was picking up on-it was more out of the context of, “I know she can be a people-pleaser.” (therapist identifies patient’s defense and own desire to intervene with the patient’s defense)
P: Right, yeah.
T: So I wanted to ask so that you could check in with yourself.
T: And ask, “Is there any people-pleasing in this?”
P: Yes. Well and that’s – that’s the second thought that I had in my head too, like that was something I spinned around in my head as well, like, I know she knows that that’s my… default. (patient acknowledges and owns her typical use of defense)
C: I know that’s my default too. So in some way I kind of knew that.
P: But the initial part of it was like that “oh….” feeling.
T: Oh, of course, of course. (therapist affirms patient’s experience, and the impact on her)
P: And then I knew, mentally I knew that about myself, and I knew you knew that about myself better than I sometimes.
T: I don’t actually think you would do that intentionally in our session. How I hold our relationship–I think I hold it consistent with the way you do. (therapist refers to the strong attachment between them)
P: Yeah, yeah.
T: That you wouldn’t intentionally say something just to please me…that you feel there’s room here to say “yes” or “no” or whatever.
P: Totally. (patient is sensing the re-alignment in the relationship which is taking place)
T: So I’m totally on the same page with you (using patient’s language). So I think it’s more out of my, um, caretaking. (therapist is searching for the right word to capture the feeling of care for the patient)
T: and I wanted to check in and make sure that there wasn’t any accidental leading on my part. (therapist acknowledging own human errors are possible)
T: Um, and just take care of you, because what we were talking about seemed like a big…
P: …big thing…
T: …thing to do…
T: And I wanted to make sure it’s yours. You have my support, but I wanted to make sure the decision was yours.
P: Yes, well and see, that’s good to talk about it. Because that makes me feel like okay, yes. And then, so if I know in the future, I mean, I don’t want to prevent you from checking in with me, because I think it is a good thing, but it was just one of those things, like ‘oh I feel strange about that.’ (patient is already referencing the creation of a mental map she can later reference which further increases her resilience as well as belief that repairs are possible)
P: so it is nice to know the, the background behind it for me. (patient is accepting the repair)
P: Just to have that clarity, kind of thing. So… okay. (patient sounds ready to move on)
A central feature of secure attachment is the person’s confidence that her emotional and mental states will be accurately assessed, clearly reflected, and appropriately responded to (Karen, 1994). The more secure the attachment within a dyad, the easier a repair of a rupture can typically be made because individuals with a secure attachment status soothe more readily (Karen, 1994).
To help make sense of the importance of what happened in this portion of the session, let’s take a closer look. In the above section of the transcription, the reader can begin to see:
1) The patient arrives to the session signaling to the therapist, her attachment figure, that a rupture occurred in the previous session.
2) Elements of a secure functioning relationship are evidenced as the reader sees that the patient expects the therapist to be open to her concerns and is hopeful that the therapist will appropriately respond to them.
3) The therapist works to facilitate the patient’s expression of her feelings and tries to understand what the patient is trying to communicate on many levels. As defenses come to the surface (e.g., minimizing the impact of her own feelings), the therapist helps to bypass them and regulate her anxiety as part of the process. Through this, the repair of the rupture has begun.
4) The reader can see how the repair process is interactive. It is through fits-and-starts of trying to communicate and understand, with both individuals in the dyad working towards a mutual coordination of states (which will become even clearer towards the end of the session, as transcribed below, that the attempt to re-coordinate is successful). It is an imperfect process, with many misses, but eventually the important goal of repair starts to take place.
5) Significantly, even beyond repairing the rupture in the therapeutic dyad, the therapy work will deepen the healing to include others in her life-past and present, touching on the triangle of comparisons.
Metatherapeutic Processing of the Repair
An integral component to the AEDP model is meta-therapeutic processing. Meta-therapeutic processing provides an opportunity to heighten the effectiveness of treatment (Fosha, 2000). Fundamental aspects to this include experience, reflection, and meaning construction. According to Fosha, “meta-therapeutic processing and their accompanying affects of transformation is a major source of healing” (Fosha, 2000, p. 4).
Before moving on in the session, the therapist initiates metaprocessing of what has transpired up to this point.
T: Yeah…How do you feel now, talking through this?
P: I feel better about it. ‘Cause I–like I said, there was a part of me that kind of knew…there was that thought process going in the back of my head as well, so I’m glad it’s that.
P: As opposed to something else, like something else that…
T: Because it really touched on something, that first reaction. (therapist can tell there’s something “more” or bigger, more important, to her reaction, which hints at the Triangle of Comparisons)
P: Yeah, there’s like…
T: It really touched on something. (facilitating patient to stay with the feelings)
P: Yeah. (Patient nods)
T: …something about it. The importance of maybe our relationship and your being able to really be yourself. (making the experience explicit and inviting her to consider what is being stirred beyond the present rupture)
P: Yes, mm-hmm, and really wanting to be myself, and wanting you to know that I’m really myself . Because I value that, a lot.
T: And so there’s also the piece of the importance that I see you (patient brightens, smiles, and her face is beaming as she listens, indicating the therapist is on track and touches something of significance for the patient)…so maybe that was the other piece too…because in that moment there was misattunement on my part and so in that moment I could see how you didn’t feel seen for who you really are, in this room. (therapist moves back to understanding and validating patient as part of the repair process; this work is touching on patient’s underlying wounds/ruptures from her past relationships; to heal the rupture and see patient for who she is now will help heal layers of similar past, unresolved ruptures)
P: Yeah, yeah, yes, I think that’s what it was.
T: And, I was…out of care-taking for you…I guess in that way I stepped too far. (therapist expresses her own feelings, vulnerability, and human error, continuing to acknowledge responsibility for the rupture)
P: Oh, but… (patient tries to interrupt therapist’s taking responsibility for the error)
T: Again, I’m not saying it in a way of “oh, I’ve done something terribly wrong,” but at the same time, also accepting responsibility for the misattunement…that happens naturally in relationships. And then you talk them through and repair them…which is what we’re doing now. (therapist blocks her defense and makes the process explicit)
P: Right. Yes, and that’s why I wanted to say something, because I knew it would be a conversation where…I understand that it’s a natural thing and…I appreciate that too. (patient looks a bit uncomfortable and reaches down to scratch her legs—the primary location of her hair pulling behavior; this is red signal affect is evidenced; some anxiety is rising; the therapist tracks this and will see what feelings are coming to the foreground)
T: I hear you trying to, in return, kind of take care of me… (therapist tracks patient moment-to-moment, seeing that the patient is uncomfortable with positive repair; this is another choice point that can be followed up on later)
T: …when I said, “Oh, I was misattuned.”
P: Yes, yes. Because I feel like I, I’ve done that before. And I…I’m just trying to really hear what you’re saying…because I, um, I appreciate that, and I accept that, and that makes me feel … good. That you’re able to tell me that, and I want to be like “yes!” I embrace that….I guess that’s what I’m trying to communicate. (patient appears more relaxed now and is sitting back again)
T: Mmmm…yeah. Also, you know, I also think there’s, there’s some learning about being able to know when we’ve done something wrong or misattuned or whatever, without necessarily beating ourselves up for it, and just knowing that’s part of being human and it’s really part of the relationship. (therapist is actively modeling having self-compassion and tolerance for making mistakes; it is important to make this explicit since patient can be very self-critical when she makes errors herself)
P: Yeah, well, I know it’s a very genuine thing from you … you know, like it’s not something that I … would question. (patient smiles and reaches towards therapist)
P: So that’s why I’m like…I guess I’m trying to say I’m very…I’m very… fine, I’m very okay with talking to you about it, and with your reaction (patient glances up)…and with my reaction. I’m very at peace with that, like I feel much better. (with this conversation, it is evident that her speech is not flowing which could indicate something further which needs addressing and healing)
T: Isn’t that nice, you know, I mean there’s something also just so precious about being able to have this relationship together where I know you’ll be okay and you know we’ll be able to work it through… (therapist expresses the security of the relationship—voicing what therapist believes patient also feels and recognizing the secure attachment they have developed, reassuring her that the patient can turn to the therapist)
P: Yeah, totally. Yes.
T: There’s nothing that’s critical or fatal to the relationship. (directly addressing patient’s worst, unspoken fears)
P: Yes, it’s a very nice thing to have.
T: So nice, isn’t it…to have that kind of solid relationship.
P: Yeah, yeah. I’ve had this feeling with you before too, you know. It just makes me smile about that. It’s just a very happy thing for me. (patient has a HUGE smile as she talks; there seems to be something very important here for the patient–that the therapist acknowledges the relationship is ok and is unharmed by the patient’s questioning)
T: Yes, so important.
P: Thank you. (healing affect of gratitude)
T: You’re so welcome. (receiving this gratitude)
P: I feel like crying, like…a happy cry. (tears of gratitude as she touches on sadness of not having this repair experience and security in other important relationships; she pulls her shoulders up, appearing as if to hug herself; some level of mourning-the-self is being activated here)
T: Yeah, feeling so touched.
P: I want to hug you! (adaptive action tendency kicks in; patient has tears and is smiling)
T: Well you can, there’s nothing against hugging (therapist allows for this adaptive action)
P: Like I just want to hug you!
T: Good. I’m so glad. (there’s laughter, genuine care, joy, and connection between patient and therapist who stand and briefly hug and sit back down)
It is important to note, depending on the patient, the relationship, and issues at hand, the therapist may ask for the patient to simply put the feelings into words rather than acting out the feeling; with this particular patient, there wasn’t anything to contraindicate the action of hugging.
T: Yes. I’m so glad that you’re listening to your feelings…our feelings help us know what to do. (continuing to affirm her need to bring up this topic, though difficult, and make explicit that action tendencies follow feelings)
P: It’s a good feeling, so thanks for letting me, thanks for letting me say that.
T: Oh, I’m so glad you brought it up.
P: Yeah, I am too. Like I just was thinking about it.
T: Yeah, so important…for you to not dismiss or blow it off, ‘cause you know…it honors our relationship that you’d even bring it up. (therapist appreciates the patient and validates the importance of her experience)
P: Mmm-hmm, yeah. Well and that’s why I, I guess that’s why I wanted to, because I didn’t want for me to harbor that, or feel weird about that, or carry it with me into the next session and the next. (and in this dyad, the hard-wiring we all have to self-correct becomes evident)
T: And it’s a wound, and you honor both the relationship and me in coming back and giving me a chance to heal that wound…to repair that. So the wound doesn’t have to stay there.
Triangle of Comparisons: Comparing Relationship Patterns
Seizing upon the opportunity that the rupture has presented, the therapist remains open and curious as to how the current disruption taps into issues with other relationships (past and present) and actively facilitates healing of relationships outside the therapy dyad in this way. This ties into the triangle of comparisons.
P: It’s nice. Exactly, exactly. And I think that’s, kind of taking that to the next step-the same conversation about talking to my mom…where I can make that step where I’m going to talk to her. (patient spontaneously shifts the conversation to her mother, with whom she’d really like to have a reparative conversation) I have them coming to babysit on Saturday, and I said to my mom, “Can we, can you and I just set aside an hour, can you come an hour earlier, and we can just go for a walk or go get some coffee and step away…let Jason (patient’s husband) and Dad take care of the kids, and you and I can just go and talk.”
T: Mmmm. (therapist simply stays with the patient who is now clearly in core affect with the easy flow of speech)
P: I’ve been thinking over and over about what I want to say to her. All I want to say to her is, “I want a better relationship with you and this is how I think I could have it.” (patient moves into spontaneous, mini-portrayal)
T: Mmm-hmm. You seem so clear and at peace and strong. (reflecting on patient’s process more than the content of what she’s saying)
P: I feel strong…Like I just got chills (tremulous affect) when we were talking about that and I feel… like that’s what I want from her, and that’s what I’m gonna ask her for and I feel good about it. I don’t feel afraid to talk to her about it at all, like I feel, I don’t know, I feel big. I feel like this might come across weird, but I feel bigger than her. (mastery affects—feeling empowered, emboldened, with just a hint of red-signal affect in her use of the word “weird” here; patient is in State 3 of the transformational process as diagramed by Fosha, 2008)
T: Yes, it’s not weird at all. You have grown past her and you’re stronger. (counteracting red signal affect with approval and support)
P: Yeah. Mmm-hmm, and I really, really want it, and I feel really good about it, I’m just so ready to just be like, “This is what I want from you.”
T: Yeah, so empowering. (mirroring to patient her experience of this)
P: Yes, it is, and there is a part of me that’s like I know it’s not gonna happen, I know I’m gonna have this conversation with her and it’s not gonna happen immediately…I know I have to work on it with her. (patient is in Triangle of Expressive Response—seeing “other” realistically, and having a sense of agency in the relationship)
T: Yeah, you’re realistic.
P: Yeah. I guess all I can do with her is just that different path myself because maybe once I start taking it then she’ll start coming along with me. (patient has a sense of agency—being able to impact her mother)
T: There’s a word that you used, that I’m so struck by, is your saying that you feel “bigger” than her. (therapist makes a choice to return patient to how she feels very different than ever before in the relationship to her mother to deepen this new, positive experience)
P: I do.
T: Because there are so many times you have felt “little” with her.
P: Mm-hmm, yes, yes, oh very, yes. (green signal affect—patient is nodding and ready to go here)
T: What growth – wow! (affirming this change in patient; therapist is consciously amplifying this experience)
P: Yes…well, I feel small in almost every conversation I have with her, because there is no, there is no, “How are you? What’s going on with you? Oh, I see that you’re feeling sad or I can tell that makes you happy.” There is no seeing of me in our conversations. (now patient gets back to the real importance of being seen by the therapist, as this session started out, which was a significant feature to the rupture: not seeing the patient as she was seeing herself)
P: Even in my conversation with her, I was saying how I was feeling about something, uh, with my friend Allie, who’s very dear to my heart, and who like, in the past like I didn’t go to her dad’s funeral, and I’ve always regretted that. I’ve always been so so sad that I’ve never gone to that.
T: Mmmm. (therapist makes a conscious choice to not follow this feeling of regret and sadness in order to stay with feelings related to her mother, and tracking patient to see if there’s another opportunity to deepen positive affect of patient feeling “bigger”)
The patient goes on to describe how unfulfilling conversations tend to be with her mother, who does not connect or mirror what the patient is feeling (much less go beyond mirroring). The transcript picks up a couple minutes later:
T: There’s not a connection, so you aren’t met. (acknowledging how patient isn’t seen by mother and affirming her experience of this)
P: No, not at all. And that’s where I feel small. That’s where I’ve always felt little. Except in that last conversation with her, I was like, “I still feel bigger than you.” Like I still feel bigger, you know?
T: That’s so amazing and healthy. (affirming her experience, amplifying her healthy, positive affect)
P: It is, like it didn’t hurt me. Because there’s a part of me, well, “I know you’re like this.” (patient speaks as if talking to her mother, and in an “adult” voice, a spontaneous mini-portrayal)
P: And it just didn’t hurt. It’s one of those things like, I’m going to work on this with you, and hopefully you can get to a point to realize, I want you to say these things.
T: Yeah. And all you can do is try, but again, you’re coming from this very adult, big…
T: …like you’ve grown in front of my eyes kind-of-place. (therapist acknowledging patient for her growth)
P: Yes, yes.
T: Mmm-hmm…you’re an empowered adult.
P: Yes. It’s—yes–exactly. And it’s so… it’s a nice feeling, you know.
P: It’s a really nice feeling.
T: What a celebration! (acknowledging patient and amplifying affect)
P: It is! I just feel very… in control of my relationship with her as opposed to just letting her…like, even when she was talking to me (something more emerges for patient in this discussion, remembering another conversation) … because she was talking to me about something about her brother, and her brother being in a bad situation, and all that stuff, and her being at peace with it. And, I said “Mom, that sounds kind of mean.” Because she did sound mean! She’s like, “I’ve just gone to a place where I just don’t care.”
P: I just thought it was mean!
T: And so for you to be able to say…
P: That sounds kind of mean! (patient accesses her feelings of anger towards her mother; it’s interesting to note that although the feeling of anger was not pursued earlier in the session, with the repair being made, she was then able to go to this core affect on her own)
T: …what’s true.
P: Yes. She says, “I’m so glad I’m doing yoga, because I’m so at peace with it.” And I’m like, are you really? Are you just disconnected? It sounds more like you’re disconnected and that you relationship with him is so far removed that you’re just–that’s why you don’t care! (core affect, adaptive action tendencies being released)
T: What a clean conversation.
P: Yes, it was cool. And that’s why I think the conversation changed for me…I was sort of looking for that same thing. (patient acted differently with her mother)
P: I wanted her (patient’s mom) to reflect back to me what I’m saying to you.
T: What you were hoping for …
P: Yes! Yes. (patient seems to feel seen and understood) And I think the weirdest thing too (an unexpected experience for patient, so in this case the word “weird” is not red-signal affect, but indicates her new experience) is that I think where I found that relationship the most is with my sister-in-law. Bizarre! Shocking! Like, it’s the craziest thing! (heralding affect: patient had a very adversarial relationship with her sister-in-law, in which it seemed she was being recruited to express her mother’s feelings)
T: Wow! (matching patient’s affect)
P: Yes, like she and I have had conversations lately, and they are the most… um… feeling, holding conversations I’ve had with anybody lately.
T: Wow, you would never have expected that.
P: Never, never, never. But I started doing it with her. And it’s so bizarre because I hated her guts for the longest time, I hated her, I hated her so bad.
T: I know, I know. (staying with patient)
P: And now I don’t hate her, I actually really like her.
T: Wow. (simply facilitating patient’s expression)
P: Mmm-hmm. Isn’t that weird?
T: The power of you being yourself.
P: Yes. It’s all like, I’m changing! (mastery affects: patient is laughing and literally claps for herself) This is a really happy day for me, I feel really happy, and I feel really good about today.
P: You know, I’m not holding a lot of other feelings, I feel really, I’m having a really powerfully strong good day, and I’m having more of them.
T: Yeah, I was going to say, “day” seems like it doesn’t capture this new growth place that you are in. (helping patient see the significance of what she’s doing)
T: Because this is not one conversation that you had today with any of these people. It’s a series of these conversations and you have internally shifted.
P: It is! Yes! And it’s so new, and it’s so, interesting, it’s been so interesting (patient looks down and becomes reflective) because I’ve been catching myself doing this lately, like when I’m having sad feelings about Clare (patient’s disabled child), I just let myself cry.
P: If I’m in my yoga class and there’s a song that comes on … I’m just like, oh my god I’m just gonna cry. And it’s not a big deal…I’m just like … (this is such a huge shift for her)
T: Yeah, and it’s okay, and people cry. (normalizing and supporting her)
P: Yes, and I’m learning how to understand my feelings in some ways.
The patient has struggled with a myriad of feelings associated with having a disabled child. Combined with the message from childhood that she couldn’t cry, this description of crying in a public place is an incredible representation of the healing that has taken place.
P: This is just really cool, like I feel so much stronger than I have in a long time…and more connected to myself…
T: More connected and accepting…
P: Yes…I’ve been able to resolve things in my head…there was a stretch of time where I was thinking about my high school boyfriend…And how I sort of was longing for him, like ooooh, I had such a great connection with him and oh, I miss him. And, then I realized, I don’t miss him, he’s a loser now. (patient and therapist laugh) I realized that what I really want is that connection from Jason (her husband). That’s what I want. (as patient gets in touch with her feelings, she becomes clear and the adaptive action tendencies come forth) And so I said to him (referring to her husband), “I miss you and I want to connect with you” and so that’s why we’re going out on Saturday. (patient’s voice is soft and clear)
T: Yeah, and to stay with it long enough to figure out, and in some way kind of respecting your own feelings, and knowing it means something.
P: Yes. It’s really cool. It’s like…I just feel like I’m seeing more of myself. (self recognizing the self)
P: Instead of being like oh it’s bad to think about him…I decided I’m just going to ponder over him…before I’d just think I was bad or I shouldn’t because I’m married…I’m just going to think about him and not push it away…you know and then I had all this clarity. (core state)
T: Yes, right.
P: I think that’s why I feel so big lately.
T: Wow, look at you! (delighting in the patient)
P: Yes! It’s been really cool…it’s really nice…I’m just having a good day.
T: It’s so much bigger than a day. (therapist helps her to own the power of the work she’s doing)
P: Yeah, I know.
T: It’s fabulous! (amplifying affect)
P: Yes-thanks for letting me just spill all this stuff. (healing affect of gratitude)
T: Yes, I’m so glad you are! It’s important to spend time and celebrate these accomplishments.
P: Yeah, well I feel like this is a place where I can do that. (receptive affective experience: she knows that the therapist sees her; the rupture from the previous session has clearly been repaired, restoring the connected, securely attached relationship)
T: I get it. I so get it. This is what we’ve been working for. (without having an agenda- in a “phenomenological” way, this is where therapist/patient wanted to go; in other words, being able to access core affect, have healthy adaptive actions, and ultimately get to the clarity and peace which comes with that: core state)
T: And it’s a Celebration-I feel an image of fireworks going off—that’s the energy that I keep getting from you as you’re talking.
T: It’s a celebration!
P: It is!
T: Pop the champagne, here we are.
P: It is! I know. That just gave me chills. (tremulous affect)
It’s just so good. It’s all good stuff. It feels good. And then…it is so awesome being in this room with you because there’s that sense…the clarity is huge….I feel so clear. (and another wave through the transformational spiral is complete)
Reflection and End-of-Session Metatherapeutic Processing
Patient is in State 4 (core state) of the transformational process (Fosha, 2008) and talks about clarity she’s having with wanting another child. She talks about differences she has with her husband on the topic. She moves right into acknowledging her previous feelings of wanting to “replace” her disabled child, which previously she couldn’t tolerate feeling even for a passing moment. From giving voice to her true feelings, she was able to come to peace and feel her love for this child, calling her a “gift” and tearfully expressing her love. After talking a bit about this topic, she spontaneously begins to express “why she loves” coming to therapy, and we move to another round of metatherapeutic processing as we’ve reached the end of her 45-minute session. Patient is calm, still, very present in the room, smiling.
T: So let’s take a few minutes just checking how this session has been, how are you now, how does it feel to be here today…
P: Yeah. I feel really good about it. I still feel really strong. Like I feel there’s a sense of like, um, a more clarity place…when I came in I was way up here. (patient refers to her happy-go-lucky, bubbly defense) And I needed to come back to reality. I feel like I was just more on top, and now I feel more and more okay. I feel the majority of our conversation was just like, “I did it!” I’m doing this thing and it’s awesome. (mastery affect; patient beautifully articulates coming into the session at the top of the triangle and ending at the bottom of the triangle)
Therapist then takes a minute here to articulate the different parts to the session, including celebrating her accomplishments, and the patient responds with:
P: Exactly. That’s how I feel. It’s really nice to have that time where it just feels good. It’s nice to be able to come here and have that heavy time and to feel good about it…(patient is learning to tolerate hard feelings without self-criticism)
P: …to really acknowledge it. … I just can’t stop smiling, it’s like a, “I’m getting there! I’m so happy!” Like it’s a good–it’s a good feeling. (healing affects)
T: Yes it’s so good and it is a celebration and I think it’s so important for us to celebrate. It’s important and it is an energy expansion. (reflecting on the energizing effect of processing feelings and the growth experience)
P: It makes me want to do it more.
P: It just makes me feel like…like I can do more. (adaptive action tendencies; mastery affect)
P: So that’s how I feel coming from this conversation. Like I can do this more. I’m gonna go out the door and do it more, you know? (mastery affect; sense of agency; adaptive action tendencies)
T: Yes, you will. Yes, I do know. Yes. (patient beams hearing this)
P: That’s pretty cool. I feel I can walk out the door feeling very proud of myself. (mastery affects: pride/joy)
T: And I’m proud of you.
P: Thanks—you should be because you helped me! (patient recognizes the collaborative relationship)
T: Yes, I’m proud of you—I’m proud of us. (therapist accepts patient’s collaborative comment)
As the reader can see, the session evolved from the start where the patient brought in the pain of a rupture from the previous session. Because of her attachment to the therapist, the error was more significant to her, and from her developed trust, there was room in the relationship to address this issue. Her drive for repair led to a corrective experience in contrast to her history with her parents who didn’t accept responsibility for their mistakes, or ruptures. Attending to the triangle of comparisons, the therapist gave her in-the-moment (the session) what she needed there and then (as well as now). Consequently, she left more empowered to take actions going forward.
This transcribed session shows how with fits-and-starts transformational moments can arise from even not-perfect sessions–or rather because they aren’t perfect, these opportunities arise. They become a chance for patients to experience how a healthy relationship can be–a dyadic dance of mis-coordinated states realigning from a genuine, caring connection. From this secure, safe place, the patient can then venture to past experiences–unhealed wounds can be healed–and subsequently the patient can return to ongoing growth, addressing present effects in day-to-day living. Repairing a rupture usually involves some form of intersubjective negotiation. Through this negotiation, “…the therapist reinforces the patient’s trust that the secure base is, in fact, secure-that it can survive the strain of disappointment, difference, and protest” (Wallin, 2007, p. 196-197).
The therapeutic work does not stop with repairing the rupture. Staying with the AEDP model, of attending to both metatherapeutic processing of the session as well as privileging the positive within the session, has led to producing a much deeper level of transformation.
Update from the patient’s future sessions
In a recent session, the patient was able to verbalize for the first time how her father taught her “better to take things out on yourself than others” and how it connects to her history of hair- pulling behaviors. Using the technique of portrayals (Fosha, 2000), she was able to express anger at her father for this, which ultimately resulted in a sense of peace and no longer feeling the temptation to repeat the self-injurious behaviors. Haley has continued her work in therapy. Indeed, she worked through the differences with her spouse about having another child and has since become joyously pregnant.
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