Transformance and the Phenomenology of Transformation

Self-transcendence as an Aspect of Core State

By Danny Yeung

Transformance, a central construct in Accelerated Experiential Dynamic Psychotherapy (AEDP), is the overarching motivational force driving positive change. Transformance is the clinical parallel of neuroplasticity in neuroscience (Fosha, 2010). A forward-moving, generative force, transformance fosters optimal growth and maximizes vitality and psychic energy. This energy resonates with that found in several ancient wisdom traditions. For example, transformance echoes the pervasive creative principle of change described in the ancient Chinese wisdom found in the Book of Changes (Wilhelm, R. & Baynes, C.F. 1967).

Within the framework of transformance, this paper will begin with a concise overview of the theory of change in AEDP, followed by a clinical case presentation illustrating how the principles are applied in psychotherapeutic treatment. Centering on transformative phenomena, this paper aims to underscore AEDP’s process of moving beyond a self that is constrictive, and ultimately limiting, into a series of ever-expansive self-states, with ego-transcending capacities. In this context, I introduce “self-transcendence,” a phenomenon that sometimes emerges as a result of many rounds of “metaprocessing”, as is shown in the first session presented here. Self-transcendence refers to the relentless act, empowered by the transformance drive, of going beyond our usual narcissistic, ultimately limiting, egotistical false self. (Fosha 2005, Winnicott, 1990) Self-transformation is viewed as the culmination of contemplative practice in many spiritual traditions.

Central to AEDP’s theory of healing is a map of transformation–transformation from a constricted, impoverished, disorganized self toward a resilient, ever growing self. This transformation is achieved by processing intense previously unbearable emotions through dyadic affect regulation. Transformance is described phenomenologically as four states and three state transformations (Fosha, 2000, 2005, 2008, 2009a, 2009b, 2010; Fosha & Yeung, 2006; Frederick, 2009; Lamagna & Gleiser, 2007; Russell & Fosha, 2008; Yeung & Cheung, 2008).

State 1: Building safety and working with the byproducts of defenses: stress, distress, and symptoms. When a person confronts an emotionally evocative situation that exceeds their internal resources, in the absence of an emotionally regulating attachment figure, psychological operations known as defenses are activated. In this state, impulses, feelings and other aspects of experience may be excluded from conscious awareness. Defenses (a metaphor with military resonance) aim to protect the ego against instinctual demands (A. Freud, 1966); they protect the self by filtering or blocking pain, distress, and excessively stressful stimuli in the face of overwhelming experience (Vaillant, 1995). Defenses, while useful in the short term to shield the self from floods of anxiety or unbearable emotion, are nevertheless restrictive and unhealthy in the long term.

To render defenses unnecessary, an attachment-informed therapist creates a secure base whereby the patient experiences emotional safety and security (Bowlby, 1988; Lamagna, in press; Lipton & Fosha, 2010; Prenn, 2010; Tunnell, 2006). From a technical standpoint, this secure base phenomenon is established through the therapist’s non-judgmental, sensitive responsiveness to the patient’s core somatic-affective experience. The therapist’s consistent modeling of curiosity, openness, acceptance and loving-kindness, fosters in patients a sustained moment-to-moment attention to his/her somatic emotional experience followed by self-expression, with the emotional experience symbolized through congruent words or imagery. The act of bypassing defenses by focusing on nascent glimmers of sensation and emotion is the first state transformation in the processing of core affective experience. (Fosha, 2009; Fosha & Yeung, 2006). It fosters the process of emotional rebirth, accomplished through processing of core affective experience. (Eigen, 1992; Osimo, 2003).

State 2: Processing Emotional Experience and Including Excluded Emotions and Self States. This second state is mediated by the therapist’s unwavering compassion, and mirrored by the emergence of the patient’s self-compassion. Previously excluded parts of self or components of emotional experience are brought into direct conscious awareness. This second state is often characterized by an increasing swell of intrapsychic emotional experience, be it grief, anger, fear, or relational experience, feeling seen, known, or intimately connected to the therapist. The therapist encourages full experiencing and expression of the core affective experience until it subsides, marking completion of the natural wave of a transformative emotion. Processing an emotional experience to completion can often be accompanied by an experience of emotional liberation, as previously exiled parts of self are now accepted and re-integrated, resulting in an enriched and enlarged sense of self.

State 3: Processing Transformational Experience. Metaprocessing the experience of transformation itself comprises the third state, which follows on the heels of the wave of core affect. In addition to emergence of adaptive action tendencies, this state is marked by a variety of possible affects: the joy of mastering previously feared emotional experience, the mourning of missed opportunities from chronic reliance of self-limiting defenses, gratitude towards the therapist midwifing the rebirthing experience (Russell & Fosha, 2008; Osimo, 2003), and tremulousness towards a new, yet unknown future. These experiences are part and parcel of journey of self-discovery.

State 4: Core State. The fourth and final state, referred to as ‘core state’ in classical AEDP metapsychology, consists of, but is not limited to: expanded perspective, wisdom, sense of well being, flow, ease, vitality and mental clarity. Relationally, core state is characterized by emotional intimacy, often experienced as an I-Thou encounter between patient and therapist. From the perspective of self-to-self and self-to-other, these characteristics observed in core state are signatures of a self that is expansive, breaking through the egotistical ‘I’ into a communal ‘we.’ It is here, in making possible the achievement of core state, that AEDP moves beyond the discipline of psychology and joins the spiritual realm of the world’s greatest wisdom traditions (Fosha & Yeung, 2006; Yeung & Cheung, 2008). Grotstein, for example, articulates a ‘transcendent position’ that strongly resonates with AEDP’s identification of core state. “[T]transcendence means having the ability to transcend our defensiveness, our pettiness, our guilt, our shame, our narcissism, our need for certainty, our strictures in order to achieve or to become…one with our aliveness…or with our very being-ness…which is a state of serenity that accompanies one who…is able to become reconciled to the experience of pure, unadulterated Being and Happening” (Grotstein, 2000, p. 300). Whereas Grotstein’s ‘transcendent position’ is descriptive, AEDP’s process of self-transcendence is prescriptive, with phenomenological markers and corresponding therapeutic interventions.

The following case presentation illustrates one such transformative process. The clinical vignettes are excerpts taken from the early, middle and termination phases of the treatment process. Each vignette will demonstrate progressively expanding states of self. The first vignette will show the breakthrough of the core experience of sadness. The second vignette will show the visceral experience of anger with fantasized aggression, followed by the emergence of a more solidified and integrated sense of self, and the eventual emergence of what I am calling “self-transcendence.” The vignette further underscores the importance of trusting the self-righting tendency of the transformance drive. The final vignette aims to show, via the metaprocessing of the therapeutic process, how resiliency is sustained, and how the self continues to flourish beyond life’s adversities.
Clinical Case: The Resilient Neuroscientist

Susanna is a 26-year-old neuroscience research assistant, self-referred for psychological treatment with a six month history of depression. Married for seven years, Susanna noticed that her husband, Mel, had become increasingly emotionally distant over the last year, culminating in his leaving a letter on the ironing board indicating that he had “no more feelings for her.” Devastated, Susanna tried in vain to seek couple therapy: Mel was uncooperative and did not follow through.

In the initial interview, the therapist found the patient psychologically insightful and motivated for treatment. Her mood was melancholic, and her speech was slowed and labored, indicating psychomotor retardation. Furthermore, Susanna exhibited a striking lack of affective intensity associated with the imminent prospect of divorce, suggesting defensive intellectualization.

The first vignette is taken from a session in the beginning phase of our treatment, where Susanna was reminded of an emotionally charged memory: a scene when she was pleading with Mel for cooperation in marital therapy. Mel turned his attention instead to the computer monitor, explicitly telling Susanna that the computer was more important than she. With this memory in mind, Susanna became aware of a sense of tightness in her chest.

Vignette 1: “I Still Feel Sad”

THERAPIST: What do you notice? [tracking somatic correlates of experience]

PATIENT: (eyes gazing down, in a melancholic tone) I still feel sad I think. (eyes welling up with tears) [tracking heralding affect]

THERAPIST: (soft, slow, with tenderness) It’s okay, it’s alright…You look sad. [mirroring emotional experience]

PATIENT: (eyes gaze down and away from therapist, smiles)…

THERAPIST: (tenderly firm) It’s okay, don’t smile the sadness away. [confronting tactical defense, inviting patient to relinquish defense] (very tender) Go with that, just be attentive to it. Allowing the sadness to come. It hurts…[encouraging the patient to stay with and tolerate the deepened affect]

PATIENT: (tears welling up in patient’s eyes, quiet sobs)…[breakthrough]

THERAPIST: …sometimes even without words…that’s what I’ve come to learn, there is some pain beyond words. It’s been there for such a long time, that’s alright…mmm…that’s okay. [acknowledging affective experience]

PATIENT: (wipes tears)…

THERAPIST: (steadfastly slow, with tenderness) You’re very brave, very courageous…holding on for so long…so, so long, that’s right, no need to condemn yourself in any way, no need to be harsh on yourself. You’ve tried so, so hard to make it work…(patient wipes tears)…He’s just not responding…hmm…(patient’s eyes gaze down) Do you sense my presence? [therapist’s conscious use of self as attachment figure to mitigate the patient’s possible unbearable pain of aloneness]

PATIENT: (nods her head)…[green-signal affect]

THERAPIST: Uh huh, no need to talk if you don’t like to, it’s alright, just allow yourself to be…let whatever wants to come through come through…hmm…hmm…that’s right…hmm, probably feeling so alone, for so long…isolated…and lost…(patient’s nods head) and confused (patient’s nods head) what’s coming up? [tentative translation of patient’s internal experience into language of feelings with tracking of patient’s non verbal affirmative response]

PATIENT: (nods her head, deep breathing) I don’t know…

THERAPIST: Let’s ask the chest…ask the chest. [tracking somatic correlates of experience]

PATIENT: It doesn’t feel as tight anymore. [somatic correlate of release of constricted emotion]

The preceding encounter illustrates AEDP’s first state transformation and state two processing, focusing on patient’s experience and expression of sadness and emotional pain with dyadic regulation: the therapist joins the patient where she is and helps her regulate the emotional experiences she is struggling with. In the process, defenses soften, anxiety decreases (i.e., the tightness disappears), and genuine emotional experience, in this case sadness, comes to the fore. The therapist needs to balance two technical concerns: on the one hand, the therapist attempts to help the patient articulate and understand sensations and emotions. At the same time, the therapist’s tentative choice of words is meant to avoid encouraging compliance on the part of the patient. In this session, the experience of loosening tension at the end would suggest that the therapist’s choice of emotional language is synchronous with patient’s inchoate experience.

The second vignette is an excerpt from two sessions later, where patient reported sensing an ‘intensity of the heart’ upon remembering the emotionally charged scene when she discovered Mel’s ‘no more feelings for her’ letter. For the first time in treatment, patient is becoming conscious of anger, both experiencing it and expressing it. Similar to the sadness in the first vignette, the direct experience of anger is a powerful transformative experience.

Vignette 2: Enraged Yet Rooted

THERAPIST: Another way to approach it is if you would allow the intensity to…take over you completely, okay? So that…mm…there’s no taboos, no holds barred, no road blocks. What does the ‘intensity’ want to do with Mike? [focusing on the somatic correlates of the emotional experience and facilitating a portrayal: an imagined scene designed to deepen and fully process emotional experience]

PATIENT: (long pause, eyes gazing down, frowning, contemplative) I’m not really sure. I think…hmm…I think there’s a part…like a part of it that’s very…hmm…just sort of enraged. [heralding affect] But…

THERAPIST: Go with that. [tracking patient’s articulation of rage as congruent with somatic energized intensity, explicit permission for patient to deepen the experience]

PATIENT: (energized, activated, gaze up at therapist) Uh…I think that it…like that type of rage translates…almost translates into kind of inactivity. In a way, like you know sometimes you can be so mad but you can’t actually physically do anything…kind of…like you’re just that kind of…[awareness of defensive freezing or shutting down, which was bypassed in the following moments]

THERAPIST: But if we would listen to that feeling of being enraged, or that rage…okay? And just listen to it…and observe it and allow it to become…almost like a fantasized script, or fantasized images…what would come out, if we listened to that part of you that feels enraged. [facilitating portrayal]

PATIENT: (energized, animated, mutual gaze with therapist) I think I’ll…I guess in a lot of ways I just want to…or it would want to totally sort of remove that aspect or that influence on my life or interaction on my life completel, and I was just thinking something along the lines…of like…not that there’s an actual place I can think of but something sort of like “end of the world type idea” (animated with both hands gesturing of pushing) and sort of pushing him off and walking away and trying to separate by physical and tangible space. [tracking awareness of action tendency and emotional experience, breakthrough of strong emotion and impulse]

THERAPIST: Can you help me imagine that…help me imagine that, go with that, you’re doing just fine…tell me how you imagine that [encouraging specificity of details to evoke full emotional response and embodied action impulse].

PATIENT: I don’t know…some kind of big hole…really big hole I guess. [breakthrough of vivid imagery]

THERAPIST: Go with that…what does the big hole look like…describe it to me. [noticing unfolding of core affective experience]

PATIENT: Well maybe…

THERAPIST: (smiling, with playfulness) Give me the beautiful details.

PATIENT: (chuckles, mutual gazing) Maybe it’s not so much a hole but um…some sort of cliff and it just ends and there’s nothing below, but then you can’t see like…ah…anything on the horizon like only on the sky and clouds. [breakthrough of vivid, right-brain imagery]

THERAPIST: Go with that.

PATIENT: And it’s sort of a void I guess.

THERAPIST: Go with that.

PATIENT: I would want to like push him (animated, both hands in pushing gesture) I guess if he was facing me I’d push him. [breakthrough of aggressive impulse]

THERAPIST: Mmm…go with that.

PATIENT: But not look over…not see what happened just sort of kind of back away…Just keep backing away and then eventually turn around from like that, that sky…and that, like, cliff edge …

THERAPIST: Uh-huh.

PATIENT: Go on from there I guess.

THERAPIST: Uh-huh…Well, let’s consult with that part of you that feels enraged.

PATIENT: Hmm…

THERAPIST: Is that enough?

PATIENT: I think so.

THERAPIST: Okay, okay. Alright. How is that part feeling at this present moment?

PATIENT: Umm..I think a little bit charged or maybe revitalized is the wrong word but something like that, like…[patient use of the words ‘charged’ and ‘revitalized’ suggest the process of transformation has taken place]

THERAPIST: Okay.

PATIENT: Not necessarily that it’s more active but more that there’s some kind of…satisfaction I guess. Yes…You know what I mean? [breakthough of acceptance of aggressive impulse]

THERAPIST: Okay… how’s the body feeling now?

PATIENT: I think pretty calm. [a hallmark of core state]

THERAPIST: Okay…okay…wow, and how do you feel, having done this work just now, in the last ten to fifteen minutes? [metaprocessing of transformative experience]

PATIENT: I don’t know…I think it’s (chuckles) very interesting.

THERAPIST: Okay.

PATIENT: I guess I’m just still allowing the experience to kind of speak…or something…or I…you know you just sort of let it sink in. [integration of experience]

THERAPIST: Say more of what you mean…I want to make sure I understand it.

PATIENT: (deep exhalation) I don’t know, just trying to kind of…I guess add some of these…like thoughts or feelings in this experience to the more solid part of me. [strengthened sense of core self]

THERAPIST: Okay.

PATIENT: (declarative) So that it’s not just kind of a passing sort of thing, and so that as different sorts of experiences happen that you can kind of look back at this as some kind of tangible and concrete sort of experience. [consolidating and solidifying the experience of transformation into her sense of self, so it becomes a new part of her autobiographical narrative].

THERAPIST: I see…hmm.

PATIENT: So maybe just trying to lay it down a little.

THERAPIST: It further adds on…(patient nodding rigorously)…to the solid part that I remember I labeled…(patient tilts head to the right, smiles, eyes lit up with curiosity)…how I labeled my last meeting with you – solid as a rock.

PATIENT: Yes…(chuckles, head nodding, big smiles of resonance) so it’s kind of adding onto that. [enjoying the breakthroughs]

THERAPIST: It’s very hard work you just did.

PATIENT: (declarative) I just…I don’t know if you remember…I think I said that normally I have sort of an emotional kind of reasoning…an ability to, you know, figure things out on my own, make good rational decisions and not just for myself but to be kind of helpful and vital to other people that know me, also. And I just feel like I lost touch with that…and “don‘t know how to help myself anymore” kind of feelings; and it’s these kinds of sessions, in the last like little chunk of time, were kind of just reminding me that I do have some sort of insight, or I have some kind of strength. [breakthrough of self-mastery]

THERAPIST: Not “some”. [challenging the patient’s mild self-abasement]

PATIENT: Well…(chuckles, bashful) [defense against taking in good things or emotional closeness]

THERAPIST: (with emphasis) Huge amounts.

PATIENT: But you know it’s there, it’s just…

THERAPIST: (crescendo emphasis) Huge amounts. [“pressure to feel” intervention to take in more good]

PATIENT: (animated with arms and hands gesturing) It’s still a bit disconnected like it’s still a process kind of.

THERAPIST: Absolutely.

PATIENT: Yeah…but I think it helps to kind of reaffirm that it might…take a little while. [patient’s declarative truth sense of an emergent strength or capacity]

THERAPIST: Absolutely.

PATIENT: Take a little while to kind of stay…like walk with that on a day to day basis in a confident sort of way. [anticipating future breakthroughs]

THERAPIST: Uh-huh.

PATIENT: Yeah but I think that there’s still a bit of a hesitation or something, you know. [therapist tracking patient’s difficulty with receiving affirmation]

THERAPIST: Uh-huh…hesitation or something.

PATIENT: Yeah.

THERAPIST: Sure, you know what that something is? [aiming to explore the hesitation, if it is a block to receptive experience, or a tremulousness around a newly emergent capacity]

PATIENT: (huge smiles, hands animated) I don’t know…I guess it’s just had some kind of failures, or I don’t intend to fail at everything really…I just…you know what I mean.

THERAPIST: Uh-huh, sure.

PATIENT: So having some kind of experience like losing your job or having a relationship that’s failing, maybe it’s thrown my normal thinking pattern or coping mechanisms a little bit out of whack, and just kind of the experiences themselves and experiencing kind of rejection…and something different sort of. [patient is putting her difficulties into context of difficult life events, not attributing them to herself]

THERAPIST: Absolutely.

PATIENT: And not just like from other people, but also disappointment in your own inability to kind of orchestrate change in your own life.

THERAPIST: Absolutely.

PATIENT: And realizing that other people have a say, too…it’s not just sort of what you will and decide , it happens, not necessarily, where other people are concerned…you know.

THERAPIST: Concerned, absolutely, uh-huh. I’m curious, I’m curious, can we get in touch with the part of you that feels solid experience now in the body. [tracking the somatic correlates of her self-at-best]

PATIENT: Mmm…(animated, pointing to her body)…it’s somewhere between my chest and my gut.

THERAPIST: Uh-huh…somewhere between your chest and your gut. [sustained focusing on the somatic correlate of self-at-best]

PATIENT: A deep feeling, like it almost feels like it’s anchored to something, um, like inside the body, but isn’t part of the body in a way.

THERAPIST: Okay.

PATIENT: (sounding curious, intrigued) Like it’s got like a deep rooted anchor…but it’s not like something tangible that you can explain…you know what I mean. [breakthrough of vivid, right-brain grounding imagery]

THERAPIST: (sustained curiosity) Uh-huh… and hmm…okay so if you stay with that, stay with that deep rooted feeling right now okay…what about the part of you that felt somehow… you know… “it’s failed”, is there a part of the body that feels that way, does it resonate with that?

PATIENT: It would be more like in my stomach kind of area…like kind of like indigestion but not…you know what I mean.

THERAPIST: Okay.

PATIENT: Like that sort of, like, that unsettled feeling.

THERAPIST: Okay.

PATIENT: Yeah.

THERAPIST: Alright, let’s do another round of work, another round of work, and then again, it seemed easy but it’s very hard.

PATIENT: It’s not easy.

THERAPIST: It’s not that easy at all, okay.

PATIENT: Okay.

THERAPIST: Umm, get in touch with the solid…the rooted feeling.

PATIENT: Mmm hmm.

THERAPIST: Paying attention to that first…and then pay attention now to the indigestion feeling.

PATIENT: Mmm hmm.

THERAPIST: Shift your focus there, okay, what do you notice?

PATIENT: I…like…this is really random but I was just thinking that I…

THERAPIST: That’s fine.

PATIENT: As I made this transition from the solid part to…like this sort of insecure…failed option, there was almost like, a some sort of like… (hands gesturing towards solar plexus)…hmm…failure part was almost scared of the solid part.

THERAPIST: Oh?

PATIENT: Like there’s some sort of quiver…like almost of like, hmm, like it couldn’t necessarily really stand up to that sort of scrutiny.

THERAPIST: Uh-huh. Okay.

PATIENT: (animated with hand gesture) But I switched gears, but in that brief second there was…like a shrinking back almost, or a…

THERAPIST: Okay, sure, go with that, okay, let’s switch back to the solid part.

PATIENT: Okay.

THERAPIST: What does that part…how would that part approach the shrinking part? [trusting the power of transformance]

PATIENT: I don’t know…I think that there’s so much, I think that what it is, that it’s more like there’s so much potential, and then, uh, just sort of goodness in life, umm, and hope, that umm, that this kind of feeling of being a failure is very transient and in response that it’s very fleeting and it can’t really stand up. [breakthrough of hope]

THERAPIST: It can, or it cannot?

PATIENT: It can’t.

THERAPIST: Okay.

PATIENT: It really like becomes a global sentence, or…

THERAPIST: Sure, absolutely.

PATIENT: Even sort of…umm…remain stronger or intense at all in the presence of that kind of rooted solid connection to, like, whoever I really am. [breakthrough of core sense of self]

THERAPIST: Sure.

PATIENT: And what I can and will do and…

THERAPIST: Uh-huh, so how would that part reach out…or reach in…to the shrinking part at this present moment?

PATIENT: I’m not sure but I think it would just slowly begin to kind of encroach on it…or take it over, you know. So maybe like a…

THERAPIST: Let’s be attentive to it right now…kind of to both if it’s possible, and just observe what’s going on inside.

PATIENT: (declarative, animated) I think it would be something like hmm, there’s enough like…life and goodness in the solid part to kind of cover this failure and sort of make it like, maybe learn from it…but not be defined by it… . It’s not going to define you, like oh you’re that person who had that failure, it might sort of be part of, you know, a foundation or part of something that you can kind of attach to and use in a good way but not, it’s not going to be visible and noticeable. [breakthrough of new perspective]

THERAPIST: Wow, wow, hmm, okay, that’s beautiful, very good, how is that part feeling? Let’s consult with that part, you know, the other part?

PATIENT: Yeah.

THERAPIST: That was shrinking.

PATIENT: Mmm hmm.

THERAPIST: How does that part feel?

PATIENT: It feels better, I think it feels a little bit more calm, and just maybe there’s some kind of peace that comes from knowing that some good, or some purpose can still be had from all this. [breakthrough of core state: calm, wisdom, emerging sense of meaning of her suffering]

THERAPIST: (amazed) Wow…so meaningful.

PATIENT: Yeah…meaningful.

THERAPIST: Wow…wow…wow, that’s beautiful…okay. You seem to make it look so easy.

PATIENT: It’s really not.

THERAPIST: Uh-huh…it’s not an easy process. I mean you do two rounds of work…in one session. I’m curious. So how do you feel about yourself having done this second round? The first round we worked with your anger.

PATIENT: Yeah.

THERAPIST: The second round we worked with your sense of self.

PATIENT: Mmm.

THERAPIST: How do you feel about having done this round? [metaprocessing of this session]

PATIENT: (declarative) It gives me a lot of hope, I feel, yeah. [breakthrough of confidence and hope]

THERAPIST: And where are you noticing the hope in the body?

PATIENT: Well it’s mostly in the center but it is kind of like resonance so it’s I think it’s beyond, like, your body. [suggestive of her sense of self as expansive and transcending beyond the boundaries of her body]

THERAPIST: Say more about the beyond your body.

PATIENT: Maybe just some kind of, maybe it’s not that it’s water, but thinking more in terms of resonance like a note, or music. [breakthrough of poetic imagery]

THERAPIST: Wow!

PATIENT: Maybe like those things that you … those pitch things…and the sound just kind of like resonates out… . It’s like if a drop goes in water you have those ripples…it’s like that.

THERAPIST: Absolutely.

PATIENT: So it’s mostly here but I feel the hope is even seeping out a little to the outside.

THERAPIST: Wow, wow!

PATIENT: (declarative, big smile) Which is good because I like hope, it feels good, it’s a good thing. [breakthrough of confidence and hope]

THERAPIST: It’s a very good thing, that’s beautiful. Thank you for sharing that with me. I mean you’re radiating that to me…wow, wow…okay, now we still have time and I will do the third round of work. [setting up for metaprocessing of patient’s transformative experiences]

PATIENT: Okay.

THERAPIST: This one, hopefully, is an easier one.

PATIENT: Okay.

THERAPIST: To review what’s your experience like with me or throughout the treatment, you know… for the last, this is session number seven.

PATIENT: Yeah, it just seems in so many ways, that it’s been like a real…progress…I don’t know, it’s almost hard to like put into words, like the help that it’s been, or the tools that it’s almost kind of given me to try to get back on track, or get centered again, or…[breakthrough of meaning of suffering]

THERAPIST: Noting…that it was not hard for me, the buds were there, I mean they were beautiful, there is some kind of weeds here and there and all you need to do is just to take, I didn’t even have to take out a whole lot of weeds, all I need to do is just a lot of watering, and put in a few fertilizers. [noting patient’s inherent potential for transformance, for a growth faciliating environment]

PATIENT: It sounds not that hard, but it’s still hard.

THERAPIST: But look at the tree that has grown. Here you have – it wasn’t always there. The roots keep going down, uh-huh…well, okay, anything else that comes to your mind about your experience in the last seven sessions in three months?

PATIENT: (amused, amazed, declarative) I don’t know…I’ve also found it kind of a little bit…hmm…encouraging, or like it’s gotten my attention sort of back interested in like school, and work, and just like brain and neuroscience and all these kinds of things, which is kind of good because that part of me just sort of went quiet, you know ‘cause life is busy and you just sort of, those kinds of ideas or ideals or goals get put on the back burner, not in a bad way necessarily, but just because life required that…I am going to work.

The previous vignette demonstrates the ‘accelerated’ healing of AEDP. In a mere 50 minute session, the patient-therapist dyad effectively completed two rounds of work, oriented around processing of anger (State 2) and strengthening sense of self (State 3), culminating in a transformative and self-transcending reconstruction of autobiographical narrative (State 4).

The therapist was humbled by the lessons learned in witnessing the speed and the depth of the transformation. Given the optimal secure base conditions co-created with the therapist, the therapist was required simply to the trust the process. Transformance, the inherent drive towards a better and fuller life, will be activated. Further, the phenomenon of transcending our narcissistic selves in state 4 affects not only the patient, but also the therapist, with a shared experience of emotional intimacy, interconnectedness to the suffering of humanity and the sacredness of the human spirit.

Two weeks after the session just presented, the patient was newly diagnosed with ovarian cancer, requiring immediate surgery to remove both ovaries and uterus, followed by an aggressive course of chemotherapy. With this life threatening development, the patient remain motivated for psychological treatment, understandably shifting focus to issues associated with cancer. In spite of major pelvic surgery, with complications resulting in recurrent severe acute renal colic, coupled with chemotherapy and its adverse effects, the patient showed resilience, to the therapist’s amazement. With divorce proceedings finalized, the patient described in later sessions a very different way of relating with her now ex-husband, closely resembling the phenomenon of reconciliation, not in the context of marriage, but in the sense of authentic human to human connection.

What captivated the therapist’s attention in these sessions was the remarkable transformation patient showed in her demeanor: from the moderate/severe psychomotor retardation in the first session, to the energetic self confidence and assertive declarations, all of this transpiring against the backdrop of divorce, a life-threatening cancer, loss of symbolic meaning of womanhood with the surgical removal of ovaries and uterus, and the complications of surgery. All of this is a testament to the relentless growth and healing the patient continues to pursue.

The following vignette is taken from the termination phase of the treatment, after successfully conclusion of chemotherapy and complete recovery from surgical complications. Contemplating her future, the patient acknowledged having resistance to facing the ‘elephant in the room’, metaphorically referring to cancer prognosis.

Vignette 3: Resistance To, But Invitation To Face “The Big Elephant,” And Extraordinary Resilience In Action

PATIENT: Yeah…for the most part I don’t feed it (cancer prognosis) or pet it or coddle it, you know, nurture it, you know what I mean? I know it’s there, but I just find that focusing all your attention on the sadness or the negativity, like, kind of robs you of what you can do right now, and what you can enjoy in this moment or in this conversation or whoever you’re with at the time, just to make the most of that opportunity or that person’s experience.

THERAPIST: You want to picture the elephant for a moment? Since we’re doing some work, right?

PATIENT: Okay.

THERAPIST: Go in your mind…(patient closes eyes)…I mean in a sense just draw your attention inward. If you can picture that big elephant and say hi to it and of course noticing what goes on in the body when you picture that big elephant. Do you know where you’re carrying this big elephant in your body at this present moment?

PATIENT: I think it’s in my gut. (pointing to solar plexus)

THERAPIST: It’s in your gut?

PATIENT: Yeah.

THERAPIST: Let’s pay attention to it. Describe the sensation that you’re noticing there.

PATIENT: Well first, right away when you said to picture it and say hi to it and stuff like that, then I right away felt like almost like something went like…‘shhhh’…(both hands clutching together signifying a collapse) in my gut. It was a reaction to that.

THERAPIST: There was a reaction to it. Kind of approach it a little more…(patient closes eyes)…Saying hi to it and kind of being gentle with it…And then notice what comes up from that place. Maybe it’s a word, maybe it’s a thought, maybe it’s a picture. Again, just kind of let yourself sit with it for a little bit…And kind of observe it. What’s coming up?

PATIENT: Well…I almost simultaneously felt two things. One was like a sadness kind of thing that I’m somewhat unfamiliar with. And the other one was like a sense of exasperation, of where I didn’t really, like, hear that or anything.

THERAPIST: You don’t like to hear that word…”exasperation”?

PATIENT: No, like I didn’t hear it, I heard like myself say when I was feeling sad, whereas this is hard, almost like “what do people expect from me?” — like that type of knee jerk reaction, where you’re like “this is hard, this is sad but what do other people want me to do, or what response am I supposed to have?” [use of “you:” remnant of some defense, transtional state, not fully in first person yet.]

THERAPIST: That’s right…that’s right.

PATIENT: I don’t know, and also I definitely notice the resistance to wanting to do that.

THERAPIST: To do which?

PATIENT: To think about the elephant.

THERAPIST: To think about the elephant.

PATIENT: Like there’s a resistance in myself. [acknowledging her defensive resistance; unstated is anger towards the therapist for inviting her to do the hard work as opposed to avoidance]

THERAPIST: I can understand that, sure. [validating her resistance]

PATIENT: Yeah.

THERAPIST: Let’s also ask that part of you what it needs…(patient closes eyes)…Draw your attention to the same place. Ask that part of you what it needs. By that I mean it could be anything that just pops up.

PATIENT: (opens eyes) I notice, well, what I thought, well I didn’t really think this, but now I would express it would be release…kind of thing, and I think that leaving it has a dual meaning of actually like expression, which I was sort of thinking about.

THERAPIST: When you say expression as a sort of release…

PATIENT: Yeah, like expressing that part or that sadness or that difficulty. But also kind of like release, like if you’re going to move forward with your life and live as if things are okay until someone tells you otherwise, that you kind of need to let that go. I think if I keep that metaphor going it would be something like telling you off and you can’t live here anymore. [expressing a variant of self protective anger] You know what I mean? Like something like that. “Get out of my house, you know, what are you doing here? Don’t follow me.” I think in some ways I still have a protective mechanism, not that I use it very often, but there’s a few times where people try to expect something of you, or get you to do something, and you’ll try to say, “I can’t,” or “I don’t want to.”

THERAPIST: Mmm hmm.

PATIENT: You’ll pull out the card – I might still have cancer, so I’m not doing it. [still using second person pronoun, “you,” instead of first person pronoun, “I”]

THERAPIST: So you give yourself permission.

PATIENT: What are you going to do? ‘I don’t know yet,’ I’m going to have to see how things go with my health, or it’s still sort of a card I have when I don’t want to make a decision.

THERAPIST: Absolutely. And rightly so.

PATIENT: Exactly, I’m not saying it’s completely wrong to have that.

THERAPIST: I think that’s pretty in touch with reality…not in denial.

PATIENT: And there are realistic constraints but I think if you want to embrace life at some point, and I don’t know when. But anytime now you just need to say “Okay, I’m done. I’m cancer free. I’m going do what I can to stay that way and it’s not going to be my identity anymore.” I think it’s still sort of is my identity right now.

THERAPIST: You can sense it you can feel it.

PATIENT: And it’s defined me in a lot of ways over the last year.

THERAPIST: So in addition to release as an expression, but you also mean a release from a prison of sorts. [transcended from previously contracted self associated with necessity of surviving through divorce and cancer]

PATIENT: Yeah, exactly.

THERAPIST: It’s like a release from being chained.

PATIENT: Or having that dark cloud or obsession, not even woeful or anything, but just that consumes a lot of things.

THERAPIST: Sure, so let’s check in with the body right now, especially in the gut area. Having said that and having articulated that, what is it like for you in the body, in the gut?

PATIENT: I think there’s still kind of like a sadness there.

THERAPIST: Could we make room for that sadness? Unless of course, you find it to be too intense, but I think normally we would like to welcome it. And give room to that sadness, is that okay? Let’s make room for that. By that I mean draw your attention inward where you carry the sadness and allow yourself to speak from that space. That’s right.

PATIENT: I don’t like crying.

THERAPIST: It’s okay.

PATIENT: (tears welling up, sniffling)…[breakthrough of mourning]

(long pause)

THERAPIST: That’s right. Mmm hmm. And when you feel ready you can put words to the tears.

PATIENT: (wipes tears) I don’t really know. It’s just sad I guess. [breakthrough of vulnerability] It’s hard too, I don’t know why it’s hard for me, but it just is, to be sad even. Yet I feel like it’s not like it’s a weakness, but kind of on some level it possesses me, and you try hard to be strong, and a lot of people tell you, “You’re so strong,” and you’re this and you’re that. Yeah.

THERAPIST: And at the same time you want to be able to become vulnerable.

PATIENT: It’s a difficult balance to master. There’s been some things recently where I felt kind of numb to certain things. I can’t think of a good example. I just remember thinking – shouldn’t I have more of a reaction to this?

THERAPIST: To?

PATIENT: To not something big, but I feel like…

THERAPIST: You mean just in general, not a specific situation.

PATIENT: Not in a specific situation, but I just think I want to do this kind of work even though it’s hard and I don’t really like it. You know what I mean?

THERAPIST: Absolutely.

PATIENT: But I want to have that connection. I want to feel more of that. Be connected to everything that’s going on. [yearning for transformance, connecting with her vulnerability, transcending her present self]

THERAPIST: That’s right. And what is it like for you giving room to the sadness, and giving your sadness a voice, what is it like for you to be able to do that?

PATIENT: It’s a little bit strange. I don’t really do it too often.

THERAPIST: And thank you for sharing those tears with me. And let’s check in with that part of you. Let’s check in with that part. How is that part doing now, the part that needed to be heard? Again try to listen to its gentle whispers.

PATIENT: I know. I don’t really know what it is, it feels like a beginning, maybe, or a start, like that’s what I was hearing, a start, you know.

THERAPIST: A start…uh-huh.

PATIENT: I guess I could see it like a journey, you know. [breakthrough of meaningful perspective]

THERAPIST: Absolutely.

PATIENT: Now that I’m taking this road now.

THERAPIST: You’re taking this journey, you’re taking this road.

PATIENT: You’ll get to this side of it, this side that happens.

THERAPIST: Look at this side, and giving yourself the room to connect emotionally with this. Again, thank you for sharing all of this with me, and at the same time I agree with you, it’s a beginning. I remain committed with you all the way, to work with you in this one. How would you describe your state of mind and body right now, having done this work with me?

PATIENT: (laughs) I don’t know, I feel a little bit raw maybe, or something.

THERAPIST: A little bit raw, okay.

PATIENT: A little bit stretched, you know…[first explicit metaphor of self-transcendence]

THERAPIST: A little bit stretched. Where do you carry the stretch, or that raw feeling? [exploring somatic correlates of experience]

PATIENT: More in my chest I think.

THERAPIST: More in your chest…okay. Can we also listen to the chest, alright? Can we consult with the chest, and ask that part of you what it needs for the moment? Again, whether it could be at random, it could be anybody that you’ve considered to be your best friend, or a character in your mind. It could be a figurative character, it could be a spiritual character, anybody. That could be one way to work with that raw feeling in the chest.

PATIENT: (nodding head) I kind of felt two things. First thing was kind of like reassurance, and then somehow, I guess…it sound really weird… somehow myself was reassuring myself. [self-at-best helping self-at-worst]

THERAPIST: That’s fine!

PATIENT: You know what I mean, like something like that. Just saying that this is also a strength. [pride of self mastery]

THERAPIST: Absolutely, you need the courage to work through…

PATIENT: (declaratively) Yeah…this takes courage too, and this is a form of strength.

THERAPIST: Absolutely.

PATIENT: Though you might feel like it’s a weakness, that kind of…

THERAPIST: Absolutely, I agree a hundred percent. I agree with it a hundred percent, a thousand percent in fact. Stay with the chest again and see how that part of you is feeling at this moment, having been reassured by your other self.

PATIENT: That sounds weird.

THERAPIST: Oh quite to the contrary, I think it’s marvelous…marvelous!

PATIENT: I feel okay now. It feels like also growth, kind of. Before I said stretching, which it was before. [second explicit metaphor of self-transcendence]

THERAPIST: It’s growing pains.

PATIENT: But now it feels more like growth, you know, where things are getting solidified maybe. [metaphor of integration]

THERAPIST: Solidified.

PATIENT: Connections maybe.

THERAPIST: Connections, connecting.

PATIENT: Connecting, or just being used again, that I haven’t used, so they’re coming alive again. [breakthrough of vitality]

In the previous vignette, the patient worked through direct experience, expression, and authentic communication of sadness and vulnerability associated with having cancer. This working through process culminated in maximizing growth and psychic integration. Transcending her resistance, the patient thus celebrated the triumph of transformance.

In this final interview, in stark contrast to the initial intake, the patient presented herself as a beautiful, attractive young woman, fashionably dressed with a colorful scarf around her neck, with shoulder length curly blonde hair. She appeared relaxed, engaged, coherent, melodic in tone, lively, animated and declarative.

Concluding Reflections

In the above paper, I have explored how AEDP’s four states and three state transformations, in theory and clinical practice, can culminate in experiences of self-transcendence. Transformation is fueled by the transformance potential and self-righting tendencies embedded in our minds and bodies. The cascade of psychobiological state changes begins with the self-limiting defensive state. What follows is a series of breakthroughs emerging under the conditions of secure attachment co-constructed by the therapist-patient dyad. Direct processing of core affective experience, previously excluded, comes to the fore in this deeply engaged state. Metaprocessing deep changes comprises the third state, characteristically associated with positive affects that broaden the mind and resource the self (see Fredrickson, 2009, for her broaden-and-build theory of positive affect). The flow of state transformations climaxes with the emergence of core state, with a strong sense of openness, flexibility and wisdom. Core state holds the dialectical tension of the holistic ‘being and becoming’ sense of self. This is the place where the self’s autobiographical narrative is often adaptively reconstructed. This is where the self feels renewed, revitalized, and reborn. As such, arriving at core state is not the end of therapy, it is only the beginning, a widening of experiential horizons, and rich with possibilities. And this is where we can witness, not only the expansion and deepening resilience of the self, where the very boundaries of self are transcended, but also the awe-inspiring phenomenon of self-transcendence.

Selected References

Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York: Basic Books.

Eigen, M. (1992). Coming through the whirlwind: Case studies in psychotherapy. Wilmette: Chiron Publications.

Fosha, D. (2000). The transforming power of affect: A model for accelerated change. New York: Basic Books.

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

Fosha, D. (2008). Transformance, recognition of self by self, and effective action. In K.J. Schneider (Ed.), Existential-integrative psychotherapy: Guideposts to the core of practice (pp. 290-320). New York: Routledge.

Fosha, D. (2009a). Emotion and recognition at work: Energy, vitality, pleasure, truth, desire, and the emergent phenomenology of transformational experience. In D. Fosha, D.J. Siegel & M.F. Solomon (Ed.) The healing power of emotion: Affective neuroscience, development & clinical practice (pp. 175-176). New York: W.W. Norton & Company.

Fosha, D., Paivio, S.C., Gleiser, K. & Ford, J. (2009b). Experiential and emotion-focused therapy. In C. Courtois & J.D. Ford (Eds.), Complex traumatic stress disorders: An evidence-based clinician’s guide. New York: Guilford Press.

Fosha, D. (2010, February). Keynote address titled The birth of transformance: Transformational theory and AEDP’s healing-based clinical practice. New York City, NY.

Fosha, D., & Yeung, D. (2006). AEDP exemplifies the seamless integration of emotional transformation and dyadic relatedness at work. In G. Stricker & J. Gold (Eds), A casebook of integrative psychotherapy. Washington, DC: American Psychological Association Press.

Frederick, R. (2009). Living like you mean it: Use the wisdom and power of your emotions to get the life you really want. San Francisco: Jossey Bass.

Fredrickson, B. (2009). Positivity: Groundbreaking research reveals how to embrace the hidden strengths of positive emotions, overcome negativity, and thrive. New York: Crown Publishers.

Freud, A. (1966). The ego and the mechanisms of defense. New York: International Universities Press.

Grotstein, J.S. (2000). Who is the dreamer who dreams the dream: A study of psychic presences. Hillsdale: Analytic Press.

Lamagna, J. (In press). On the Self, by the Self and for the Self: Internal attachment, attunement and psychological change. Journal of Psychotherapy Integration.

Lamagna, J., & Gleiser, K. (2007). Building a secure internal attachment: An intra-relational approach to ego strengthening and emotional processing with chronically traumatized clients. Journal of Trauma and Dissociation 8(1), (pp. 25 -52).

Lipton, B. & Fosha, D. (In press, 2010). Attachment as a transformative process in AEDP: Operationalizing the intersection of attachment theory and affective neuroscience. Journal of Psychotherapy Integration.

Osimo, F. (2003). Experiential short-term dynamic psychotherapy: A manual. Bloomington: 1stBooks.

Prenn, N. (In press, 2010). Mind the gap: Attachment interventions translating attachment theory into clinical practice. Journal of Psychotherapy Integration.

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

Tunnell, G. (2006). An affirmational approach to treating gay male couples. Group 30 (2), (pp. 133-151).

Vaillant, G.E. (1995). The wisdom of the ego. Cambridge: Harvard University Press.

Vaillant, G.E. (2009). Spiritual evolution: A scientific defense of faith. New York: Broadway Books.

Wilhelm, R. & Baynes, C.F. (1967). The I ching or book of changes. Princeton: Princeton University Press.

Winnicott, D. W. (1990). The maturational processes and the facilitating environment. London: Karnac.

Yeung, D., & Cheung, V. (2008). The rainbow after: Psychological trauma and accelerated experiential dynamic psychotherapy. Hong Kong: Ming Fung Press.

Names used are pseudonyms.