“Unequivocal Affirmation” of True Self in 16-session AEDP with Gay Men:Using Relational Metaprocessing to Increase Receptive Affective Capacity
Gil Tunnell, PhD.
Abstract. Two case studies of gay men from the AEDP 16-session research project are described in which the therapist’s primary AEDP intervention was continually “privileging the True Self.” Privileging the True Self is crucial when working with queer-identified patients who often have constructed a “false self” as they attempt to “pass” and fit into a largely heterosexual world. In initial sessions with each patient, the therapist established a strong affirmational stance by highlighting his inherent strengths and maintained that stance throughout treatment. The primary mechanism of change was the therapist’s relational metaprocessing of that stance, activating the men’s receptive affective capacities to fully absorb his “unequivocal affirmation” of them, providing “an explicit ‘yes’ to the whole self of the client.” Rounds of relational metaprocessing produced the primary “core affective experience,” as contrasted to processing specific negative core affects such as anger or sadness in AEDP State 2. Primitive receptive affective capacity is innate: Human beings are born ready to emotionally attach to their caregivers. When the caregivers’ nurturance is not forthcoming, receptive capacity remains constricted, like a bud that does not bloom. While both treatments were first and foremost relational therapies, they differ in that the second patient had a much less developed receptive capacity when treatment began. Upon taking in the therapist’s affirmation, he began to experience in real life that other people also appreciate his specialness. That external validation led to his exuberantly expressing “joy,” a core affect he had rarely experienced in his life. The author discusses how “joy” may be an underrated positive affect in AEDP clinical work. Both patients made
Introduction
Diana Fosha has reiterated more recently in AEDP 2.0 (2021) her long-standing premise (2005, 2000) that “a model of therapy needs in its essence to be a model of change,” p.29. From the outset, Accelerated Experiential Dynamic Psychotherapy (AEDP) was designed to create a particular type of change that heals the patient’s psychopathology. Fosha redefined most psychopathology as the outcome of the individual being faced with overwhelming emotions that could not be managed alone (Fosha, 2000). Based on this new understanding of psychopathology, AEDP was purposely developed to facilitate expression of these suppressed affects while simultaneously undoing aloneness.
In developing AEDP, Fosha extensively studied the phenomenology of quantum emotion-centric change in non-therapeutic context1 and attempted to “harness” and “systematically activate these affective change processes” (2005) into her therapeutic model. From these transformational studies, she concluded that such dramatic change usually occurred in the context of an affirming relationship. Hence the first requirement in AEDP is to build a safe, affirmational attachment- based therapeutic relationship from the get-go (Kranz, 2021).
Fosha and her colleagues (2021) have now elaborated a comprehensive 4-state model of transformational change oriented toward healing beyond the get-go, leading to flourishing after treatment ends. AEDP’s focus on healing stands in stark contrast to other psychodynamic approaches that explore the patient’s psychopathology as the analyst interprets it, with the assumption that once the patient has insight into their psyche, change will follow. In psychoanalytic treatments, insight is the goal, not quantum change that heals (Tunnell & Osiason, 2021).
Although AEDP is theoretically a more accelerated treatment model than psychoanalysis, in reality AEDP can continue for many months if not years. The 16-session research project, designed to compare AEDP with other evidence-based treatments (Iwakabe et al, 2020), puts the “A” back in Accelerated in that it attempts to create healing change within a very brief treatment. Quite a task, but, in fact, a major advantage for therapists who work within the 16-session paradigm is that they are far more likely to stay on course to accomplish the overarching goal to transform “suffering into flourishing,” ever mindful that time is pressing on. The advantage for patients in 16-session treatment is similar: Aware they only have 16 sessions—which we emphasize in the first session—patients become more motivated to receive help from the get-go. The pressure of time on both therapist and patient sets the stage of allowing major change to occur more rapidly (Woods, 2023).
This article describes two cases where transformational change occurred within 16 sessions. My own therapeutic stance within AEDP has been to adopt a strong affirmational approach (Tunnell, 2006, 2011, 2012), beginning in the first session where I identify the patient’s existing strengths and resources, and then continually elaborating upon those strengths throughout the treatment.
Regardless of what the patient brings to session, I strive to affirm their strengths and, above all, “to privilege the self.” To privilege the True Self is to value it, especially when significant others have not.
Privileging the true self is of paramount importance for gay men (Medley, 2021), who have often been forced to develop a “false self” (Winnicott, 1965), a façade they may have carefully and deliberately constructed to deal with being homosexual in a heterosexual world.2 The “false self” in gay men can be an elaborate defense structure to vend off prejudice, discrimination and intimidation by peers and significant others if their true gay self were to become known. In everyday parlance, presenting the false self to others is known as “passing as straight” (Goffman, 1959, 1963), an option not available to most minorities where skin color is the basis of discrimination. In Couple Therapy with Gay Men (Greenan & Tunnell, 2003), we argued that the false self—even when it is no longer necessary—can stand in the way of developing deeply intimate male-male relationships, which requires authenticity in both men, where “one true self embraces another true self.”3
In the two individual cases discussed here, the process of privileging the true self by affirming it repeatedly across the 16 sessions created strong attachment bonds between myself and each patient. In the first case, the attachment bond created in early sessions allowed for deeper processing of core emotions (AEDP State 2) in subsequent sessions, the usual sequence in AEDP treatment. In the second case, shoring up the attachment bond became the primary focus carried throughout the treatment, as the patient’s aloneness was palpable and compelling.
In both cases, the attachment bond was “explicitly and experientially” explored relentlessly through relational metaprocessing. In introducing her innovative technique of metatherapeutic processing, Fosha (2000) distinguished between “intrapsychic” metaprocessing of core emotions (“what’s it like to express your anger here?”) and “relational metaprocessing” (“what’s it like to express your anger here with me?) which speaks to AEDP’s dual goal of “undoing aloneness.” This new relational experience—where the patient is no longer alone—needs to be fully registered, received and experienced by the patient (Fosha, 2017; Frederick, 2021, Piliero, 2021). Especially in the case of severe early attachment trauma, which the second patient had experienced, increasing his receptive capacity became a primary focus (Fosha, 2009; Lipton & Fosha, 2011).
Affirmational attachment-based therapy4 is distinct from both supportive therapy and “positive psychology” (Seligman, 2002). While most therapists are generally supportive and positive, few are strongly affirmational5 , and fewer still are attachment-based. Client-Centered Psychotherapy (Rogers, 1957) exemplifies a well-established supportive model. Indeed, the unqualified support from a Rogerian therapist, known as “unconditional positive regard,” can be nurturing for patients in that it provides a “corrective emotional experience” for what they failed to get from earlier caregivers, but rarely is the experience of being nurtured explored in Rogerian treatment. The fact that AEDP does this in its metaprocessing sets it apart from other affirmational treatments (Medley, 2021). In short, relational metaprocessing allows the therapist’s nurturance and affirmation to “sink in,” to provide more thorough healing of early attachment wounds compared to Rogerian treatment.
When this process goes well, the patient’s internal working model for how close relationships work (Bowlby, 1969) gets reorganized from one of insecure attachment to more secure attachment (Frederick, 2021). This simple yet powerful technique of relational metaprocessing is a primary mechanism that facilitates deeper healing, a re-wiring of the brain that helps produce more enduring change beyond termination (Tunnell & Osiason, 2021): Eighteen months after termination with the first patient, he wrote that he is now able to receive love without questioning it. The second patient told me in the 16th session, “You instilled in me that I am worthwhile.” Four months after termination, he emailed me that he was now in love with a man, “I just gotta keep in mind that I am worth it and as lucky as I feel to be with him, he is lucky to have me too.”
Both Ben Medley (2021) and I have previously discussed why gay patients require a strong affirmational stance on the part of their therapists (Tunnell, 2011, 2006). The silence of their previous therapists—who remained psychoanalytically neutral by portraying a blank screen for the patient’s projections—proved deafening to many of my gay patients and conveyed a lack of acceptance. In fact, rather than being a corrective experience, the therapist’s neutral stance sometimes induced more shame about their gayness. Most gay individuals have experienced some degree of shaming, either by their own families, their peers, their teachers, their communities, and society at large. Having had such experiences myself as a gay man, I resonate with my queer patients on what they may have endured, sometimes by using judicious self- disclosure (Prenn, 2009) about my own experiences. My attention and therapeutic presence around this particular issue helps de-stigmatize their experiences by providing them not only a safe place, but a “resonating” place, to explore the harsh effects of shaming and prejudice with a therapist who has experienced both.
After the two treatments were completed, I discovered a recent article by Iwakabe, Edlin and Thoma (2022) who coined the term “unequivocal affirmation” to describe how a patient had perceived Diana Fosha in his first session. The authors define “unequivocal affirmation” as “an explicit ‘yes’ to the whole self of the client” (p. 369). In retrospect, I believe “unequivocal affirmation” describes more precisely what I did with both men. Although Fosha’s patient described his first session this way, in these two cases “unequivocal affirmation” might well describe the entire 16-session treatment. Moreover, “unequivocal affirmation” was followed by relational metaprocessing to ensure that the patient had fully metabolized it. For queer-identified patients who have experienced shame about their gayness, the therapist’s unequivocally affirming them can be a powerful de-shaming antidote.
Case 1: Seth Seth is a single gay man, 35, referred from the 16-session research team. All sessions were held in person. In the first meeting, Seth reported much anxiety about where he was in life, saying he was “untethered,” in both his career and his relationships. He was struggling to make a living as a performing artist in New York City. He had recently broken off an 8-year relationship and was unable to resume dating. He is the middle child of three sons and reports a relatively happy childhood growing up outside NYC. He reports no significant childhood Big-T trauma when treatment begins.
However, in Session 2, he tells me of a distressing and shaming conversation he had recently with his mother who was usually gay-supportive. Having broken up with his long-term partner and no longer able to provide her with grandchildren, she had told him, “You are a complete failure,” adding that he barely ekes out a living as an actor. In that session, I tentatively explored his reaction to what his Mother had said, which was, “Well, I believe her: I am a complete disaster and failure.”
Seth’s response was a maladaptive reaction that needed to be transformed (Fosha, 2021) 7, so I took it back up in Session 3:
Pt: Her comment made me angry, but not at her.. but at myself [AEDP State 1, defensive exclusion]. And, if anything, I didn’t think it was a totally bad thing because my experience with anger is sometimes if it’s the right kind of anger…. it’s like what John Steinbeck talks about in The Grapes of Wrath……that anger can mobilize you.
Th: Ok, right…
Pt The anger in this sense makes me want to change [transformance glimmer], rather than saying it’s hopeless.
Th: Ok…… but if I were your Mother, I would have said something like, “It will happen. Keep the faith.” [making my first overt affirmational statement]
Pt: You’re right (nods but looks unconvinced).
Th: I know it was not a good way (for her) to put it [still defending his Mother, i.e., she was correct in the gist of what she said].
Pt: She also told me I should give up on the thoughts of having children, that it was too late.
Th: Oh my god!! (groaning loudly, protesting her offensive statement)
Pt: She said, well, it’s just too bad because I think you would have made a good Father.
Th: Oh my god!! I think you’d make a good Father now! [more therapist affirmation].
Pt: (smiling briefly)
Pt: Then she said, “But when you get too old, it’s more difficult to do it. When you were with (previous boyfriend), I consulted a gay doctor friend about how to help you guys adopt a child.”
Th: So, on the one hand, she can be supportive.
Pt: Yes, but a complaint that my brothers and I have had is that we wonder whether what we do is for ourselves or for her. She just wanted more grandchildren! [He goes briefly into State 2 anger, which I chose not to explore, as I wanted to circle back to relationally metaprocess my affirmation of him, which initiated AEDP State 3.]
Th: How does it feel when I say to you, “I think you’d make a good Father now? That I don’t think it’s too late, and….”
Pt: … pauses…ah.. ah…. it’s what I want to hear, that the choices I have made have not… (foreclosed on my options). (As the patient takes in my support, his eyes tear up slightly, beginning a transformational spiral.)
Th: You look a little teary when you say that [moment-to-moment tracking].
Pt: Yeah… (tears now flowing)
Th: (quietly) What are the tears? [taking a position of not knowing8]
Pt: Well, I don’t want to give up hope that there are still lots of possibilities…. So, it makes me feel good to think that… that it’s not too late… for these other ways of being, other options you could have for your life.
Th: [pressuring with affirmation] And again, how does it feel when I nurture you and say, “that you’d be a good father, and that you are going to find somebody.”
Pt: (swallows hard) That kind of support is empowering! This statement indicates that Seth’s basic receptive capacity is intact if unpracticed, in that he does not respond by questioning my belief in him by saying something like, “how do you know all this?” Seth continues his silence, deep in thought.
Th: (breaking the silence) Mmm, mmm, You look like you are having a lot of feeling right now. Tell me what you are feeling inside [somatic focus].
Pt: (lips quivering, taking big breath) “I’m scared.” [State 3 tremulous affects] I’m just scared sometimes… (wiping eyes)… and I’m really happy to have you say those things because I.. ugh ugh.. because I am scared that I fucked up……
Th: ……and I’m kinda telling you that you haven’t.
Pt: (more emotional, wiping away more tears) … Because I believed it for a long time, but recently it’s been harder for me to believe it. I want to regain… I was really a joyful person for a really long time.
Th: Well, I saw that joy today when you arrived today, like you were walking on air. You kinda “popped in.”
Pt: (wiping eyes) Yeah, sometimes I can do it. It’s what people look for me to do (always to be chipper, optimistic).
Th: You don’t let people see the heavy part?
Pt: Right. Th: What’s it like to share the heavy part with me? [relational metaprocessing]
Pt: It’s really a relief. I don’t… I have to know that it’s okay I feel this way right now because I also want to change [transformance drive]… it’s not helpful for me just to say, “it’s all fine and it will all work out.” Th: Right! You must believe it in your heart.
Pt: Right, I do have to believe it in my heart…that I can change my perception and thereby…. make some of these things easier for myself (pauses and inhales deeply) [This very long, deep breath signals a change that we are moving from State 3 to State 4.]
Th: What are you feeling right now? [somatic focus]
Pt: (deep breath again) I feel good!!
Th: Yeah, your breathing has slowed down.
Pt: (opening his eyes wide, sitting more erect) It’s really, really nice right now that I’m up in this high room, and I feel… (big exclamation and big smile as he boldly affirms himself:) You’re all right! You got it man, you got this! [State 3 mastery affect, which unleashes an adaptive action tendency, as he suddenly becomes more self-confident.]
Th: Oh wow.. I love it.. I love it! [therapist delighting in his reclaimed self]
Pt: (big sigh) Wow… (leaning back into the chair resting his neck while looking up, he seemingly goes into Core State)
The patient’s apparent movement into Core State genuinely surprised me: How could my rather simple statements of affirmation have had such a huge effect? This sudden transition into Core State indicates again that both (a) his receptive capacity to take in my nurturance and (b) his transformance drive to grow and heal are very much alive and well. As human beings, we arrive “attachment-ready,” waiting to be nurtured once safety is established (Russell, 2015; Frederick, 2021).
(He takes a very long pause.)
Th: You look so peaceful from over here… are you? [again taking a not-knowing stance]
Pt: (big smile toward me with direct eye contact). Yeah, I am peaceful. And I’m excited! I don’t feel defeated right now, I feel excited [State 3 exuberance affect]… Go go go! Just fly! Not fly away! Don’t escape, just fly! (He then tells me about once going sky diving out of an airplane.)
Th: (teasing him in a playful mood) And your chute opened obviously! [attuned tracking, delighting in his new authentic exuberance]
Pt: Yep, I’m here! It’s a beautiful experience. It’s terrifying when you throw yourself out of the plane. But once out of the plane it was just beautiful (stretches his arms wide) free!!
His analogy suggests that the last few minutes have indeed had a liberating effect: Riding a wave of affect can be as scary as jumping out of a plane, yet can lead to exhilaration.
In the final end-of-session metaprocessing, Seth says:
Pt: I feel really good! I feel more connected to myself, to my body (clutches his heart). That he had a somatic response was reassuring to me that the change I witnessed was real. Frankly, I was astonished that I had just witnessed an example of quantum change in the third session.
Th: Well, I took you at your word last week when you said, “Where is all this talking going? So, we did something together today! [Again, the pressure of time in the short-term model on him and on me to make something happen that’s both different and positive].
In Session 3 above, Seth goes briefly through all four AEDP states, but mostly “skips” the more typical State 2, i.e., successfully feeling and managing a specific core affect with the therapist. However, the State 2 core affective experience here was a corrective receptive affective experience, (Fosha, 2021) i.e., his taking in my nurturance. Note that a supportive therapist might well have offered similar encouragement, but possibly would not have shared the same outrage I shared, as a gay man himself, about what his Mother had said. Yet it was the exploration of my unequivocal support via relational metaprocessing that led to a deeper affective experience.
In Session 5, Seth goes through all four states as he expresses his anger in an extended portrayal directed first at his Mother as if to strangle her, and then more intense anger at what he calls “my inner critic tapes,” which he agreed had his Mother’s voice in them. He concludes the lengthy portrayal saying angrily:
Pt: Yeah, fuck off inner critic, go somewhere else!! (fiercely flicks his hand away from his head) It’s like a fucking fly that you want to flick away… I have a lot to give, and you keep telling me I don’t. (Long pause as he becomes noticeably calmer)
Th: What’s it like to say that? [intrapsychic metaprocessing]
Pt: Really a relief!! Just saying it makes me feel it’s not that big a deal!! Go back out there and try AGAIN! [full emergence of agency and transformance drive]
Th: Can you imagine saying that tomorrow morning when that shit is going through your head?
Pt: I hope so! I really want to try! Those tapes are a narrowing (where) things get smaller…
Th: …. and you want to go the other way, to feel expansive?
Pt: Yes! We metaprocess at the end:
Pt: Thank you. It was a great release… this roundabout way of yelling at this critic, that it’s not me… it’s not all of me.. it’s one small voice trying to dominate me.
Th: So, you are fighting back! Pt: Yes!!
Around Session 10, a major theater agrees to produce and stage for the first time a dance performance he had choreographed and will star in. When I ask him if I could attend one evening, he says he would like that. After the performance, I go to the stage door. He comes out and spontaneously hugs me. While in that hug, I praise his performance and tell him it was beautiful 9 , that he is beautiful, that I loved his performance, and I love him.
Telling Seth I loved him was not planned; it was a spontaneous in-the-moment response to his spontaneously hugging me. When we metaprocessed it in the next session (“Did you realize I told you I loved you that night? What was that like?”), he said it was a wonderful moment for him, that he “kinda knew it anyway” and it was great to hear me verbalize it.
Termination begins “There is a Golden Sun in my solar plexus; I’m like a snake, decaying and regenerating a new skin.”
In Session 12, perhaps anticipating the end of our work, Seth begins termination himself:
Pt: I don’t feel I’m cured but I have to say these tapes have stopped, there is an acceptance happening, they are there when I need them.
Th: That’s wonderful music to me, what you are saying right now…
Pt: I want to know for myself what this feeling is, so I have ways of identifying it [He now has a curiosity about the process of AEDP, indicating he feels safe to explore more.]
Th: What feeling? Where do you feel it in your body? [experiential focus]
Pt: It’s lightness instead of weight… I’m no longer short of breath, and no one is standing on me. There is a Golden Sun in my solar plexus. I look up more, like…. noticing things for the first time…. my new mantra: turn your fucking head, look up, change your perspective……….[AEDP State 4, exalted state of his true self]
In Session 13, he continues to describe his new experience (a feeling of lightness that is being radiated to others) and wants to understand it better. Suddenly, an unexpected breakthrough of affect occurs, crying very forcefully, but I don’t know what’s going on, so I ask.
Pt: I don’t whether I’m happy or sad……But I think I just verbalized something kinda big and scary: we all live everyday but we don’t always like to reflect on what it’s like to live… that it’s scary and painful [State 3 tremulous affects]. It’s good to say it out loud [emergence of Truth Sense]… it has to do with the transition I’m in…. it’s easier to live when you are younger. I made choices and didn’t always think of the consequences. I think about how precious things are and how hard they are to come by… not only love, but these qualities of existence. My father used to say it: Life is fucking hard!!! [a strong declaration of an existential Truth Sense]
Th: I think you’re doing something right now…what we call mourning the self… mourning your old self.
Pt: That’s interesting. Can you tell me about that? [Again curious about what we are doing.]
Th: I think you are discussing regrets you’ve had, and you are kind of forgiving yourself for those things that caused you regrets, and you are kind of a new self in a way?
Pt: (eyes big and wide) Yep! I do feel like a snake! Shedding of an old skin… but that’s what life is like: We decay, and we regenerate and grow a new skin.
There, in his own words, he describes the transformational change he has experienced in a brief 16-session treatment. In the final sessions, we said our tearful goodbyes to one another. Eighteen months later, Seth emailed me:
Hi Gil, After so many months, it feels right to reach out. I’ve been thinking about the time we spent together. As with so much in life, it often takes distance to discover how one has been changed or affected by an experience. I just wanted to say thank you. Our time together was so important and necessary for my journey. I came to you in a bad place in many ways. And as the year has rolled on it’s become so clear to me that I gained a lot of freedom through processing many of those things with you. I broke down the walls of the labyrinth I’d trapped myself in. “I turned off the tapes,” as you might say. I’m working on a new piece that premieres next May. In other news, I’ve fallen in love; a feeling I haven’t felt in so long. We met in January and have been inseparable ever since. His heart is massive, and he treats me so well. Luckily, with help from you, I’m able to receive it without questioning whether it’s deserved. Thank you, Seth.
This report, especially how he is now able to receive love without questioning it, provides anecdotal evidence that he has continued to “flourish” (Fosha, 2021).
Case 2: Drake
Unlike Seth whose receptive capacity to take in my affirmation and nurturance was fundamentally intact though unpracticed, Drake initially questioned my affirmations during relational metaprocessing (e.g., “I pay you to say things like that”). Indeed, unlike the first patient’s upbringing, Drake had suffered more severe attachment injuries in his childhood on the part of his Father who had mostly ignored him, an upbringing that made it difficult to trust my nurturance.
Drake had contacted me several months before we began treatment but said as a self-employed freelancer he could not afford my fee. When he called later, he said he was desperate and wanted to meet anyway. When I learned more about his circumstances, I suggested we see if he qualified for the 16-session research study, which in exchange for a reduced fee, patients agree to videotaping and completing scales after each session and follow-ups. The research team screened him and accepted him into the project. Unlike Seth, I saw Drake entirely on Zoom sessions.
Drake is a widowed gay man in his early 40s. After a 10-year relationship, his husband had passed away 18 months earlier from cancer and dementia at age 75. Drake said he was depressed, isolated and very anxious. He complained bitterly that “no one has ever listened to me” and that he gets very irritated now when others don’t pay attention to him. He grew up in a chaotic family, where his Father had married several times, producing children in each marriage. Drake wasn’t close to his half siblings but was very close to his older “full sibling” brother. He explained that his Father adored the brother, several times saying, “but I was always under my father’s radar.”
Drake had been in recovery from alcohol and other drugs for several years. He returned to college while in recovery, strengths I highlighted and affirmed in our first session, “Wow! You were determined to make something of yourself.” His Father was a lifelong alcoholic. The Father never showed affection to him or to his Mother, only to the older brother. Drake longed to be as close to his Father as the brother was, did not understand why he wasn’t, and blamed himself, “You know, Gil, I am really lovable, why couldn’t he love me?”
When he was 5, he climbed into his Father’s warm bed early one morning. The older brother came in and asked why Drake was in the bed. The Father replied, “Oh, Drake is weird that way. Just ignore him.” Devastated and shamed, the incident was lodged in his memory. I immediately responded in an attempt to de-shame him: “A young child wanting the warmth of a parent’s bed is entirely natural and normal, and your Father should have never, ever shamed you that way.” Drake had a quizzical but positive reaction to what I had said: “I’d never thought of it like that.”
He also told me in the first session that he has always been attracted to much older men in their 70s, rationalizing “because my Father never loved me.” His Finnish maternal grandmother whom he loved to visit had an elderly male neighbor who took Drake fishing and taught him about plants. The grandmother thought they were getting too close and forbade Drake to see him anymore, saying he was a pedophile. That “grandfatherly” neighbor was the only quasi-parental male who showed interest and kindness to him in his upbringing. Drake showed insight in that relationship when he said, “It was a nurturing relationship, but I sexualized it.” Perhaps this was partly because the grandmother in the same conversation, warned him: “You know, Greek men had their boys.”
Although Drake was now trying to date men, he said it was probably too early because he still missed his husband, whom he had cared for during the last 7 years of their 10-year relationship. He felt extremely isolated: His “only three friends in the world” were his straight brother, a straight friend he enjoyed going to concerts with, and a straight woman at work. He had no gay friends of his own, only acquaintances of his deceased husband.
I found the patient’s aloneness painful and striking. I set upon the goal of making him feel less alone, not only with me, but encouraging him to make new friends who are gay. In problem- solving mode, I suggested places where that might happen. Gay friendships play an extremely important role in the lives of queer people (Nardi, 1991), and often become a “family of choice” when their birth families disavow them. But Drake explained the only time he was around gay men was when he would go to gay bars seeking sex, although he did not drink. In his view, “gay men are only and always about sex.”10
In Session 7, he told me he was born with a cleft lip, that he “was broken at birth,” had required multiple surgeries, and speculated whether his birth defect was the reason his Father couldn’t love him. He added, “I assume people won’t love me, but I know I am lovable. This is who I am!” This proclamation—now for a second time—seemed to be evidence of a core neurobiological self (Fosha, 2013, 2021) that the patient knows to be intrinsically good. This time when he said it, I spontaneously affirmed and accentuated it: “Indeed, you are lovable!” and enumerated several reasons why: His intelligence, quirkiness, and quick wit.
In the early sessions, I checked in with him whether he felt I was listening to him, knowing it was a sore spot. Yes, he felt I was, that I understood him. In most sessions, he repeatedly reminded me that he only liked gay men in their 70s. In Session 8, when I suggested he volunteer at SAGE, 11 an organization that serves gay elders, he said, “Well, they should be careful because I’d try to seduce them,” and, laughing aloud, I told him his humor was delightful. Yet he kept saying, “It’s so hard to be me. That’s why I make people laugh, to get others to like me.” (In Session 15, he acknowledged, insightfully, that he used humor also as a defense to avoid rejection.)
In Session 9, as he continued to make me laugh. I sensed he was flirting and that he might be attracted to me, a gay man in my early 70s. When I asked him about it directly, he blushed: Yes, that that “had occurred” to him. Smiling, I gently responded that I was flattered but explained I was here to “nurture you, not seduce you,” a boundary which he understood yet wished that we might at least become friends (Drake was already anticipating termination; would we remain in contact?). This was somewhat tricky in that I was attempting to “uncouple gay sex from gay friendship.” I explained that wanting to befriend their therapists is natural when patients sense that their therapists care about them, which I assured him I did.
As I continued to extol the value of having gay friends, I decided to reveal that I had been on two recent knitting retreats with other gay men. Self-disclosing that personal information intrigued him. In that session, I suggested he check out gay “Meet Up” Groups in NYC. Over the next few sessions, he did so and began going on hiking trips and to Broadway shows with other gay men. He volunteered that he was feeling less lonely even though he detested some “holier than thou” people he was meeting, and he proclaimed again, “I am who I am.” Affirming him, I said I admired that about him: “You are who you are; I like how you can sense bullshit, and you don’t take it!”
In Session 10, as he continued to complain about being “under my Father’s radar” and “how he never knew me,” I said rather spontaneously without much forethought, “You know, I think your Father was the one who got cheated out of knowing you. He never got to know how wonderful you really are.”12 As I elaborated on that idea, he said he never thought of it that way, that instead he was the one who got cheated.
Then, on his own, Drake researched “a gay tour of Greece.” His Mother’s comment that “Greek men had their boys” had fueled his long-standing interest in Greek culture. He then embarked on, during treatment, a two-week Greece tour with 9 older gay men. Before Session 13, he emailed me that he was back and couldn’t wait to tell me about his trip. Here I became almost as exuberate as he is, delighting in the joy he had on this trip:
Th: Hello, world traveler! How did you find the Greeks?
Pt: I really couldn’t wait to tell you about it. I made a lot of friends on this trip (huge smile). Th: That’s wonderful! Pt: Everybody loved me!! Th: I am not at all surprised!!
Pt: I know you have told me that, and others have told me that, but on the trip, I was just being myself, quirky and weird. But I wasn’t trying to impress everyone by making them laugh. I was just being myself, and they loved me!! (looking somewhat incredulous).
Th: I love it!! [taking intersubjective delight in his experiencing that the group loved him].
Pt: I was the youngest man on the trip… men in their 70s! I was in heaven!!
Th: You were in your element! [de-shaming him about his interest in older men]
Pt: This past weekend I asked a local man who’d been on the trip to go to a play with me. He told me I had really made this trip special to him.
Th: So, how are you handling all this? [intrapsychic metaprocessing]
Pt: I loved it! It definitely went to my head. I told that guy, “Can you say that louder so my brother can hear? That I am special!”
There was also one younger guy in his 40s on the trip who told me has always liked older men and that I didn’t need to feel so weird about it. There was also a married guy on the trip I flirted with a lot, and he with me. Although we talked about our sexual attraction to one another, nothing happened. It felt romantic… he took pictures of me when I wasn’t looking. Those pictures show how happy I was.
Th: Wow! This is something I’ve thought you’ve needed a long while, making gay friends! [celebrating how he was expanding himself in the real world as we begin Termination in Session 13]
Pt: And they want me to meet their friends!
Th: This sounds like an absolutely amazing trip for you!
Pt: It was… just what the doctor ordered, ha, ha. And there was no sex on the tour, as far as I know!
As Drake described a series of sexual innuendos that went on, I shared with him that’s also what happens on my knitting retreats with other gay men. Being real and sharing information about my being gay can be invaluable in undoing aloneness and helps create closeness between therapist and client (Kort, 2018; Medley, 2021).
Pt: The whole trip was interesting because I had been so anti-gay everything.
Th: So, the trip kinda changed your perspective about being gay?
Pt: I think so! Here I was running around with gay guys doing a trip together. No one gave a shit about us being gay…. The tour guide told me afterward that I should come on all his trips because I’d be a selling point for him, the way I am funny and witty and how I flirt with the older men. I’d be an asset on future trips.
Th: Wait a minute… (teasingly) this is a little hard to believe!
Pt: I am NOT making it up! The tour guide said he’d make up a special package tour around ME.
Th: Well, the interesting thing to me is what you just said: You weren’t trying to be a hit; you were just being yourself [celebrating his authentic True Self and realizing that others also appreciated it]
Pt: On the fourth day, one guy said I was starting to “grow on him.” I told him, “What? Like a wart? Like a fungus?”
Th: There you go again, making a joke [noting how he used humor to deflect a lovely compliment]. But you know, Drake, that’s kinda how I feel about you. You have grown on me!! [strong spontaneous affirmation of how much I like him]
Pt: (big laugh) I thought I was charming from the beginning.
Th: Yes, you were, but you have grown on me even more: I have this fondness for you, and I love who you are.
Pt: You are going to make me blush (big smile, long pause). I don’t know; it just feels good. (elaborating on his own:)
I came back with my eyes open, with no care in the world, considering where I was when we started earlier this year. I was in a very dark place. I thought men only liked me because they wanted me for sex. I realize now there’s more to me than that. But on the trip, I wasn’t questioning these people. I just thought, oh they all like me! They loved me because I was funny, smart, and weird. I wasn’t trying to make excuses about why they were liking me, you know, just to put up with me while on the trip.
Th: It is so important for you to take all this in [taking time to then enumerate in detail everything positive that had happened on the trip].
Pt: (smiles big) Th: I can’t imagine a more fun vacation, and a more appropriate vacation for you right now. (exclaiming) My god! [intersubjective delight in celebrating how he was experiencing “joy” which he had not had in a long time.]
Pt: It was perfect, everything I needed: A gay group I was historically not a part of, a group of older guys, so I was in my element. It was great. The tour guide from Boston will be in NYC this weekend leading a gay tour of the Metropolitan Museum. I will go and meet even more people there.
Th: This is amazing! [Again, I am sharing in intersubjective joy as he describes his new experiences in the outside world, much like in the Circle of Security (Powell et al., 2013) where a Mother welcomes her toddler back, delighting in his new adventures.]
Pt: I know! It’s a whole new me (huge smile). [Transformational change has occurred!]
Th: So…. you are filing this experience away in your brain and your heart? [intrapsychic metaprocessing of his discovering “a whole new me”]
Pt: Yes. You can see the smile on my face in all the pictures. It’s documented!
Th: Send me some pictures! I want to see!
Pt: I was not trying to put on a face. I was just being happy. I don’t know: This is what I should be doing with my life, being me. I just felt good the whole time.
Th: It’s so interesting your Mother told you about Greek men having their boys for sex. Although she was warning you, do you think she sensed you might be gay and was trying to comfort you in some way?
Pt: Well, she certainly did not do that when I was older. When I came out to her, she cried, said it was her fault because she didn’t give me the proper father figure.
Th: Well, that part is true. Pt: Right, but I wouldn’t be here without my Father [again reminding me of his yearning for his Father].
Th: Would he have been delighted with your report of the Greece trip?
Pt: Maybe. He loved Greece. He went on a cruise there after one of his divorces. I’ve never seen him so enthusiastic; he could not stop talking about it. So, yes, he would be excited! Definitely! It would be one thing we could bond over.
Th: Wow! Hmmm…….do you think your Father had “a slice of gay” in him?
Pt: Well, he could have been hiding something. Remember he took up community theater after he gave up becoming a Jesuit priest. And many priests, actors and alcoholics hide from something or other. I know I did.
Th: How do you feel if he was a closeted gay man?
Pt: If that were the case, I wish I had had that moment. Unlike my Mother, he didn’t cry when I came out to him; he immediately said he loved me [He is beginning to write a less judgmental narrative about his Father.]
Th: So, you got love all around you, and you are basking in it [again celebrating him].
Pt: I am! I love it! Th: We have to stop, but I have to say again: I am so, so happy for you, with you. This has just made my day. No question about it: You were a hit! (Again, intersubjective delight! In fact, in reviewing the video, I was surprised at how excited I became as I listened to him describe so many positive and joyful affirmational experiences.)
Pt: (blushing) Oh good! I made your day! The student has become the teacher!
Th: Can you see the smile on my face? Pt: Yes, I’m surprised that I’m happy, but I’m even more surprised YOU are so happy [He initiates relational metaprocessing: He is happy that I am happy along with him.]
Th: There’s a part of me that is not surprised at all. I knew you would be a hit.
Pt: (rolling his eyes in disbelief) Well, I didn’t (big smile): It was a surprise ending! When I repeat that we do need to end the session, he suddenly asks, “Oh! Is this Session 13?” (He is now very aware that we must end soon.)
Th: Yes.
Pt: (big grimace) Th: Wow. Well, we will talk about that. Send me those pictures! Immediately after the session he emailed me the pictures, and he is smiling radiantly in them all.
In Session 15, the patient himself brings up termination at the very start of the session (“you were a little late signing onto Zoom, and I thought you were leaving me already”), which evoked memories of losing his Husband. In that session, he proceeds to tell me for the first time the details of what it was like for him to experience his Husband literally leave him as he died with Drake holding him as he took his last breath, without hospice there. He cried for days afterward.
I include an extended transcript on termination in our 16th session for several reasons. Because I had indeed been 5 minutes late the previous week (in retrospect, I realize I was not fully prepared for us to terminate as I so enjoyed working with him), I asked if he could meet for 90 minutes instead of the usual hour, which he greatly appreciated.
Our final session proved to be powerful in unexpected ways for both the patient and me. First, I was struck about how much the patient needed to describe his feelings of loss, and when I drifted away from that myself, undoubtedly because I was avoiding my own feeling the loss of him for me, he would bring us right back to his sadness [dyadic regulation really works both ways (Ruggieri, 2023)] which I validated, joining with him that it is quite sad for me as well.
Second, I believe Session 16 illustrates what Lipton and Fosha (2011) described when the “patient’s positive experiences attachment within the here-and-now of the therapy relationship” allows deeper transformation to occur, especially as the patient describes his previous issues with attachment. When the patient says therapy is just about “transference,” I say emphatically that our relationship was not all transference, that it was quite real to me.
Third, there emerged an opportunity for me once again to inquire about how it was for him that I shared personal details about my own life, 13 as he was so sensitive about others taking over the conversation when he had the floor. Fourth, he begins to rewrite the narrative of his own life, as he realizes that some people have always been there for him. And fifth, we have an unexpected discussion on the pros and cons of the 16-week paradigm.
Th: So here we are: Our final session.
Pt: I’ve been sad all day.
Th: So have I.
Pt: You’ve been sad? Why? You have plenty of patients!
Th: None like you! (laughing) [continuing to delight in the specialness of him]
Pt: (laughs). Your patients are still getting into their issues?
Th: Have you gotten into yours?
Pt: I think so. I’m definitely in a better place than when we started. You gave me a different perspective, that I’m funny, attractive, amazing, a genius.
Th: (playfully) I don’t think I used “genius” but ok!
Pt: I guess I never felt worthwhile…. that I contributed much to other people. You instilled in me that I am worthwhile.
Like Seth, Drake has now fully incorporated my affirmations of his authentic True Self, and this has been infused with adaptive strivings to express his core-self with ease, clarity and with the new belief that it cannot be otherwise.14
Pt: The greatest thing you said to me was that it was sad my Dad didn’t get to know me. That it was his loss, not just my loss. I never looked at it that way. I was always trying to figure out why he ignored me. I thought it was my fault. I was totally under his radar. Not that I’m tooting my own horn, but I think I’m a better person than my Dad [owning his newly appreciated specialness]. He could have learned something from me. I could have been beneficial to him. I took care of Harold (his Husband) in his old age; maybe I could have taken care of my Dad. Maybe I could have brought joy to his life. I saw him for the last time a few months after Harold died. My Father was in a coma, and they almost pulled the plug before I got there. He came out of the coma when he saw me. I told him Harold had died. He was compassionate and said he would pray for him. It’s so sad he died without knowing me. [now deeply in touch with his feelings]
Th: It IS sad… so very sad.
Pt: I was already beginning to feel part of the gay community, and then the Greek trip. Thank you. Th: Well, I made some suggestions, but YOU were the one who took me up on them. That YOU found that Greece trip was amazing to me. YOU did that. YOU sought it out, and the Greek trip was therapeutic for you. Pt: But it was your suggestion that I go to the Meet-Up group website. [Drake wants me to share in the success of the trip, perhaps stretching my own receptive capacity to take in his gratitude.] The Greek trip was amazing, and then I got back I started reflecting on other relationships I have had or am in that I took for granted.
Th: Oh! Thank you for that! Tell me. As he rewrites his life narrative more coherently, he recognizes how some people have always been there for him and were “like an extended family when my husband died, encouraging me to mourn with them however long it took, that I didn’t have to return to real life so quickly.” He especially liked how they checked on him after the death and still seek him out now, along with a new acknowledgment that he is the one who often does not follow through, still fearing possible rejection.
(Back in Session 4, Drake had debated attending a memorial service on the West Coast for his Father who had died a year earlier. I strongly encouraged his going to evoke more deeply his conflictual feelings about his Father. But Drake got COVID and was unable to fly there. He assumed his family, knowing he and the Father were a bit estranged, might have assumed he made up COVID as an excuse to avoid going. But he was extremely disappointed he could not attend.
In Session 4, I attempted a portrayal of what he might have said as a more truthful eulogy if he had been able to go: “He was an asshole! Most people knew that already so it wouldn’t have been a revelation.” However, his brother did go to the funeral and met a distant uncle, who had come to visit them in New York just before our final 16th session.)
Pt: I am now more curious about my father’s life and sorry he’s not here so I can ask more questions [Once Drake’s anger has subsided, he becomes more “empathically interested” in his Father, which can happen as patients revise the narrative of their lives]. I don’t know much about his childhood. He was in a Navy family, and his friends were always moving around; he became aloof and didn’t make friends easily. And then there’s the question you brought up…. could he have been gay? Maybe he was using alcohol to avoid that. Certainly, I used alcohol to hide that, and I thought I’d be more interesting drunk than sober. I learned later I didn’t have to be drunk to be interesting. My Father was more interested in acting and drinking than being with his family.
Th: (10 minutes before our final hour ends) So… how do you feel this being our last Wednesday? [eliciting his feelings about termination]
Pt: It’s sad (screeching). Yes, and I’ve told you before I have trouble with boundaries….
Th: Well… we may not be meeting on Wednesdays anymore, but you are NOT going to go away for me. You have become, over our time together, very special to me and I will never forget you [stating firmly and explicitly during termination that the patient has had a positive impact on me during our brief work together] (patient takes that in, breathing deeply, becoming calm while smiling big). I think you know it already, but I want to say it again, you are very special to me.
Pt: Well, thank you. (pause) Th: And it looks like you are not making a joke… that it’s actually registering. Pt: Right………(apparently blushing)
Th: Are you blushing?
Pt: Yes, I am…… but I’m sad. Th: I have tears in my eyes just thinking about all this. Can you see them?
Pt: Yes. Me too. Only 16 sessions???? Really?? Th: I know! I know! I want to ask for more!! (As I say that, patient smiles big, seeing that I too would desire more sessions with him.)
Pt: Tell them I’m a real nut case and I need at least another 3 years.
Th: But you know, one advantage of the 16 sessions is that you and I both knew from the get-go we only had 16 sessions, so we got serious fairly quickly.
Pt: I’ve never been in therapy successfully…I never had any breakthroughs. One therapist just kept telling me about HIS life instead of listening to mine.
Th: You’ve been OK when I share some details about my life?
Pt: Yes, ‘cause when you have done it, it’s relevant to what we are talking about, and you are not taking over the entire session. I really liked when you told me how your dad made fun of you for being unable to throw a baseball overhanded, which you still can’t do!!! (teasing me)
Th: Can you?
Pt: Yes, of course I can.
Th: (continuing the tease) Now you are telling me you’re a jock?
Pt: Well, at least I can throw a ball……..
Pt: Oh!! I signed up for a gay tour of Berlin. And next month I’m going on a gay cruise that’s promises to be very sexual. A little debauchery.
Th: It’s wonderful how you are opening yourself up to all of life [celebrating his newly expanded True Self and his zest for life].
Pt: My favorite rock group has this ballad, “I’ll Miss You”… I loved listening to that song when Harold died. After he died, I decided I’d follow the group. I’ve gone to every city on their nationwide tour this year! People who follow them recognize me at concerts and are glad to see me. They love how I dance to the songs. The group played uptown last night. I’m surprised you didn’t go; I’ve been talking them up to you. …….
Pt: (He returns to talking about the pictures a new friend took on the Greece trip). I look genuinely happy, and I’m not genuinely happy usually. The Greece pictures are the only pix I have where I look happy when I wasn’t posing; these were taken spontaneously. They remind me how much joy I had on the trip.
Th: Hmm… can you say more what it’s like inside you when you look at those pictures of yourself where you are joyful and happy? [intrapsychic metaprocessing of the core emotion joy]
Pt: Even when I’m alone, I smile big when I look at those pictures. I feel warm inside. It just makes me feel good. And on the Greek trip there was no sex! And I still had freedom and fun. I had a much better time because of it… that sex was not included. When we first started talking, you asked me what does gay mean to you? And I said gay was only about sex. Now it feels more like a community.
Th: (widening my eyes) Wow.. so you’ve come to appreciate…. (the gay community?)
Pt: Yes, and I like the book you recommended: Gay Like Me (Jackson, 2020). The guys on the trip talked about how much they loved the movie Call Me by My Name. 15 I had never seen it, and they watched it together with me on Netflix. …….
Pt: (long pause) Now what?
Th: Now what?! It’s the witching hour… we have to say goodbye.
Pt: What time do we have to say goodbye? This isn’t nice!
Th: No, it’s absolutely not nice……… Right now, I’m thinking about that ballad from your rock group: “I’ll Miss You.”
Pt: Yeah…..you should listen to it.. it will bring tears to your eyes (which I already had).
(We make steady eye contact and shake our heads silently together in right-brain to right- brain synchrony.)
Th: Can you give voice to what’s going on inside you? You seem to be full of feeling [experiential focus]. What does the feeling want to say?
Pt: It’s about loss… losing a friend.. it’s a professional relationship, I know. But we’ve become friends. I was telling someone about my therapy, and they said therapy is all about transference. You get connected to your therapist because he listens to you when others don’t.
Th: That is how some therapists work, but not the way I work. THIS HAS BEEN REAL.. it’s not all about transference. This has been a real relationship………..
Pt : and it’s ending.. it’s sad.. it’s sad.. (pauses then says abruptly) IT’S YOUR FAULT!! Th: What??
Pt: That it’s ending. You put me in this 16-session thing to save me some money……… [hinting correctly if it wasn’t for the fixed time limit, we could continue]
Th: I go back to what I said earlier: The 16-session thing was partly what made it successful.
Pt: Yeah…you’re right. I work better when there is a deadline. I can’t work unless there is a deadline; otherwise, I procrastinate……having just16 weeks, I knew there was a time frame to get cured. [His statement illustrates how the pressure of the 16-session time limit energized him to get the most out of his therapy.]
Th: Have you been cured?
Pt: Yeah, I think so. I am much happier now.
Th: What struck me in our first session was your loneliness [engaging in termination a discussion of what has changed for the better].
Pt: Yes……I didn’t have friends then, now I do.
Th: And now you have backups when one friend is busy.
Pt: Right.. but at this moment I am losing my therapist [Yet again, Drake brings our dialogue back to his feeling of loss.]
Th: …and I am losing my client….. [joining him in a shared experience of loss; we are in this together]
Pt: But I don’t have a backup therapist! Th: Ouch that hurt!! Pt: WHAT?? YOU ARE MY ONLY THERAPIST I don’t have a backup [full separation protest that we must stop seeing one another]. I guess I’m not cut out for this therapy thing; I get too attached.
Th: Oh, I think you were very cut out for it!
Pt: I just get too attached. I don’t know how to deal with boundaries and professionalism.
Th: Well, you haven’t been too, too bad about that.
Pt: But I am now… I should be celebrating I accomplished so much in 16 weeks, but I am sad I am losing Gil. 16
Th: Well, it’s a mix, right?
Pt: Yes. It’s certainly been worth it. Th: It’s been an amazing experience for me too [validating that his experience matches my own]. You were ready to do some work and you did it. (Very long pause as we stare at one another in silence without losing eye contact) As we close, we do a gentle royal wave like Queen Elizabeth did, who had died the week before.
Pt: Maybe I’ll see you at my hard rock concerts.
Th: Good luck to you!
Pt: And good luck to you.. auf verstehen. And maybe you will learn to throw a ball.
Th: I’m too old for that!
Pt: You are never too old!
Conclusion
Both cases are examples of transformational change possible in brief 16-session AEDP with patients who have significant trauma. At post-treatment follow-up. both patients showed clinically significant changes in depression, automatic negative thoughts, emotion regulation, self-compassion and experiential avoidance (Iwakabe, 2023).
For Drake there was profound early childhood trauma of being totally ignored by his Father (“a
sin of omission”); for Seth, the trauma was a recent shocking betrayal by his normally supportive
Mother, (“a sin of commission”). In both cases I maintained a strong affirmational stance and
worked relationally, experientially, and explicitly with each man. Building beyond the strong
affirmational stance, the major change mechanism that produced deeper healing was my relational metaprocessing of that stance at every opportunity, which facilitated the men
absorbing my affirmation and affection, letting them know without question that they were
having a positive impact on me.
Iwakabe, Edlin and Thoma (2022) distinguish “unequivocal affirmation” (“an explicit ‘yes’ to
the whole self of the client”) from empathy (“the therapist’s tuning into and understanding the
client’s emotional state,” p. 369). “Unequivocal affirmation” also includes encouragement, and
“an open, receptive and welcoming attitude” (p. 369). Compared to other supportive therapies,
unequivocal affirmation requires the therapist to more actively use himself to become a strong
advocate of the patient, much like Piliero does in her “fierce love” model. In both cases, there is
surprisingly little AEDP State 2 processing of categorical emotions such as anger or grief.
17
Instead, both treatments were primarily relational therapies where the healing mechanism of
change was the therapist’s unequivocal affirmation. Only with Seth in Session 5, once he felt
safe with me, did we do a successful anger portrayal in State 2. In fact, it was the earlier Session
3 that may have been more meaningful for him, where my few simple statements of affirmation,
followed by metaprocessing, launched him into a deep core state. With Drake, there was
virtually no processing of categorical emotions. Instead, the primary focus throughout his
treatment was increasing his receptive capacity to take in my caring and celebration of him,
providing him with a corrective relational affective experience, which later proved “portable” as
it helped him take in the love and acceptance from men on the Greece trip and beyond the
treatment.
In the final sessions with Drake, “joy” emerges as the core affect he had never really
experienced. Here “joy” becomes more than a mastery affect in metaprocessing following a
successful State 2 affective experience (Fosha, 2000; Hanakawa, 2021) or at the end of
treatment, as in the case of Seth who says he now has “a Golden Sun in my solar plexus.” Drake
explicitly uses the term “joy” several times to describe his Greece trip. As I celebrated his joy
along with him, he detects the joy in my face, which increases his own joy. Joy became
contagious.
Although joy is a primary emotion (Darwin, 1872/1965), joy may be underrated in our work as
AEDP therapists. For some individuals in early childhood, joy can become a core affect that had
to be suppressed when it upset their depressed caregivers who could not show delight in their
infant, probably the case with Drake’s Father. All core emotions (anger, fear, sadness, joy,
desire) unleash adaptive action tendencies. As such, there is a wisdom behind every core emotion (Joyce, 2022). The wisdom behind joy is “to call attention to something that needs to be
appreciated and celebrated.” Joy connects us “to our core identity and values” and “makes life
worth living in the moment” (Van Campellen, 2019).19
Both men possessed qualities that made it easy for me to affirm from the get-go. In fact, these
two cases may represent what Iwakabe at al. refer to as a “pure gold sample” of two, in that there
was a goodness-of-fit match between patient and therapist.20 Seth had a basic receptive capacity
to take in my affirmation; Drake less so. It seems important again to emphasize that rudimentary
“receptive capacity” is innate and present in everyone (Schore, 2009), much like the
transformance drive, awaiting activation by a nurturing environment (Russell, 2015; Frederick,
2021). In short, we arrive at birth “attachment ready.” As Fosha (2000) described, receptive
capacity can be cultivated, and once online, helps the patient develop and maintain close
relationships in the outside world, which occurred in both cases here.
But here’s a caveat: Once Drake’s receptive capacity was activated and he had taken in my
fondness for him, he had a far more difficult time than Seth separating from me (indeed,
separation protest is an early sign of secure attachment). He did not want to give me up so
readily, and termination became more difficult [see Harrison (2020; 2023) for an excellent
discussion on termination in brief therapy]. An extended therapy might have contrasted more
explicitly what was different in what he experienced with his Father versus what he had
experienced with me.21 In retrospect, I regret not doing more of that than I did.
22 I also regret that
I did not sufficiently bring up termination itself earlier in Drake’s treatment, which is particularly
recommended in the 16-session format with patients who have a difficult time leaving us
(Harrison, 2023).
Gil Tunnell, PhD. Is a senior faculty member of the AEDP Institute and editor of Transformance: The AEDP Journal. He is an adjunct associate professor of counseling psychology at Teachers College, Columbia University. Address correspondence to Gil Tunnell, PhD 300 West 23rd St., NY, NY 10011, giltunnell@gmail.com.
1 Fosha (2000, 2021) was especially interested in quantum change that occurs in several contexts: The adaptive value of the categorical emotions required for long-term survival and transformation of the species (Darwin, 1872/1965), early childhood attachment experiences (Bowlby, 1988), romantic passion and the state of being in love (Person, 1988) and religious experiences (James, 1902).
2 Gay male patients have told me how they practiced (a) holding their elementary school books down by their side, instead of clutching them as girls do; (b) uncrossing their legs to be like other boys; (c) firming up a limp wrist and keeping the pinky down; (d) no longer wearing pastels; and (e) dating girls when there was no sexual attraction. 3 Siegal and Walker (1999) in their work with gay couples during the AIDS crisis described the difficulty men had with intimacy: “One man said that, as he revealed something about himself, he would scan his partner for the effect of his revelation. The moment the other person was about to answer, he could feel himself withdrawing, every inch of his body filled with defensiveness and silence, expecting punishment for any act that revealed his authentic experience. It was reflective—in his muscles. He longed for an authentically honest relationship, but of course his reflexive behavior was not conducive to trust and dialogue, nor was he in fact trained to be comfortable with intimacy” (p. 40).
4 See Medley (2021) for an excellent summary and history of Gay Affirmative Therapy (GAT). 5 For a strongly affirmational approach within AEDP, see Piliero (2022) for her “fierce love” approach.
6 Names and identifying information have been changed for both cases presented here to protect their confidentiality. 7 Fosha’s edited book (2021) includes three chapters on how to work with maladaptive affects.
8 Taking a “not knowing” stance is borrowed from Solution-Focused Therapy (Tunnell & Osiason, 2021), used here I do not truly understand his tears at this point and want to explore their meaning. AEDP usually takes a “not knowing” stance through treatment by not prejudging what the underlying core emotion will be. Instead, we express curiosity about “what is coming up.”
9 It can be risky to attend our patient’s artistic events because we might not like them, and then what will we say?! But when I have done it, patients greatly appreciate the fact that I was in the audience, more than my evaluation of the event.
10 Nardi (1991), from interviewing many gay men, found that in many instances a lifelong friendship began with having sex, and some men reported “it was good to get sex out of the way.” 11 SAGE, formerly Senior Action in a Gay Environment, now called Advocacy and Services for LGBTQ+ Elders, is an agency that recruits volunteers to visit gay elders who are homebound, to offer friendship and sometimes run errand.
12 This is an example of what Lipton (2021, 2020) discusses in regard to “therapeutic presence:” The therapist is so deeply present and attuned with the patient that he sometimes says or does things so spontaneously that he surprises even himself. Yet often these not-so-well-thought-out interventions turn out to be therapeutically appropriate and deeply meaningful. Indeed, in the 16th session, Drake tells me, “That was the greatest thing you told me: It was my father’s loss not knowing me.”
13 A few clients have told me during metaprocessing that my self-disclosures were not helpful, resenting I was taking up “their time” and intruding on their process. Sometimes asking permission to share something personal that might be helpful allowed them to receive it and they could decide if it was useful or not. Clients with a strong avoidant attachment style seemed to want me to remain distant rather than get too close. When there was continued pushback, I simply stopped self-disclosing. In short, if therapists choose to self-disclose, it is imperative that we metaprocess it (Prenn, 2009). 14 As this was our final session, I asked for an update about his volunteering for SAGE. He said, “I reached out to my contact at SAGE: What’s going on? It seems to take forever. I won’t be devastated if the man doesn’t choose me. It would be HIS loss!”
15 Call Me by Your Name is a poignant novel (2008) and movie (2017) about a gay teen who falls in love with a graduate student visiting the family for the summer. At the end, the Father described how beautiful it was to watch his son explore his sexuality with the older student. This again brought up for the patient painful memories of how his Father never got to know him.
16 As Harrison (2020, 2023) notes, termination is both a celebration of what’s been accomplished as well as processing the loss of the therapist.
17 As Fosha (2021) describes, AEDP State 2 encompasses more than processing Darwinian core emotions. It can also include processing a new corrective relational experience (Fosha, 2021), which these cases illustrate. 18 As I was editing this paper, I received an email from Drake. He had met a man on his gay cruise whom he appears to have fallen in love with. Drake writes, “I just gotta keep in mind that I am worth it, and as lucky as I feel to be with him, he is lucky to have me too.”
19 For some patients, joy can be elusive. I occasionally ask my patients who seem bored with life, “But where is your passion? What brings you joy?”
20 The question of how affirmation works when patients are not so easily likeable is not addressed here.
21 I thank my colleague Gail Woods for her careful reading of an earlier draft; she noted how an extended therapy would have been different. In a lengthier treatment, his safe and solid attachment to me would have become a scaffolding for deeper work.
22 Frankly, I was frustrated with myself not doing deeper work around his pain of being ignored by his Father, which would be bad enough if the Father had ignored all his children, but Drake watched his Father delight in his older brother, making the pain of being ignored by a parent excruciating. Yet in our brief time frame, it seemed more important to focus on the here-and-now positive “corrective relational experiences” he was having with me as an older man who delighted in him. As he himself said, the work was partly successful because of the limited time frame; otherwise, he’d procrastinate.
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