Together We Say Goodbye: Termination in 16-session AEDP

Richard L, Harrison, Ph.D.

Abstract: This paper explores the termination process in 16-session AEDP. The fixed treatment length and predetermined endpoint are regarded as additive and enhancing of the change process. Strategies and interventions to address and process termination are delineated and demonstrated with verbatim clinical exchanges; and potential challenges faced during termination are addressed. Congruent with AEDP’s healing orientation, termination is reframed as completion and launching: Although treatment ends, the change process begun in therapy continues, as does the therapist’s care for the patient. AEDP interventions during termination include: (1) relational strategies to undo aloneness, co-engender safety, and foster connection; (2) affirmation of patient resilience and celebration of personal growth; (3) affirmative work with defenses against loss; (4) dyadic affect regulation of patient’s core affective experience (CAE); (5) experiential, bodily-rooted strategies to process and transform negative emotions; and 6) metatherapeutic processing of ensuing, vitalizing positive emotions and in- session experiences of change-for-the-better, to expand these and promote positive neuroplasticity and flourishing. Therapists aim: (a) to elicit and process emotions related to the completion of treatment; (b) to celebrate patients’ affective achievements; and (c) to convey trust and confidence in an ongoing transformational process, predicted to yield not only diminishment of symptoms and suffering, but also upward spirals of flourishing. In providing patients a new, positive attachment experience of togetherness as therapy ends, termination in 16-session AEDP offers a unique opportunity to disconfirm earlier attachment-based expectations, revise internal working models, and help patients grow in self-confidence as they face, accept, and thrive in the wake of loss.

Richard Harrison, Ph.D. is a certified AEDP therapist and supervisor and an AEDP Institute adjunct faculty member . He is Adjunct Professor at University of British Columbia, Counselling Psychology Program and Dept. of Psychiatry. Address correspondence to: Richard Harrison, Ph.D. 400-601 W. Broadway, Vancouver, BC V5Z 4C2, rhpsych@gmail.com.

Introduction

This article is a reworking and expansion of my previous publication, “Termination in 16-session accelerated experiential dynamic psychotherapy (AEDP)¹: Together in how we say goodbye” (Harrison, 2020), which I have revised specifically for readers of Transformance and clinicians who practice AEDP. This article retains the essence and substance of the original article, while offering additional descriptions of the arc of therapy for two case examples; AEDP-centric annotations of transcribed clinical vignettes; and a new discussion of self-of-the-therapist considerations that may arise in the process of saying goodbye to a beloved patient (the latter from a personal perspective).

This article focuses on the termination process in a time-limited, 16-session treatment protocol of AEDP. Initially conceived and practiced as a treatment with no pre-set time frame, where duration is determined by collaboration between therapist and patient, Fosha and colleagues subsequently developed a 16-session AEDP treatment protocol (Iwakabe et al., 2020, 2021) in conversation with Mann’s (1973) Time-Limited Psychotherapy (TLP). In 16–session AEDP, we do not view the predetermined length of treatment and fixed endpoint as a limitation that deprives patients (and therapists) by shortening the therapy. Instead, the time limit adds to the treatment and has much to offer: It helps accelerate the therapy and the healing! The fixed length and built-in impending ending bring attachment needs, longings, and fears to the foreground, rapidly, where these can be met and attended to with sensitivity, skill, and care. ² Moreover, the limited time frame further enriches the treatment, because patients benefit from facing and going through a goodbye together with their therapist. 16-session AEDP de facto gives us our endings back!

For those of us who work in private practice settings, it is not uncommon for patients to want to continue therapy indefinitely (sometimes for years!), because they value their deep connection with their therapist and all they’ve gained. And who can blame them. Nonetheless, AEDP therapy with no fixed length may paradoxically deprive some patients of the rich therapeutic potential of going through the ending together. Additionally, patients may drift away from a therapy of no fixed length (particularly for therapists whose practice schedules are structured in such a way that patients do not have a regular recurring weekly time). Our patients may take a hiatus, fully intending to return, or otherwise discontinue treatment, without either partner in the therapy pair realizing at the actual time of parting that the therapy is ending, thereby losing the opportunity to make this explicit and thus a focus and important component of the treatment. Both of the above described scenarios deprive patient of the benefits of termination– of simultaneously processing the loss together with their therapist while also celebrating the therapeutic gains and accomplishments.

In 16-session AEDP, termination is conceptualized as completion, as a “graduation” and launching rather than an ending per se. Although the 16-session treatment comes to a finish, the change process begun in therapy is understood to continue on in the patient’s life, as does the care felt between therapist and patient, even though treatment has ended. Informed by Mann’s (1973) research and theory of time-limited treatment, 16-session AEDP proposes that awareness of the set time-limit, established at the outset of therapy, accelerates and amplifies AEDP’s change mechanisms, which operate throughout the termination process itself. ³ This is good news, because we don’t have to learn how to do AEDP differently to bring therapy successfully to completion in 16 sessions! The very same transformational processes are at play in and through the termination phase of 16 session AEDP as they are throughout any AEDP therapy, yet the predetermined time limit and approaching endpoint enhance their potency.

The change process in every AEDP therapy is multifold, experiential, and synergistic. Broadly speaking, change in AEDP is fueled by embodied experience and its metaprocessing:

the experience of attachment — the security of the dyad, and its metaprocessing;
The experience of core affect, a fortiori, emotions, the wellsprings of adaptation (Fosha 2002), and its metaprocessing;
The experience of transformation, of positive change, which feels good and begets further change, through its metaprocessing;
The experience of core state’s deep knowledge and calm integrative clarity
In a general sense, these four aspects of embodied experience correspond with the therapeutic focus in the four states of AEDP’s phenomenological map of the terrain of transformation. They are also fundamental elements of AEDP’s alchemy in the termination phase of 16 session AEDP.

Below, I further discuss how these fundamental elements of AEDP theory and practice both guide and manifest in the termination phase of 16-session AEDP. Key intervention strategies to facilitate successful therapy completion in 16 sessions are identified and illustrated with vignettes from case examples of patients with different levels of emotional expressiveness (and different attachment strategies). Verbatim clinical exchanges are interwoven throughout, to help bring the termination process in 16-session AEDP to life.

Termination in 16-session AEDP is “AEDP even more so”

We conceptualize and approach the 16-session treatment protocol of AEDP as “AEDP, even more so” (Fosha, personal communication, November 8, 2022). As with any AEDP therapy, the attachment relationship between patient and therapist and the dyadic regulation of affect are powerful change processes in 16-session AEDP. As the therapy pair (i.e., the dyad) approach the end of their time together, the 16 session treatment is ripe with healing potential:

A primary goal of AEDP, as an attachment-based psychotherapy, is for the relationship between therapist and patient to become internalized by the individual patient. A related goal is for the emotion-regulating strategies of the therapy pair to become part of the individual’s emotional regulatory repertoire. Put another way, a primary goal of AEDP is to develop the patient’s affective capacity, i.e., their ability to “feel and deal” while relating (Fosha, 2000). Because the approaching end of therapy is so laden with attachment-related emotion, the termination stage in AEDP treatment, a fortiori in the 16-session protocol, offers rich potential with regard to these therapeutic goals. (Harrison, 2020, p. 532)

AEDP reframes psychopathology as resulting from experiences of “unwilled and unwanted aloneness” (Fosha, 2009, p. 182) in the face of emotions too overwhelming to regulate and process. Termination in 16-session AEDP has the potential to be uniquely generative because it provides such a powerful, fertile opportunity to undo aloneness, as the therapy pair face and process the approaching separation and goodbye. In doing so, we help our patients deal with inevitable loss and limitations, within the context of an affirming and reparative relationship. Therapy, like all things in life, must come to an end.

The patient experience of termination in AEDP is believed to parallel what happens in secure attachment – for it is not that separation, sadness, and loss don’t occur for securely attached folks. These are inevitable in life. However, being able to traverse these events with a trusted companion is what makes the emotions associated with them bearable. Moreover, the positive emotions associated with togetherness are energy-enriching (Fosha et al., 2019); loss itself becomes counterbalanced by the attachment experience. Importantly, the AEDP therapist helps the patient differentiate between the therapy coming to an end, and the caring relationship shared between patient and therapist, which need not end. The latter lives on, because it is internalized (i.e., attachment). We take our patients with us in our hearts and minds, and they us. Thus, much like the process of change itself, the attachment relationship between therapist and patient can continue far beyond the formal ending of the finite treatment. (Harrison, 2020, p. 534)

Attachment theory and research tell us that knowing that one can reliably turn to a caring, responsive other leads to increased openness to exploration and greater cognitive flexibility, including flexibility with regard to inner models of self and other. During the termination process, we actively invite our patients’ feelings, including feelings of sadness, and disclose our own feelings of loss as well. Patients frequently allow tears to flow, and report that they feel relieved in doing so. They describe taking solace in the therapist’s presence and accompaniment through the sadness. This sharing of sadness is adaptive.

Bowlby (1988) theorized that the primary attachment (i.e., survival) strategy when suffering, frightened, or in need is to turn toward a caring other and seek emotional support. When patients share their grief and fears about the approaching end of treatment in 16-session AEDP, this is precisely what they are doing. As AEDP therapists, we nurture this healthy behavior, and respond by being emotionally available, authentic, and explicitly expressive of our care. By providing patients a new corrective attachment experience of togetherness and emotion-in- connection as therapy comes to an end, the termination process in 16-session AEDP offers a powerful opportunity to disconfirm patients’ earlier attachment-based expectations, revise internal working models, and help patients face and accept loss, and thrive in its wake.

While the therapy pair work with separation and loss during the termination process, they also celebrate patient successes and therapeutic accomplishments achieved together. Furthermore, the AEDP therapist’s trust in their patient’s capacity to launch and put to use what they have learned in therapy, or to “graduate” from treatment (as my patient, Sam, described below, put it), is itself a powerful source of inspiration and motivation. Our patients feel our faith and trust in them, and in turn, they feel supported and bolstered by this as therapy comes to completion. This is so

important as patients take us and all they’ve gained with them into their lives beyond the end of treatment.

Case Example # 1: Sam

“Sam,” 4 a 48 year-old, single, heterosexual male of Afro-Caribbean and Asian heritage, sought treatment for feelings of inadequacy, anxiety, and interpersonal difficulties. He entered therapy with a clearly expressed goal: to be able to “autonomously” manage his emotions, which he experienced as overwhelming, chaotic, and disruptive — especially feelings of anger. 5 Sam described having been brutally abused by his stepfather in childhood and scorned and shunned by his mother throughout life, particularly when he expressed vulnerable feelings and needs for comfort. He tried hard to “shut down” his emotions, which he dreaded, because they so overwhelmed him. However, Sam recognized that this strategy was not working for him, because he felt deeply insecure, self-conscious, and worried virtually “all the time.” He described suffering longstanding irritable bowel symptoms daily, as well as relatively infrequent but nonetheless recurring and highly distressing periods of silent brooding (over the course of many weeks) followed by emotional outbursts, which depleted him terribly.

Sam works in law enforcement as a detective, where he has experienced institutional racism and overt discrimination by colleagues and superiors, as well near-death experiences in the field. He described having lived his life in a subservient role within hierarchical institutions in which he experienced little autonomy: his family, the church, and his profession. Sam longed for intimacy with a romantic partner but was wary of closeness, after having repeatedly found himself drawn into emotionally tumultuous relationships in which his own needs went unrecognized and unmet. He described feeling “desperate for a new way to live,” which to me, signalled both the intensity of his suffering and the strength of his transformance strivings. In this sense, his expression of desperation was also a big green light for our work together! Although this patient is remarkably self-aware and articulate, this doesn’t render his symptoms any less serious or his presenting distress any less great.

Arc of the Therapy

Early in our first session, Sam described previous therapy experiences in which he had felt very alone with overwhelming feelings. He described his former therapist’s face as “blank,” and told me that he didn’t know whether feeling less alone with his feelings would help or distract from his goal of being able to manage his emotions on his own. Sam was grateful and visibly moved when I told him, that I strongly believe we learn to manage our emotions first in connection with a caring other. His eyes filled as he responded, “Thank you for saying so!” As we worked experientially in the moment, Sam became “quite emotional” because he didn’t “feel so alone.” In metaprocesing this micromoment of change-for-the-better, he experienced an affective shift from fear that we were “opening up a tap” and he didn’t know “what all was in there,” to delight, as he discovered that with my help and accompaniment, he actually felt calm again. Thus, in true AEDP healing-from-the-get-go style, we were off and running! Later in the session, we did our first portrayal (drawing on a specific experience he’d mentioned earlier) and processed anger to an affective shift. Sam was astonished and delighted to discover he could feel and express anger and return to a state of calm. I affirmed Sam’s having done something he didn’t think he could do, and we spiraled into States 3 and 4.

At the end of our first session, I asked if it would be OK for us to spend some time in our next meeting talking about culture, identity, and similarities and differences between us, including racialization and his feelings about working with me, a white therapist. This initiated a series of conversations about and experiential work with Sam’s lived experience as a Black man in a racist world, which we revisited and expanded upon at different times throughout the treatment. After nine sessions, we began meeting online because of the COVID-19 pandemic, and some of our subsequent work included exploration (and undoing aloneness) of Sam’s (and my) distress and outrage about structural and racial disparities in health, laid bare by the pandemic, and further violent attacks directed towards Black citizens in the USA, which took place during the course of Sam’s and my work together.

^⁶Consistently throughout treatment, Sam described experiencing my presence as calming, welcoming, and palpably settling, which was itself a novel experience and welcome change for him. As his internal working models (IWM’s) of self, other, and relatedness began to shift with me, Sam could explore more of his affective world. Over time we did increasingly deep work, involving a series of portrayals, with his stepfather, his mother, intra-relational work in which he soothed his younger self and redressed wrongs in early attachment relationships, as well as healing work addressing racial trauma he suffered in his profession. Sam was deeply moved by my having told him that I not only welcomed, but also celebrated “the beauty of his capacity to feel deeply,” and that I was so happy that he had never lost this. The patient’s growing affective capacity and deep valuing of our relationship frequently led us into State 3 transformational experience and Core State. This continued as we approached the final third of our 16 sessions, at which juncture I had begun to shift our clinical focus to the approaching end of treatment and what I imagined would be a heartfelt and emotional good-bye, for both of us.

AEDP Interventions in Psychotherapy Termination: Together in How We Say Goodbye

AEDP Interventions in the process of bringing a 16-session therapy to successful completion are the same as those employed throughout treatment and are understood to involve the same change processes as any AEDP treatment, of any length, with an increased focus on affective, relational, and transformational experiences related to the end of the therapy⁷ In 16-session AEDP, therapists focus increasingly on the approaching end of treatment in the final four sessions. Because Sam’s attachment to me was so significant, I began to explore his feelings about our saying goodbye earlier than I typically might. The following series of vignettes from Sam’s 12th session offer a window into one patient’s experience of the AEDP’s change processes as the therapy pair enter the termination phase of a 16-session treatment. The therapist celebrates, experientially explores, and metaprocesses the patient’s experiences of success in treatment, while simultaneously undoing aloneness by explicitly inviting and welcoming feelings about the approaching end of therapy. This clinical example also illustrates how AEDP’s bodily-based experiential and affective focus within the context of an emotionally engaged, security- engendering therapy relationship, can culminate in deep core state knowing, self-compassion, confidence, and trust in self and others.

Affirmation, Celebration, and Expansion of Patient’s Experiences of Success in Treatment

Sam began our 12th session by telling me about his growing, albeit intermittent, ability to manage difficult feelings between sessions. The previous week had been challenging for him, “given this whole scenario right now like with COVID and the other things.” 8 He said, “I think that without the work that we’re doing, I would be suffering a lot.” Sam was, in his own words, benefitting from “the fruits of our labour.” Together we explored his embodied felt sense, in the moment, which he experienced as “pleasure” and “comfort” in being together with me in a time of so much uncertainty. He was particularly pleased and “amazed” that his longstanding irritable bowel symptoms had alleviated:

T: This is big, this is huge!… Let’s just be together with the amazement of that – – that when you attend to your experience, just as we attend to your experience, here, you can do things really differently than before? So, feel amazement of that.

Pt: Yeah, it’s very empowering! Like something I’ve struggled with my whole life. I’ve never been able to do that. Like, this the first time in my life that I can change that… behaviour.

T: (nodding, eyes wide, eyebrows raised, face saying, “Wow!”) What’s…How do you experience that empowerment, right in this moment? (slow and deep voice) In the body… or with a gesture… or an image? Help me be with this. [experiential focus]

Pt: I feel like it’s a light inside me… it’s powerful for me, because (faster) I literally used to feel like it had power over me. I was a slave to it.

T: (Softly and slowly) So this is really, really different. [affirmation of change]

Pt: Yeah! I’m used to walking around with tension in my body all the time, it’s just normal to me, and right now I don’t feel that. Yeah, it’s good.

T: So, Sam, again… When you have the image of a light in your body, and you can really hold the difference between before and now, what happens (voice deepens) physically, inside? [metaprocessing: inviting exploration of embodied experience of positive change]

Pt: (pauses then smiles broadly) The light gives me energy, I think. Which is really nice. Because that’s something I was struggling with in the week, I was finding difficulty…

T: So, I’m going to interrupt you for just a half sec, if that’s OK?

[Pt: Sure]

Because there’s value in staying (voice deepens) with the energy. And I notice you kinda want to tell me about the how come, and (chuckles) how you like it because it’s different than the unwanted (Pt laughs deeply). So stay a moment longer, if it’s OK, with the energy. [focusing on new positive affective experience]

Pt: Yeah… The light makes me feel good, (looking up to the right)…like I have energy… Yeah! it’s my strength, and my ability that I create in myself, and it doesn’t matter what’s going on, on the outside, and it can stay with me and I can create it. That’s the most freeing feeling. [T: Mhm!]… Yeah, I never felt that way before… it’s like a new way to live (both smiling broadly, nodding)

T: Yeah! Let yourself be with that, too (voice deepens), with… the newness of it. Feel into that. [experiential focus on the newness of transformational experience of strength, ability, agency, and internal locus of control, which is “freeing”]

Pt: (gaze upward, to the right, smiling) Yeah…to feel that kind of feeling amongst all the stuff that’s going on, it’s a very, very different way of dealing with it, and it’s so much easier (laughs heartily) and better!

T: Mm-hmm. Mm-hmm. (long pause, both smiling, nodding in synchrony)

T: (softly) Wow, this is just big success! [affirmation and celebration of therapeutic achievement]

Pt: (smiling broadly) Mhm. It feels very good, very healthy.

Experiential Work with Emotions Related to Completion of Treatment: Undoing Aloneness

Importantly, in AEDP we do not focus exclusively on positive emotions. Nor do we avoid or in any way eschew “negative” emotions (e.g., feelings of sadness or fear at the prospect of completing treatment and ending therapy). Rather, we seek to invite, accompany, and thus transform the latter. Consequently, I redirect therapeutic focus (approximately 13 minutes into the session) back to the approaching conclusion of our work together:

T: (softly) Mm-hmm. And I do find myself curious… how you feel about session 12 of the 16? [Pt: mm-hmm (nodding)]… that we’re at this stage of the work and it’s so exciting, and there’s also an end (firm downward gesture with hand) [Pt: Yeah]… an end that will be coming. And I wonder if you have feelings about that?

Pt: Yeah. Actually, I thought about that this week… I was feeling, like: Wow, I am progressing, and I am making changes in my life that (shrugs, shakes head) I never knew how to…. and then, I also felt very sad, because I knew that this is limited and… there’s also times where I’m like, (louder) Well what happens when I’m really struggling, and I miss Richard and I want to connect with him? How will I manage that? … And then there’s some times when I felt a little scared thinking that too! But then there’s also parts of me where I realize that I am changing, and I want to be autonomous, and it’s OK and I know will struggle. Yeah, it’s kind of like I’m doing this dance.

Sam’s expression of these feelings to me was itself an adaptive action: that of turning towards a comforting other and leaning in, rather than anxiously attempting to suppress feared emotion by shutting down or pulling away in the face of feelings of sadness and fear. He then told me he had been uncharacteristically open to help from a friend over the past two weeks, during emotionally difficult periods. Congruent with AEDP theory, this suggested that Sam’s IWM’s, his inner representations of self, other, and relationship were shifting: He was viewing self as deserving of care, select others as reliably responsive, and relationships as potentially safe and trustworthy. Again, I redirected our therapeutic focus back to the patient’s feelings about ending therapy, which I welcomed via an affective self-disclosure:

T: Sam, let’s loop back for a moment, also. I just wanna say, I’m so glad that you are letting yourself feel the feelings of sadness (pause) and fear, but also…your confidence in yourself. But I’m glad you’re also sharing the sadness and the fear, so we can be together with all aspects of your feelings. [undoing aloneness: Relational focus and self-disclosure (“I’m so glad…”) to explicitly invite and facilitate affective experience]

Pt: (pauses) Yeah. There’s definitely the full spectrum of it… Like even as you were saying those feelings, I was feeling… sadness to say “goodbye”, I could feel fear. I could also feel satisfaction. I even feel pride, when I think of the work that we’ve done, and how far we’ve come, it’s remarkable.

Metaprocessing in Termination: Fueling a Non-finite Spiral of Change

The experience of therapeutic change is itself an important agent and mechanism of change in AEDP (Fosha, 2000; 2017). Change begets change. Thus, that which is often an endpoint in many therapeutic modalities becomes a new launching point in AEDP (Fosha 2000, 2020). The successful in-session processing and resolution of painful emotions invariably gives rise to positive emotion, which in turn becomes the focus of clinical attention in AEDP. AEDP therapists attentively explore, experientially process, and invite reflection upon (i.e., metaprocess) these emergent positive experiences, in order to facilitate their further unfolding. This is equally true in 16-session AEDP (i.e., AEDP even more so!). Hence, we metaprocess during the termination process in 16-session AEDP as assiduously and fully as we do in any AEDP treatment. Moreover, we are rigorously on the lookout for opportunities to do so because we know our time is limited. Indeed, a number of participating therapists in the AEDP research study have come to recognize that the fixed ending and time limit in 16-session AEDP focus the therapist as well as our patients.⁹ Just as the time limit focuses our patients to bring important material forward, it focuses the therapist to seize every opportunity to metaprocess or engage any other change process that is well suited to the given moment (Tunnell, this issue).

Metatherapeutic processing is particularly important in the termination phase of 16-session AEDP, because it so often unleashes an expansive, non-finite upward spiral of positive change, powered by alternating rounds of emergent positive emotional experience and reflection on this good new experience (Fosha, 2000, 2009; Fosha & Thoma, 2020; Iwakabe and Conceição, 2016)¹⁰. Metaprocessing thus fuels an ongoing change process that continues beyond the end of treatment. This kind of mindful attention to and embodiment of present moment positive emotional experience, under conditions of safety, is consonant with Frederickson’s (2013) broaden-and-build evolutionary theory of positive emotion, which has been found to promote increased emotional and physical well-being and to broaden thought-action repertoires (Frederickson & Joiner, 2018). It is also a version of what Rick Hanson (2013) calls “taking in the good,” which is understood to facilitate positive neuroplasticity (Hanson, 2013, 2017)¹¹. Metaprocessing helps patients realize that they have been successful and that they have received help, which can enhance their self-efficacy and their capacity to trust others (Fosha & Thoma, 2020). These are important qualities to cultivate as therapy comes to completion and patients transition into their post-therapy lives, in which self-reliance and support from community replace that offered by the therapist.

Congruent with AEDP’s change-focused orientation, psychotherapy completion in 16-session AEDP is construed not as an ending, but as a transition that feeds the next round of a non-finite spiral of change, catalyzed in the therapy. Although treatment ends, the transformational process continues, as does the therapist’s care for the patient. (Harrison, 2020, p. 534)

Here’s how Sam described this phenomenon, at the end of treatment, in his own experience-near language:

The change keeps growing and expanding… and evolving. That’s the exciting part, because exploring these other parts of me with… this sense of freedom and liberty, and where do I want to go with it? Coming and talking with you and dealing with these emotions and letting them out and liberating all of them… those things don’t hold me down the way they used to. And so, all this changing is like still rolling and growing. And so, more and more, that it kinda rolls and gets bigger, the less they hold me back… And then the less fear I have, the more momentum I have, because I feel more comfortable with the new changes and… they’re kinda picking up more strength… and it feels healthier and healthier and healthier all the time.

Patients in 16-session AEDP commonly experience State 3 transformational affects when reflecting on their therapeutic experience and accomplishments. These may include: pride and joy in one’s newfound capacities (mastery affects); feelings of gratitude and tenderness towards the therapist and/or being poignantly moved within oneself by the depth and scope of the transformation of the self (healing affects); awe and “wow!” of new understandings, including taking in the enormity of the change (realization affects); and exuberance, excitement, motivation, and exploratory zest for exploration beyond the end of therapy (enlivening affects), among others. Just as light is simultaneously a wave and a particle, in AEDP, we understand transformational affects to also be transformational processes, which promote (i.e., broaden and build) flourishing on the part of the patient as they embark on a new journey, after the completion of treatment. Thus, the experience of psychotherapy termination in 16-session AEDP is conceptualized and approached as not only an ending but also an exciting new beginning (S. Iwakabe, personal communication, April 1, 2020).

As we saw above with Sam, in addition to feelings of sadness, the shared end-of-therapy experience in AEDP can also yield a boost in confidence and determination on the part of the patient that they can and will manage after having completed treatment (see also Mann, 1973). Thus, as treatment comes to an end, patients frequently experience curiosity, excitement, and a forward-moving appetitive zest for exploration of their post-therapy life, along with newfound feelings of strength and belief in self. And then we build on this through metatherapeutic processing.

We return now to Sam’s experience of pride in Session 12. As the patient reflected upon this present moment experience of change-for-the-better, new positive emotion arose. We subsequently metaprocessed, by engaging in recursive rounds of exploration and reflection upon emergent positive experience. The exchange below demonstrates State 3 work and illustrates how each reflection by the patient on his evolving emotional and/or relational experience launches the next round of exploration of the unfolding dyadic experience. Speaking slowly, in a deep tone of voice, I invited Sam to notice the pride, physically:

T: What’s that feel like, in the body? [Pt: Mmm]… (softly) What does it feel like, pride? [experiential focus on emergent positive emotion]

Pt: Kind of… a warm temperature feeling, like a fire burning. And it’s not out of control. It’s just a nice, slow burning fire, and it kinda gives me…comfort and… it’s stable and calm but… (looking up to the right) Yeah! It’s sustaining… (looking directly at therapist with broad, open smile). Yeah. It’s very satisfying. [reflection on experience]

T: Mmm. (deep and slow) Where do you feel it? [experiential focus]

Pt: (slowly, declarative) I feel it in my heart. My chest. Very much so. (both nodding, patient beaming) [experiencing]

T: (deep slow voice) How is it to share it with me? [relational metaprocessing]

Pt: It feels really good to share it with you because you’re so open… So, it feels easy to share with you (pause, both smile, nodding). Yeah. And I think…(slower) the more we’ve been doing it, the more and more… uh… (looks up) The feeling of satisfaction has always eluded me, and… by overcoming a lot of these issues, like internally in my body, especially like my bowels (shakes head almost in disbelief), that is like an immensely satisfying thing, that I felt like handicapping me in my life, and uh, the warmth I feel from that (laughs joyfully) because the freedom it gives me is so different! (patient laughs heartily) [reflection on expanded experience]

T: (eyes widen, nodding) Mm-hmmm! Mm-hmmm.

P: Before, the environment controlled me, dictated how I responded… As Sam reflected on his new lived experience, which he described as “leading from a place of calmness and stability and connectedness with myself as opposed to… living in fear,” he experienced joy. His emotional experience deepened further when I disclosed how his change process affected me:

T: Wow! How incredibly satisfying for me as well. I’m so… I’m thrilled, I’m proud of you… [judicious self-disclosure]

Pt: (softly) Thank you.

T: …And I’m kind of in awe at how remarkably ready you were to receive what I wanted to offer (gestures from chest towards patient, smiling). [affirmation of patient’s transformance] How is it to know I’m proud of you? [metaprocessing of self-disclosure]

Pt: It makes me, uhh…quite emotional inside… there’s tears… it makes me feel very cared for and appreciated. I feel… yeah… (swallowing, face filled with emotion, looking up to the right).

T: (softly and slowly) Just let that come… (pause). Mmm-hmm. [dyadic affect regulation]

Pt: (eyes wet with tears) Yeah. I don’t know what I would have… I was desperate for change and I wanted to change. And this kind of perfect connection I had with you in terms of how open you are and I’ve loved it, and still do.

T: I’m moved to tears too. Mmm. Wow. [judicious self-disclosure: therapist’s affective response to the patient and unfolding process]

Pt: (tears streaming) I don’t feel like I’ve had anyone kind of mentor me, and I’ve always wanted that (wipes tears)… [State 3: Mourning the Self and Healing Affects] I feel it in my heart as well, like how warm you are, and welcoming, and comforting. And it makes me feel like I’m becoming a better human and I appreciate that. It’s healing so much. So many things that really hurt me through my life. I feel like I’m able to move past them and free myself from them. Yeah. [Core State: Deep, calm, open knowing; positive valuing of the self]

T: (deep, steady voice): Mmmmm. Let yourself know that and feel the knowing of it. [Therapist is also in Core State: Resonance, declarative language, “letting it be.”]

Pt: (nodding peacefully, then looking upward to the right with a very open gaze) And I think, what also is a beautiful thing is I feel like you are proud of me for the things inside of me. Not for things I’m doing outside of me, like my accomplishments, and I find that to be a very beautiful thing. (long pause)

T: (face full of emotion, hand on heart, nodding, softly exhaling) Yeahhhhhh.

Pt: (nodding, crying) I don’t think I’ve ever felt like anyone cared for me in that way in my life. mourning the self It’s very different.

T: (softly and slowly) Mm-hmm. Again, what are you feeling inside right now? [experiential, in- the-moment somatic/affective focus]

Pt: I think I’m feeling the warmth of your care! [receptive affective experience] And it’s making me feel really good inside that I can feel all of those (feelings), in such an interesting wave (gesturing an arc with arm, smiling), like, the sadness and the compassion from you, and then… uh… the space to share all of it and have it be welcomed and cared for and also nurtured. And also the other part—coming out at the end, the freedom from it, to go through that whole space. It’s a remarkable feeling for me. [reflection on transformational experience] And right now, I feel calm and safe again and satisfied that I can go through all that. And it’s interesting, like, how quickly it happens. I don’t get stuck, which is a nice freedom as well. [Core State, open, calm, knowing/truth sense]

T: Absolutely. Absolutely. Really feel that knowing. You don’t get stuck, which is freeing. [Resonating energetically with patient’s Core State experience; both patient and therapist are in State 4]

Pt: Mm-hmm. (laughs) Very freeing!… I have felt stuck, so to feel it all flow through me so… effortlessly, so naturally… It’s a very different way of knowing myself… There is like a knowing that this is part of me, and I can come back to it. It’s a very satisfying, pleasurable feeling… very healing. [State 4: unitive, flow, deep knowing, confidence, and pleasure]

The preceding vignette demonstrates how metatherapeutic processing (through recursive rounds of experiential exploration and reflection on emergent experience) and judicious self-disclosure, in the context of moments of change, can deepen and expand emergent positive emotion. This process often deepens into State 4 integration, openness, ease, and trust, infused with a deep sense of subjective truth.12 Together, Sam and I deepened into Core State resonance, knowing and being. This example also illustrates how AEDP interventions aim to facilitate neuroplasticity: Neurons that fire together wire together (Hanson, 2013, Siegel, 2006). Hence, “the more we do it, the more….” satisfying, trustworthy, solid, and pleasurable it becomes. The more the healing integrates. In Sam’s words:

Internalization of the Attachment Relationship & Affect-Regulating Strategies of the therapy pair

This ongoing change process is further illustrated in the following vignette from session 15, the penultimate meeting, with the same patient. Although Sam still felt sadness at the prospect of saying goodbye, he no longer feared completing therapy:

T: I’m wondering how it is for you to be able to do this together when you’ve had other experiences (of endings and good-bye) that you tell me were less healthy, or “unhealthy”?

Pt: Yeah, I feel…exactly what you’ve prepared me for, by talking about it, that it doesn’t feel scary, and that we’ve done the work and its now part of me… I feel safe in myself and so I also feel safe to go do my own thing and fly (smiling as he gestures forward with hand). And so I feel confident and I feel ready. I also feel that, uh, that was a really good model for me to discuss (hand moves toward therapist and back toward self)… to discuss things that were internally, yeah, it was a bit scary for me. And I think as much as…

T: (leaning forward) Tell me? That was a good model…?¹³

Pt: Yeah! Because it was something that I knew was coming. And…I kind of knew that I needed to talk about with you (hand gesturing upwards and out from chest), and you brought it up very gently, and we talked about it numerous times that it, just basically calmed that whole fear (hand gestures slowly downward), and it didn’t feel scary to me anymore. Because, equally at the same time, I was growing that capacity to be safe on my own. And that’s really kind of… progress in the, you know, last two to three weeks… I guess what I’m saying is I have a model now too, in my healthy relationships, to feel like it’s OK to talk about… something [T smiles and nods] if they come up for me and if they’re scary. Before, other relationships in the past, like I said, I would get punished for talking about scary things, so I would feel afraid. And I don’t feel like that… The people that I do feel safe with, they will have very similar, uh… (smiling and gesturing with hand between self and therapist, who smiles in response), and it’s not going to be scary at all.

T: Uh-huh.

Pt: Yeah.

T: Wow!

Here again, the patient’s internal working models appeared to be shifting: He now envisioned that people in his life who care for him will respond with interest and comfort when he turns toward them in times of need. He described a new ability to discern between people who are responsive and care about him and those to whom he was historically drawn with anxious, fearful preoccupation. He also spoke of having newfound clarity about his needs in relationship, which had previously confused him. Furthermore, Sam was speaking coherently and cohesively about previously overwhelming emotional experience. He was demonstrating reflective capacity. His ability to make sense of his past experience and integrate this into his autobiographical narrative is a hallmark of earned attachment security. Through facing and processing his feelings about the approaching goodbye, and doing so together with me, Sam appeared to be internalizing our attachment relationship, as well as the affect-regulating strategies of our therapy dyad. He described these changes as “real” and “part of me now.” In previous sessions these novel changes felt surprising and less solid; whereas, by the end of treatment, he was confident in his ability to take me (and the affect-regulating strategies of our therapy dyad) with him, internally:

It’s powerful! I can have you with me and I have those (mental) pictures– not just of your face– I have the sound of your exhale, and the feeling I get in my body (when I hear it), the calm and vitality. And I’ll take that… it is something that is with me. You’ve become part of me. I take you with me. And it lives within me, and it changed me. And I see the fruit of it. Even this past week, like I told you…¹⁴

Moreover, Sam’s earlier statement, “the more we do it the more…” and his subsequent description of a progressive change process that gains momentum as it builds upon itself (e.g., “And that’s really, kind of… progress in the, you know, last two to three weeks”) is consonant with Frederickson and Joiner’s (2002, 2018) empirically supported broaden-and-build model of positive emotion. This model of change “posits that momentary experiences of mild, everyday positive emotions broaden people’s awareness in ways that, over time and with frequent recurrence, build consequential personal resources that contribute to their overall emotional and physical well-being.” (p. 194). These enhanced personal resources, in turn, lead to further experiences of positive emotion, in a self-reinforcing upward spiral of wellbeing.

In the final moments of Session 15, Sam had yet another mastery experience of what Fosha calls “feeling and dealing while relating” (Fosha, 2000, p. 42), when I re-evoked the approaching goodbye. He felt another big wave of previously overwhelming emotion rise and crest within him, then returned to a state of calm that was becoming increasingly familiar:

Pt: Yeah, I felt a lot of deep sadness there, when I thought of saying goodbye to you, and now it’s kind of moved through me. I still feel a little bit sad, but there was a strong wave of it that went through me. But I feel… the word is “sad”, but… calmer energy… kind of more slow.

Sam’s ability to autonomously manage challenging emotions was growing, both within session and beyond the therapy hour, which was his original goal for therapy. Prior to our work together, Sam had felt unbearably alone with overwhelming emotions, including those that had arisen in his previous therapy. His transformance strivings had brought him to AEDP, yet at the outset of our work together, Sam had told me that he didn’t know whether feeling less alone with his big emotions would be “a distraction from” or in service of his goal of being able to autonomously and healthily manage his emotions. However, the experience of being accompanied, helped, cared for, and of making an emotional impact upon me, his therapist, from the first session and onward throughout the 16-sessions of AEDP, left him with no doubt that the latter was true: he did not need to learn to feel and deal on his own!

Moreover, the rapidly approaching end of our time together appeared to be advancing and augmenting Sam’s internalization of the affect-regulating strategies and capacity of the therapy dyad. This was further evidenced as we began our final session, when he told me that he had gotten in touch with feelings of sadness at the prospect of saying goodbye, just prior to our meeting. He described having effectively tended to the sadness, which then abated. During the final session, Sam’s feelings of sadness were counterbalanced, and indeed outweighed, by excitement and curiosity about the change that “keeps rolling and growing,” and where it will lead him. He felt proud and confident as he told me of a new experience in the past week, in which he calmly asserted a boundary that was protective of him and also of his relational partner. As we prepared to say our final goodbye, Sam embraced me in a “virtual hug” and expressed his deep gratitude. I expressed my delight and told him I was deeply honored to have been part of his profound change process. We continued to maintain an experiential and relational focus through the final moments of our last session, in which Sam expressed curiosity and optimism about the future:

Pt: Now I know how I want to have relationships. And it feels like we kinda talked about, freeing, like where will this take me in the future now? (laughs heartily)

T: (smiling, soft voice) I love it! This feels like such a fitting way to say farewell.

Pt: Yes. It does… it’s a warm farewell. Thank you, Richard.

T: You’re welcome. It feels honouring of our work in just the right way. (big smile, hand gesturing between self and patient) And now I do feel the wave (softly) of sadness. The sweet, sweet sadness when shared. [resonant, affective self-disclosure]

Pt: (smiles, eyes full of feeling). Yeah, that’s a nice way of saying it. (more solemn) A sweet sadness…because of all the things we’ve shared. And I’m glad that I can feel that sadness and express it. That’s part of the work that we’ve done, because before I wouldn’t want to acknowledge it, and I couldn’t acknowledge it. [T: (softly exhaling, as though whispered) Yeahhh]. And I see that I can, so openly, and have it reciprocated, and also feel that warmth, all that complexity (arm sweeps in an arc) of all those emotions. And I can feel them in me and understand them and enjoy them (laughs heartily). [Core State integration, openness, and joy]

T: Yeahhh! Mmmmm. Just let yourself feel all of that.

Pt: Yeah. it is nice to feel that, to savor all of it.

T: OK my friend, my traveling companion. I love that you have said to me that you feel like this is you, flying… this is the launching. And your heart opening and your wings expanding, is so heart opening for me (fingers point to sternum and down front of torso), and so deeply satisfying.

Pt: Wow! Thank you. I love those words. And it’s like the perfect metaphor. I feel free to fly… and give love and have it returned to me and… enjoy it (smiling broadly, taking his time to find his words). And… feel calm… and secure and safe. It’s a good place! (joyful laugh).

T: Fare well! (hands to chest in prayer position, little bow)

Pt: (hands to chest in prayer position). You take care my friend.

T: You too! I will and you too. OK Sam (little wave) Goodbye.

Pt: (overlapping, in synch, waves). Goodbye.

These final moments were infused with a core-state quality, as Sam and I were together in the truth of our good work and the sweet sadness of farewell. Together, we openly shared feelings of not only sadness, but also of satisfaction, and mutual affection as we said goodbye. Sam ended treatment feeling grateful, “inspired”, and curious to explore what was to come. Throughout the process of bringing therapy to completion, we had simultaneously celebrated his therapeutic accomplishments and processed his feelings about the approaching end of treatment, while affirming that our relationship and his change process continue after the therapy itself comes to an end.

Self-of-the-Therapist Considerations in Bringing 16-session AEDP Therapy to Completion

This was a very moving therapy for me. I was deeply touched by my work with Sam. Although in a professional role, I nonetheless seek to bring myself fully to the work and into the therapy relationship– to be this person in the role, which means including my humanity and my heart. Our therapy relationships are very much real relationships, albeit within clearly delineated professional parameters; and without question, Sam and I shared a unique intimacy. When working in 16-session AEDP, we therapists will likely have our own feelings about goodbyes, which may be charged with — and evoke — prior experiences of loss. Consequently, it is imperative for therapists to be aware of and attend to their own feelings about separation and loss, whether through self-reflection, peer consultation, supervision, or personal therapy.

Sometimes goodbyes are hard for me. My mother died when I was a toddler, and my family constellation shifted repeatedly, as my father remarried and divorced several times. I rolled with those changes and formed new bonds, but they also involved further losses in my attachment relationships. I live with these early experiences of loss, and, for the most part, I believe I’ve come to live with them well. For many years I coped by ignoring transitions until they were upon me, at which point I then jumped to whatever came next and usually landed on my feet. That strategy worked well for me and my family in childhood, but that way of approaching impending separations, and moving through them, definitely does not work in my role as a therapist! I have had to adapt and learn new ways to face and be with goodbyes, and I am proud of having done so.

With Sam, the depth of my feelings at the prospect of saying goodbye genuinely surprised me. Something about the intimacy of this work, the deep care I felt towards Sam in combination with how important I was to him as an attachment figure, seemed to really tap into the early loss that I live with, and that lives in me. While I was not swamped or overwhelmed by my feelings, I did touch into a familiar sadness and an inchoate sense of limbic fear, both of which I experienced as disproportionate to (i.e., bigger/deeper than) the context of my relationship with Sam, which was indeed a loving one. Without question, these feelings warranted attention, both for my own sake and for Sam’s. I know from a singular experience, early in my work as a therapist, that I cannot safely and steadily accompany and steward a patient through their own experience of loss, if my own wounding is activated out of awareness.

I was grateful to be able to lean into the supervision group for therapists participating in the AEDP research study, where I could openly share my feelings with trusted colleagues. This was a deeply moving experience of undoing aloneness and being known in a rare way, which filled my heart with gratitude and a unique, core state kind of richness or joy that comes with allowing the truth, when that truth is deeply sad or painful. For me, there is a paradoxical beauty in this kind of allowing of what is and has been, even when it was and remains unwanted and unwilled.

As my work with Sam approached completion, I brought some of these feelings to the second of two individual supervision sessions that therapists who participate in the research study receive at no cost, in support of each 16-session treatment. My AEDP Institute faculty supervisor, Karen Pando Mars, helped me be with and hold my vulnerable feelings around saying goodbye to Sam, whom I experienced to be an extraordinary man with a very pure and loving heart. Karen invited me to connect and be in relationship with my two-and-a-half year old self, in order to take the little boy who had lost his mother, into my adult heart, and hold him close. I then took him my “little one” with me into my last two sessions with Sam and felt centered and grounded in doing so. In parallel process, I believe Karen trusted in my ability to navigate the goodbye, just as we therapists trust our patients in their capacity and ability to do so, in 16-session AEDP.

I share all of this to underscore the importance for therapists to engage in curiosity and gentle self-awareness, with regard to earlier experiences of goodbyes, transition, and loss, when approaching the completion of 16-session AEDP. I tell my patients (and teach my counselling students) that saying goodbye to one’s therapist can evoke powerful and sometimes surprising feelings, and that these may resonate with previous experiences of goodbye. This can be equally true for therapists themselves. Thus, I want to underscore the importance of peer support and/or supervision in this work (as well as personal therapy), so that we can undo aloneness in relation to our own feelings about saying goodbye to patients.

The case example above demonstrates many of the interventions that help patients experience a satisfying, and generative completion of treatment in 16-session AEDP. Because AEDP is dyad- specific, the termination process looks different with different patients. The preceding clinical example involved a fortuitous and remarkable goodness of fit between method (16-session AEDP) and patient (Sam), as well as between patient and therapist, with a very articulate and expressive patient. Despite his troubling history and his suffering, Sam was remarkably open to the therapist and expressive of his emotional and relational experience. This is not always the case, as I describe below.

Case Example #2: Axel

The following case example demonstrates interventions and key therapist tasks in the termination process with a patient whose affective expression remains more constricted throughout treatment. The ensuing discussion is organized into four sections: (1) initiating discussion of therapy termination; (2) processing the completion of treatment; (3) key aspects of the final session, and 4) the very end of the final session: saying “goodbye.” Axel¹⁵is a 39-year-old heterosexual male of Swedish ancestry, with a history of childhood trauma. He is married, has two young children, and works as an aircraft mechanic. Axel sought treatment (his first experience of psychotherapy) after a distressing workplace event that evoked crippling shame and deeply shook his sense of self, his identity as a good employee and a good person. His main goal for therapy was to be able to feel and regulate his emotions, rather than automatically shut down or become overly reactive and push away in anger ¹⁶ The patient made remarkable progress over the course of our 16 sessions and increased his emotional awareness, tolerance, expressiveness, and receptive affective capacity with surprising rapidity.

Arc of Therapy

Axel and I worked together in person, prior to the pandemic. As is often the case, thanks to AEDP’s healing-orientation and change-forward methodology, Axel was surprised that his first session was less onerous than he had anticipated (he told me, “It went better than I thought”). He felt understood by me, from the get-go, and undoing aloneness was a key change process in the treatment. Beginning in that first session and throughout treatment, our work together involved helping the patient organize and be in touch with his feelings in vivo. This included much affirmative work with Axel’s defenses – validating and exploring the costs as well as the benefits of his “checking out” in the face of emotional experience. I had to learn to leave him a lot of space and to work at a pace that worked for both of us (working so spaciously and slowly was a growing edge for me at the time).

Axel was very goal-oriented and results-focused. He loved a challenge, and he wanted to be able to share himself with others, which was a major transformance manifestation! So, he was willing to be playful and to try portrayals –starting with a recent event with his distant, authoritarian father. A pivotal moment in the treatment occurred when I helped him make emotional sense of a childhood event (a betrayal by parents) that affected him in ways he found bewildering. He felt I had “hit the nail on the head,” which helped him “connect his head to his heart.” Axel frequently used very visual metaphors. He had a sense he had “opened a door” that he could not and didn’t want to close. Mid treatment, his sense was that he was doing “a jigsaw puzzle without the picture on the box,” and that he was “unpacking boxes blindfolded.”

Over time, however, he began to have more access to his emotional experience within and outside of sessions, and spontaneous memories from childhood arose, as well. We subsequently did portrayals with his overwhelmed mother and with his young child self, who had been bullied by peers, and too often left to his own devices by parents. Feeling known and seen by me was “turning everything on its head” in terms of Axel’s strategy of “keeping everything to myself.” Eventually, he felt ready to revisit the precipitating event that had brought him into therapy: He was able to connect with his young self who had sunk into the pit of shame, and Axel the adult knew himself to be a good person, despite having made a mistake. This portrayal work led to State 3 Transformational affects of mastery, tremulousness, realization, and enlivenment.

Axel described his newfound ability to face big emotions in terms of “slaying a big fiery dragon, without armour or weapons.” His change process further deepened in response to my disclosing that I knew him to be deserving of feeling and speaking the truth of his experience. As we approached the final four sessions, the focus of our work shifted increasingly (but not exclusively) to the approaching completion of the therapy.

Initiating Discussion of Therapy Completion in 16-session AEDP

Therapy completion (aka: Termination) is anticipated, envisioned, and explicitly discussed from the outset of treatment in 16-session AEDP. The therapist addresses and engages the patient’s transformance strivings and capacity for resilience from the very start, by acknowledging the fixed end point at the outset of therapy. In naming the end point from the start, we convey our confidence in the patient’s capacity to do well within the parameters of the limited time frame and to successfully navigate the built-in ending. Mann (1973) viewed the “use of time as a powerful motivating force in treatment” (p. 31). According to TLP (Time Limited Psychotherapy), the known time limit simultaneously evokes anxiety about and defenses against loss and an idealistic yearning for boundless care. When met with confidence on the part of the therapist that good work can be accomplished in a short period of time, the defined end point also evokes a sense of hope and optimism that accelerates the patient’s investment in the therapy and the development of a strong therapeutic alliance. Hence, from an AEDP perspective, the patient’s attachment-related schema (i.e., internal working models of self, other, and relationship) and interpersonal strategies are evoked from the get-go, as are the patient’s transformance strivings. This affords the AEDP therapist a rich opportunity to provide, from the very outset of treatment and throughout, therapeutic experiences that are new and good, and thus disconfirming of the patient’s expectations based on their previous attachment relationships (and thus of the need for defensive adaptations developed therein).

In the first session, 16-Session AEDP therapists ask a version of the question: “When our work is completed, and provided we’ve worked well together, what will be different for you at the end of our 16 sessions?” This serves a four-fold purpose to: (1) elicit goals and a focus for the work; (2) raise awareness that therapy, like life, is a finite process, to be maximized; (3) plant the seeds of potential change; and (4) foster attachment in the therapy relationship and undo patient’s aloneness with their struggles by foregrounding that therapy is a collaborative process, something we do together. In each subsequent session termination is similarly foregrounded, e.g., “So this is our fifth of the 16 sessions, and I’m just wondering what you are aware of as you shift from your busy day to our being here together?” As the final session date nears, I begin to explore with patients their thoughts and feelings about the impending completion of therapy, making explicit that this will be the ending of our work together and not the ending of my feelings for the patient. While doing so, I convey that we still have time to do good work.

The following exchange from session 13 provides an example of how I seek to offer Axel an experience of emotion-in-connection as we approach the end of our work together. I invite and evoke his emotional experience, then welcome its complexity, by responding to and holding space for his feelings of sadness, while also affirming his sense of affective accomplishment in therapy¹⁷ I also convey that (a) the change process is ongoing and not over; (b) his emotional experience is deserving of our attention; and (c) he has self-knowledge about his affective needs:

T: So, we have three sessions together after today, and I’m just wondering how you think and feel about that? Or vice-versa, (slower) how you feel and think about it?

Pt: Hmm. In a way sad. Will definitely miss this. But I also feel like… (calm, quiet, declarative) we’ve done a tremendous amount of work in our time. I didn’t know what to expect, I guess, but… If I think of maybe the first day and just from there … (long pause) Feels like we’ve been doing it for a long time? But it’s gone by quick, I guess. Yeah. (smiling, louder) Maybe 13 sessions is a lot for some people, I have no idea?!

T: So, a lot can happen in 13 sessions, but I just want to… like, agree or validate your experience that we have done a lot. [Pt: mm-hmm.] When you look at where we started, and where you are now, I think we’ve done a whole lot in 13 sessions. [Pt: Yeah]… So, I get the sa…(sadness) — both. The sense of: “Wow, we’ve done good work!” [Pt: Yes!)]… And there’s a sadness that will come with saying goodbye (hand moving between self and patient). [affective resonance]

Pt: (nodding in resonance) That’s right. Yeah.

T: (softly) Yeah. Yeah. (long pause while the therapy pair engage in open eye contact, both nodding slowly and subvocalizing in resonance). And in a way we’re not there yet, but we’re approaching that. [gently shifting focus to the bottom of the Triangle of Experience] [Pt: Yeah]… So I also want to kind of hold that knowing and whatever feelings come with it (open hand gesture of holding), but also ask you: Are there parts of your experience that want some attention in the time we have left, (softly) parts of your experience where you feel deserve attention? [undoing aloneness]

Processing the Completion of 16-session AEDP

In the final two sessions, interventions aim primarily to: (1) access feelings about, and (2) process the shared experience of ending therapy; (3) celebrate the patient’s emotional achievements and growth; and (4) affirm the ongoing nature of the change process begun in therapy. In the exchange below from last two minutes of Axel’s 14th session, I gently focus on and invite Axel to stay with his emergent feelings of sadness about the ending of our time together, while also affirming his affective accomplishments in therapy. I purposefully undo his aloneness through the use of collaborative “we” language, and I self-disclose my own feelings about the process in order to deepen both a felt sense of togetherness and the patient’s emergent affective experience. I explicitly introduce the therapeutic task – and proffered opportunity — of staying connected and present through the shared experience of an ending; and I use present- tense language to convey that the change process we are undertaking together, through the privileging of his emotional experience, is ongoing:

T: And so, we meet next week and the week after, and then we say goodbye.

Pt: (long pause, maintaining eye contact, head nodding) It will be sad.

T: (long pause) And somehow, over here, it feels really right and fitting at the same time as sad [affective self-disclosure]. [Pt: Yes] In the sense that [Pt: Yeah] we’ve… My sense is we are really accomplishing a lot of what you set out to do.

Pt: I think so too. Yeah. I don’t feel like I’m… uhm, at the beginning. I feel like I’m at…where I should be, if that makes sense? (Pt considers, takes stock) Yeah. I feel that I trusted the process, in terms of trusting myself and you— first you, and then probably myself. Yeah. I feel like it is towards the end.

T: That’s how I feel too, and so we can have the sadness (extending hand toward patient), because it’s pleasurable and productive to be here together… [Pt: that’s right]. And it also is towards the end [lightly pressuring with empathy]. [Pt: mm-hmm]. So, I have a challenge for us actually [Pt: Great]18 And it’s a continuation of what we’ve been doing [Pt: mm-hmm], and I think it’s to be together, with the sadness [Pt: (nods) mm-hmm!] and the satisfaction [Pt: hmm]. What happens when I offer that? [metaprocessing invitation to “be together, with the sadness”]

Pt: (laughs) Part of me doesn’t want to feel it now. [Patient acknowledges his own defense against feelings of sadness and loss.]

T: I don’t mean now, I mean that’s our work. [Pt: Yeah, that’s right!] I do think we’re both feeling a little of it now (pointing to own face then to patient, making stirring gesture with finger). We don’t need to feel it just yet. [defense softening]

Pt: (laughing) No, we don’t. No.

T: But it looks like you’re aware of it, nonetheless.

Pt: Yes, I am. Definitely. Yeah. I feel like I’ve been watching a great movie. It’s kind of a cheap analogy because it’s more than a movie… But it’s over. We got to enjoy it though. So great. You know what I mean?

T: I think I do, actually. And so now (smiling) we get to be together through the end of it [Pt: Right] and find out what that is. And stay present with it together. [relational focus and gentle “pressure” to prime the affective experience that part of him “doesn’t want to feel”]

Pt: Right.

T: Great. Let’s finish right here, but I just love… because I think we’re both being with all of it right now. I’m not sure, I mean, I don’t want to speak for your experience…

Pt: Oh yeah. I feel that. Yeah.

T: I’m seeing a lot of feeling. Mmm. [moment-to-moment tracking, holding space for emergent affect through parabverbal sound] [Pt: Mmm]. See you next week.

Pt: See you next week.

When a patient’s defenses (e.g., against sadness) arise in the termination process, the AEDP therapist seeks to melt or bypass these through validation and empathy (Fosha, 2000), rather than forceful confrontation. In the excerpt above, when Axel acknowledged his defenses, I worked affirmatively and somewhat playfully with them, in order to access more of the underlying sadness, by suggesting: “We don’t need to feel it just yet;” while gently acknowledging and tracking that we were “both feeling a little of it now.”

As discussed in Case Example 1 above, it is imperative that therapists also be aware of and attend to their own feelings related to separation and loss, and any potential defenses that may arise on the part of the self of the therapist. When the patient does not spontaneously address feelings related to loss and separation, the therapist does so through judicious self-disclosure

(Prenn, 2009), which is an important intervention throughout AEDP therapy. This stands in contrast to many other therapy modalities, in which therapist self-disclosure begins only during termination. Often in the 14th or 15th session, patients manifest a resurgence of symptoms, a backsliding, that Mann (1973) understood as protest against the inevitable termination. At these times, it is important for the therapist: (1) to hold the frame with confidence, with the understanding that this is an expected part of the process; and (2) to trust and lean into the patient’s transformance and their (perhaps unconscious) ability to navigate the end of therapy and organize the experience. The therapist’s trust in the transformational process, which AEDP views as non-finite and expansive, and their trust in the patient, helps assuage anxiety on the part of the patient (and perhaps the therapist, too). This is particularly important when either member of the therapy dyad feels that aspects of the patient’s change process are not complete, as described below.

Completion in 16-session AEDP does not always evoke loss. Sometimes it is solely a celebration of therapeutic achievement. Often it is a combination of both. In our penultimate session, Axel told me he felt sad but not scared about the end of our time together, because he felt “that much more ready to be with myself and the world, experiencing feelings that I never really allowed myself to feel, but also realizing that it’s not a light switch, it’s a process.” I responded: “We’ve been developing your capacity to be with yourself and with others, and part of the loss for me is that I don’t get to see how that unfolds.” I also let him know that “along with the loss in there for me there is also the excitement, the sense of satisfaction, the sense of accomplishment, that we’ve accomplished something. They are both there.” When the therapy pair attends to “both,” the sadness and the shared pride, satisfaction, and pleasure of accomplishment and mutual affection, this can help the patient find the strength to be with the loss and carry all that is good and right, and which has worked so well in the treatment (including the therapist’s care) forward in their life.

Mann viewed the ending of therapy as an opportunity to redress patients’ earlier experiences of “separation without resolution” (Mann, 1973, p. 35). From an AEDP perspective, we aim for separation with resolution. The process offers a unique opportunity to disconfirm the patient’s earlier attachment-based expectations, revise internal working models, and help patients face and accept loss, and discover that it is possible to thrive in its wake. I tell patients that saying goodbye in psychotherapy can be surprisingly powerful and evocative of earlier goodbyes, and I ask about their prior experiences of endings in relationship. I make explicit that, because our ending is planned, it is an opportunity for things to go differently than previous separations. I ask patients how they would like our final session to go, to best honour our goodbye and the completion of the work that we’ve done together. Axel’s response took me by surprise: He wished we could sit down for a drink together, because he wanted to know more about me. He wanted our final session to be more “casual” and reciprocal. I asked him if we could also reflect

together on the work we’d done, and he agreed, saying it would be helpful and integrative for him to do so. My sense was that his request was not a defense against the separation, but rather an honoring of the transition, in which he was no longer relying on me, and wanted to be in a more equal and mature exchange, and that perhaps this was his “guy-to-guy” way of being close. So, I brought sparkling apple juice to our final session and served it in beer glasses. Key Aspects of Final Session In the final session of 16-session AEDP, the therapy dyad attends to the patient’s experience of a new kind of separation, one in which the patient has had agency and a receptive, responsive relational partner. And we metaprocess this new kind of goodbye. Should the patient leave with sadness, this does not mean that the therapy has been unsuccessful. Indeed, the patient will leave with more than sadness because they also leave with whatever comes of metaprocessing the feeling of sadness (Fosha, 2019, personal communication). The therapist explicitly conveys that the change process does not end with the conclusion of the 16th session, and that the therapy relationship can also live on. Here each therapist is invited to find their own authentic way of letting the patient know they will continue to exist in the therapist’s heart and mind. I let patients know that I am taking them and our shared experience with me, in my thoughts and in my heart, and I invite them to do the same. Then I express curiosity about how the patient receives this. The following excerpt provides an example from my final session with Axel. As with any and every AEDP session, I seek to provide the patient a new experience and for that experience to be good and to be felt by the patient. Hence, we work experientially and somatically with Axel’s felt sense that our care for each other does not end with the completion of treatment. I want him to feel how he knows what he knows, in order to extend and deepen this positively valanced affective experience, with the intention of promoting positive neuroplasticity (Fosha et al., 2019; Hanson, 2013, 2017). Moreover, I want to provide him a new-and-good experience of emotion- in-connection, in the face of an ending, while also affirming his change process and conveying trust that this too continues on after we say goodbye.

As our session began, Axel told me that he’d been able to both stay present in the face of heightened emotional experience over the past week and regulate his affective experience, rather than shut down or become reactive as he typically did prior to treatment. This helped him feel empathy for loved ones who were struggling:

Pt: So it was nice to do it, because I was able to… I pray and I prayed for them and I was able to… kind of sit with it for a bit, actually, and let it… let me think about their situation and what they are going through, and pray specifically to certain areas. (Soft, contemplative) It was nice. Yeah, it’s new. It was new. So it’s good. Mmm. (smiles)

T: Yeah. I see you smile, and I’m happy too… [Pt: Yeah!]… knowing that our work is… [Pt: Mm-hmm]… manifesting, that it is expanding (arms wide open) in your life. [moment-to-moment tracking, affective self-disclosure to affirm and expand patient’s therapeutic growth]

Pt: That’s right. Yeah. Yes.

T: Mm-hmm. Because that’s what this is, right? [Pt: I think so.] This is in some ways planting, not just seeds, but…growing shoots that continue (arms open outward).

Pt. (softly, nodding head) Mmm. That’s right. Yeah. And in a way, I’m not… being trapped in my head– it’s kind of nice. I did it privately but I feel like I experienced the world in a way that I don’t know… I feel like it wasn’t intellectual. It was emotional. [This is huge change for this patient, and in the moment, I missed the deep significance of his simple, declarative statement: “I feel like it wasn’t intellectual. It was emotional.”

T: So, it’s dynamic. Our 16 sessions are coming to completion but the process that we’ve been doing, goes on [Pt: That’s right. Mm]… and in that regard, (voice deepens) I totally know I take with me “you and me” and carry you forward (hands on heart) and us forward, (softly) and I invite you to do the same [Pt: Yes!]… because it doesn’t need to end that way, either.

Pt: (softly, nodding) That’s correct. Yeah. I feel that. Mmm. hmm. (long pause)

T: I want to ask you how you know that? (voice deepens) Like, what your inner experience of knowing that and feeling that and getting that– because it’s so evident that you get it– is like? [experiential focus]

Pt: (pause) It’s really hard to explain it (shifts in seat, crosses leg). Uhmm [Patient moves towards top right corner of triangle of experience, a moment of anxiety and red signal affect.]

T: (softly) Let yourself touch back into it, this sense that (moving hand to chest) I’m taking us and you (pause) with me, and as I say, “I invite you to do the same,” what’s there? [dyadic affect regulation and redirecting focus to the bottom of the triangle and patient’s internal affective experience]

In processing the completion of 16-session AEDP, I affirm and celebrate growth by asking patients to reflect on their experience of change. I then share my own recollections of their affective accomplishments and key moments of our shared experience in therapy and explore how the patient receives and experiences this. This is akin to metaprocessing the therapy-as-a- whole. This shared reflection upon and experiencing of the patient’s therapeutic accomplishments during the final session often evokes emotions such as pride, joy, agency, and/or confidence on the part of the patient, as well as feelings of gratitude, exuberance, and sometimes awe. AEDP theory and clinical observation suggests that when fully experienced and further reflected upon (i.e., metaprocessed), these affects deepen and strengthen the ongoing transformational process (Fosha et al., 2019; Iwakabe & Conceição, 2016; Russell, 2015). Throughout the final session (as in all AEDP sessions), I continue to invite and facilitate the patient’s emergent embodied emotional experience. When sadness arises, I affirm the importance of the patient sharing their feelings with me, so we can be with them together. I let myself feel my own feelings, so I can be with the patient authentically in empathic resonance.

Axel and I had framed his final session as an opportunity to mark and celebrate the completion of our work, and to reflect together on its significance. In preparation, I had written a letter that I read aloud to Axel, in which I highlighted key moments we’d shared and underscored qualities and capabilities that I recognized and valued in him. After having shared and metaprocessed our respective perspectives on Axel’s change process, I re-evoked his metaphor from previous sessions of therapy as a movie, to further elicit his feelings about our impending goodbye. I expressed my own genuine feelings about saying goodbye, in order to deepen our connection and his affective experience; I also reaffirmed my trust in his capacity to continue to grow and share his feelings, beyond the end of treatment:

T: I was also thinking about how it’s been like a movie where we get to discover the plot, and now this part of the movie is coming to an end (long mutual gaze, faces full of feeling)…and there’s clearly such sweetness in it, [Pt: Yes!] in what it’s… in how we are. And then you said “bittersweet,” so… can we make a little room for that part too? It’s here. [inviting patient’s feelings about our shared experience of ending therapy]

Pt: Yeah. I think those moments where I’ll realize something and I’ll want to tell you and I won’t have that option. Yeah. I’ll miss that, sharing those moments. (softly) It’ll be tough. [State 2 sadness]

T: I’m so glad you are letting yourself feel that now, so we can be together with that, too (gesturing between self and patient) [undoing aloneness]

Pt: (long pause) That part of me is wondering, can I share that with somebody else? And I think I can. Mmm. I remember you talking about having big feelings and having people there with you? And maybe these aren’t big feelings, but they feel like big moments where I feel like maybe I do need someone there with me.

T: I have great confidence in your ability… [Pt: Mmm]… (softly) even though you’ll miss being able to share them with me, I want to hold both, [Pt: Mmm]… because there’s the sadness in that and I also have great trust and confidence that you will be… you know, more than OK [Pt: Mmm]… And I love the idea, like, who could you share them with?

Pt: My wife. Three friends.

T: And could you imagine doing so?

Pt: Oh yeah.

T: So to me, that’s richness [Pt: Mmm]… there’s the richness of our experience—it’s been so rich—and you’ve got rich resources in yourself and in your community. [affirmation]

Pt: I do. Yeah.

T: So, can we be with all of that and the sadness, I think, of saying goodbye?

Pt: (nodding as he and T sit in silence, looking at each other with sad smiles and faces full of feeling) [subtle State 2 processing of shared experience of ending therapy]

T: (slowly) Because I feel it, here too. I feel sad too, because as I said, I so enjoy you. [Pt: Thank you]… And being with you. (softly) So there’s a loss here, for me too. (pause) How’s that to hear? [metaprocessing affective self-disclosure]

Pt: It’s nice. It’s… (pauses, nods and speaks softly and declaratively) Yeah. Thank you.

T: (softly) You’re welcome. (long pause) How did we do today? In terms of your desire to keep it casual and also to find out a little bit more about me, as we say goodbye? [dyad-specific metaprocessing, tailored to patient’s affective capacity, cognitive style, and preferred way of doing so]19

Pt: Good. I like knowing (about you, too).

Very End of Final Session: Saying “Goodbye”

In 16-session AEDP, the final goodbye, itself, is emergent and authentic, and flows spontaneously and genuinely, from all that has preceded. It is often bittersweet, and like everything in AEDP, it is dyad-specific. And so it was for Axel and me:

T: And now we do have to say goodbye. And as I say so, I feel the sadness a little more, but as you say, there’s a sweetness to it, and it’s shared…Someone once said to me, “the club of… loss—of sadness, actually—is so sweet when shared.”

Pt: Mmm. That fits well. Thank you.

T: You’re welcome. Such a pleasure, and an honour… [Pt: Thank you]..to have spent this time with you.

Pt: Thank you for taking me. That was a shot in the dark, for sure (laughs)

T: You’re most welcome. (Softer, slowly) You are most welcome.

Pt: It was great.

T: And I wish you, and your loved ones all the best. All good things. And as you’ve said, life has hard knocks too, and I love knowing that you have—and we have—grown your capacity to be with life in its complexity. [Pt: Mmm] Does that fit?

Pt: It does fit.

T: (raising glass) Here’s to you. (Pt raises glass and we reach to clink in a toast)

Pt: (nods acknowledging completion) Great.

T: (smiling broadly) The next time… when I have a glass of wine tonight, I’ll toast you.Pt: (laughing), When I have my beer, I’ll do the same.

T: (rising from chair) OK. Take good care.

Pt: Thanks Richard (picks up phone from couch and stands)

T: You’re welcome (we approach and shake hands). Can I give you a hug?

Pt: Of course. Please! (We embrace heartily, and I hand him the letter I had read in session).

In the vignette above, Axel and I are celebrating his therapeutic accomplishments and growth (which I reaffirm) and sharing feelings of sadness, as we say goodbye. I simultaneously reinforce that I am taking him with me, (i.e., in saying that I will toast him tonight) to which he responds that he will do the same.

Significantly, in both case examples above, the patients emphasized an enhanced trust in self as therapy concluded. Sam spoke of feeling “safe in myself.” Similarly, Axel described a process in which he trusted first in his therapist and subsequently in himself, which left him feeling “I’m… where I should be.” Both patients also spoke of the importance of autonomy. Understandably, each wanted to be able to manage his inner, emotional world and his external life well, independent of therapy. As treatment progressed, both Sam and Axel recounted a growing ability to stay present to and regulate their emotional experience, on their own, between sessions.²⁰ Axel described this important form of autonomy in terms of feeling “that much more ready to be with myself and the world, experiencing feelings that I never really allowed myself to feel.” This suggests that the emotion–regulating strategies of the therapy pair were internalized by the patient. This is understood to be a primary change mechanism and goal of AEDP, and an important aspect and consequence of attachment security.

Potential Challenges Encountered in the Process of Therapy Completion

Some endings in 16-session AEDP are more challenging than the examples above. Patients (or therapists) may feel not only sad but also fearful about concluding treatment before the patient feels ready. At times, both members of the therapy pair have the sense that there is still work to do, that there is a potential for more healing, which might be accomplished in an open-ended or longer-term therapy. At these times, my colleagues and I have found it helpful to fully trust the process of 16-session AEDP, and to remind ourselves that: (a) change begets change; (b) having done a piece of the work (e.g., having helped a patient become more open to another’s offer of help and/or to receive care and feel their own emotions; or to have addressed and processed some past trauma, even though other life challenges are not yet fully resolved) leaves the patient in a better place than they were prior to treatment; and perhaps most importantly, (c) that the change process does not need to end with the completion of treatment. Neither therapist nor patient knows at the end of the 16th session how the process begun in therapy may continue to manifest in the patient’s life. However, the experiences the patient has had in treatment: of connection and togetherness; of receiving and expressing care; of increased self-trust, self-knowledge, and openness to another, are indeed conducive to further and ongoing experiences of this kind.

When the patient expresses fear about ending treatment or a desire for ongoing, continued support, the 16-session AEDP therapist attunes to and processes the patient’s feelings about the ending, reaffirms the good work they’ve done together, and like therapists in Mann’s TLP (1973; Mann & Goldman, 1982), expresses belief in the patient’s capacity to launch and put to use in their life what they’ve gained, accomplished, and learned in therapy. When our patients feel our belief in them, this instills self-confidence and hope on the part of the patient and is itself a form of support that is portable, which the patient can take with them beyond the end of treatment. Consequently, as the end of therapy approaches, I want to ensure the patient has internalized our relationship and to help them to do so if they have not.

For example, Leila²¹, age 36, entered treatment with significant ambivalence about therapy and about opening up to me. In our 15th session, she expressed sadness at the prospect of ending treatment at a time she was considering leaving her marriage. She feared that what we’d done wasn’t enough, that she had not changed enough for her critical and distant husband, and consequently couldn’t have the closeness she longed for. I empathized with Leila’s fears and reflected that her changes had been big changes and not “little changes.” I affirmed specific ways in which I had witnessed her growth, and I shared my genuine desire for her to feel emotionally safe with her partner. Doing so, I became deeply moved. This in turn touched and moved Leila. I also shared my conviction that the work we had been doing– and her growing capacity to attend to and regulate her feelings– would help guide her in navigating her relationship distress and the important life decision she was facing. In response, Leila felt hopeful and had an image of a sunrise on a new day. When she contemplated aloud whether she could go forth on her own (i.e., without further services) after therapy ended, I told her she did not need to do it on her own— that she could take me, us, and all the good work we’d done together, with her. She left the session feeling lighter in her chest and less distressed than when she came in, though understandably still sad.

In our final session, Leila again shared with me her fear that the ending was coming at a time when she still needed the support. Importantly, she felt comforted in doing so. Leila was now using me as an attachment figure– she experienced solace in turning to me with her fear, which is exactly the way healthy attachment is supposed to work! This was an important moment of change-for-the-better, and in a sense, the culmination of our work together, for this patient who had embarked on therapy with pronounced ambivalence and very reluctant to open up to me. In this moment, Leila’s internal working model of relatedness appeared to be shifting, which I wanted to strengthen through metatherapeutic processing. As we worked experientially to explore Leila’s felt sense of comfort, she reflected on the changes she had made in therapy. She was pleased and impressed with her growing ability to be less reactive, and more open with her spouse about her vulnerable feelings. I shared with her my sadness that our time together was ending, and my appreciation and gratitude for having gotten to know her. I again let her know that I would take our time together and her, with me. She told me she had always felt my care from the start of the therapy. Metaprocessing this felt sense of my care, she said “it puts a little pep in my step” to know that it was important to me that she could feel cared about– by me and by others. She envisioned taking our work with her by asking herself, “what would Richard say,” and that this would help her stay with her feelings and cope with her situation. We hugged and said goodbye, thus completing the 16-session treatment. Despite her fears, Leila made use of the 16-session therapy and she completed the 6 months and 12 months follow up.

Another challenge in therapy completion may arise with a patient who has indeed internalized the therapist and for whom the bond experienced with the therapist is unlike any they’ve ever experienced in life and thus deeply meaningful and uniquely important (as was the case for Sam). With such a patient, the therapist is advised to begin to process the ending earlier than usual. This affords the therapy pair more time to be together with the patient’s feelings of grief and gratitude; and to fully experience and metaprocess both the significance of the therapy relationship and a new experience of closeness through an ending.

When a patient does not feel ready to conclude treatment after 16 sessions, the therapist allows the patient to fully express and process anxiety over the separation and related grief. The therapy pair then process the experience of being accompanied in these painful feelings. The therapist also aims to help the patient internalize the therapist (e.g., by explicitly expressing their care and inviting the patient to fully receive this, then exploring the experience of doing so). As described above, the therapist also helps the patient identify the strengths that they have gained, and to take these in. When patients feel they absolutely need or want more support and/or further therapy, a therapist might offer one of several courses of action. Options include: Inviting the patient to contact their therapist in the future and provide an update of how things are going; offering a “booster” session at a future date; validating the patient’s sense of need and adding an additional session to further process the separation; or possibly allowing a “weaning period” of a few extra sessions. Similarly, if a patient should experience an unanticipated and destabilizing life event (such as the death of a loved one) during the termination stage of therapy, the therapist might extend the time frame to provide further support. These decisions are determined on a case-by- case basis.

Notwithstanding the above, in 16-session AEDP, we encourage patients to discover how they fare after treatment. Rather than defaulting to an assumption that the treatment was insufficient and that the patient needs more support, we encourage therapists (and their patients) to lean into the possibility that the work has indeed taken root, and for the patients to test it out in their life, as it were, and discover how things go, how the ongoing change process manifests, over time. Patients and therapists, alike, are advised to trust in the seeds sewn and the change process catalyzed through their work together, rather than preemptively concluding that the treatment was insufficient.

Conclusion

In 16-session AEDP, we approach psychotherapy termination as a launching: a completion of treatment that yields a continuation of the ongoing change process catalyzed therein. The metaphor of a garden aptly captures this: One plants a garden in Spring; when Spring ends, the garden is not over. It continues to grow. This reframing of the completion process in 16-session AEDP helps therapists and patients navigate this important stage of treatment, which is not necessarily or solely evocative of loss. Termination in 16-session AEDP is also a celebration of achievement. ²² Moreover, the ending of AEDP therapy has the potential to be an additive and healing component of treatment: The ending itself can contribute to an ongoing process of change in the patient’s life that extends beyond the final goodbye. When the therapist makes explicit that their care for the patient does not end with the completion of treatment, this can help the patient internalize the therapy relationship and may further contribute to the restructuring of

internal working models of self, other, and relationship. Moreover, metatherapeutic processing of emotions experienced during the therapy completion has the rich potential to: (1) amplify and deepen the positive emotions that organically arise in the wake of a healing, therapeutic experience, including the “good feeling” that comes with sharing sadness; (2) help patients recognize that they have been successful and have been helped, thereby contributing to self- efficacy and the capacity to trust another; and (3) simultaneously consolidate and expand experiences of therapeutic change.

In summary, AEDP’s healing-oriented, change-forward orientation and methodology offer a unique combination of strategies to approach, navigate, and move through the termination stage in therapy, which can be an important juncture and portal in treatment and in the patient’s life. AEDP’s therapist stance, which is intentionally positive, attachment-based, emotionally engaged, affect-facilitating, and judiciously self-disclosing, and AEDP interventions, are all facilitative of patients having an efficient and effective, integrative end of therapy experience in this 16-session treatment protocol.

¹ Copyright © 2023 by American Psychological Association. Reproduced and adapted permission. The official citation that should be used in referencing this material is Harrison, R. L. (2020). Termination in 16-session accelerated experiential dynamic psychotherapy (AEDP): Together in how we say goodbye. Psychotherapy, 57(4), 531-547 https://doi.org/10.1037/pst0000343. No further reproduction or distribution is permitted without written permission from the American Psychological Association.

²Albeit for some patients, not all aspects of their trauma can be healed in the 16-session course of treatment. Nonetheless, important healing takes place which may foster further healing, in the future.

³There are important differences between James Mann’s TLP and AEDP, 16-session or otherwise. The former is a psychodynamic/object relations treatment that seeks to resolve patient conflict between idealistic longing for endless connection and dreaded fear of loss; whereas AEDP is an affective-experiential and psychodynamic treatment that seeks to put positive neuroplasticity into action through the provision of corrective emotional/relational experiences and the processing of both past trauma and present-moment experiences of therapeutic change for the better. Additionally, AEDP’s attachment-based therapist stance is more actively and emotionally engaged and judiciously self-disclosing than that of TLP. Nonetheless, both TLP and AEDP View the time limit as a valuable catalyst for change, and one which enriches the treatment.

⁴ Aspects of the patient’s identity and background have been disguised to protect confidentiality.

⁵ In the opening minutes of our first session, Sam told me “I’ve never felt comfortable expressing anger and don’t really know how to. I think it kinda scares me.”

⁶ Including the murder of Ahmaud Arbery, while he was out jogging, and racist aggression directed towards Chris Cooper

⁷ Previously, I identified these interventions as: 1) relational strategies to undo aloneness and maintain a security-engendering therapeutic relationship, via an actively and emotionally engaged, resilience-focused therapeutic stance that is explicitly empathic, affect-facilitating, and judiciously self-disclosing; 2) affirmation and celebration of patient’s successes in treatment; 3) affirmative work with defenses around loss; 4) co-regulation of patient’s affective experience within the therapy dyad; 5) experiential-affective strategies to deepen, process, and transform energy-consuming negative emotions –and thus allow for something new to take place; and 6) metatherapeutic processing to explore and expand vitalizing positive emotions that arise

following successful processing of primary negative emotions in the context of the patient- therapist relationship, i.e., metatherapeutic processing, with the intent of fostering enhanced attachment security, wellbeing, and flourishing (Fosha & Thoma, 2020; Iwakabe et al., 2020). Although the interventions, techniques, and change mechanisms that comprise AEDP have been identified and delineated for didactic purposes, they are not sequential or linear in practice. Nor is it my intention to suggest that they are discrete and operate independently of each other. Rather, they may function synergistically and holographically (Harrison, 2020).

⁸ He is referring to racial justice issues related to and concurrent with the pandemic, as well as other ways COVID-19 was affecting his personal and professional life in unsettling ways.

⁹ This awareness has emerged in conversations between the following research therapists/colleagues in the 16-session research supervision group led by Diana Fosha: Penelope Andrade, Mary Androff, Sigal Bahat, Emily Bilbao, Jenn Edlin, Eileen Epstein, Diana Fosha, Stephen McDonnell, Judy Silvan, Kaori Stram, Jason Trowbridge, Gail Woods, and me.

¹⁰ See Iwakabe and Conceição’s (2016) process model of metatherapeutic processing for an elaboration of this, as well as the clinical vignettes below for demonstration and further explication of this important intervention.

¹¹ According to Hanson, this helps redress our species’ survival-based bias to attend to that which is feared (i.e., anxiety).

¹² N.B. The change process in AEDP is non-linear. Hence, State 3 metaprocessing does not always lead to Core State. Nor do I expect to go through all four states in any or every session.

¹³ I’m taken by surprise in hearing Sam describe this in terms of having acquired a “model”—an internal working model, as it were. I had never never used this term myself in our work, nor had I offered any psychoeducation about this concept.

¹⁴Sam contacted me approximately one year post-treatment and told me these changes have endured, and that he is both delighted by and proud of this outcome.

¹⁵ Aspects of the patient’s identity and background have been disguised to protect confidentiality.

¹⁶ The termination process in AEDP, like therapy itself, is dyad-specific. In contrast to the preceding case example, Axel was more emotionally constricted in his expression of affect than Sam. Axel’s secondary attachment strategies were more consistently along the avoidance dimension; whereas Sam described mixed secondary strategies of anxious preoccupation with relational partners and fearful avoidance, as well as moments of disorganization.

¹⁷ Affective neurobiology informs us that the complexity of emotional experience is a place of maximum flexibility and adaptability (Siegel, 2009)

¹⁸ In previous sessions he has explicitly stated how much he enjoys challenging himself.

¹⁹ Axel had struggled with my metaprocessing questions earlier in the treatment. He found them confusing if too abstract. Eventually, we found our way to my asking him, “What do you want to remember from today?” at the end of sessions, which he liked, and which worked for him.

²⁰ In our final session, Sam gave an example of having managed challenging emotion then asserting himself calmly in an interpersonal situation that he said would have been triggering to him prior to therapy (i.e., in response to a woman expressing disapproval and anger towards him that he thought unwarranted).

²¹ Aspects of the patient’s identity and background have been disguised to protect confidentiality.

²²Similarly, therapy completion can be viewed as a portal and an exciting new beginning of the next stage of a patient’s life journey.

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