Annika Medbo

Abstract: This article presents my work with a patient whose sense of Self was profoundly unformed, necessitating extensive engagement within the realm of State 2 maladaptive affective experience. An AEDP’s guiding ethos – to create our interventions, moment-to- moment, by tracking the unfolding phenomenology – allowed me to innovate within the AEDP framework. In the course of my work with this client I devised two new triangles of experience: the Triangle of Finding and Rescuing the Self, and the Triangle of The Emerging Self. These triangles offer a conceptual visualization of the work primarily happening within maladaptive State 2 affective experience and in the process of moving from maladaptive affective experience into adaptive affective experience.

The theoretical framework in this article builds on Eileen Russell’s (2021) incorporation of agency, will, and desire as State 2 affective experiences. She proposes the idea that “neglect, exploitation, and oppression of any kind leave holes in the development of self” (p.244), a deficit that Fosha has similarly described as unformed experience (Fosha, 2013). I propose that when working with clients who present with an unformed Self, we must connect with our patient within the realm of State 2 maladaptive affect; it is there that we encounter the neglected split-off part of the Self, needing to be rescued. As was true for my patient, the maladaptive affective experience might be the (yet) only “road” to their inner emotional life. Without being recognized, witnessed, and felt in the presence of a safe ‘other’ the split-off divided self cannot be unified, and the True Self cannot form and transform. Simply said, the patient needs to know they have a Self and have a felt sense of that Self before they can feel about and for the Self.

Introduction

This article draws on a decade of experience using AEDP when working with the deepest forms of attachment trauma, specifically, the trauma of deep neglect. This type of trauma results in a state of emotional isolation bereft of a felt sense of Self, of other, and of existing as oneself in the world. In the emotionally isolated patient, though a patient is estranged from a sense of self, this Self does exist. This True Self resides as the neurobiological core self (Fosha, 2013; 2021), but for relationally traumatized clients it is out of reach. This is because the neurobiological core self can only be accessed and felt in the context of relational safety;

Annika Medbo, L.P., is a licensed psychotherapist and licensed physiotherapist. She is an adjunct faculty member of the AEDP Institute, and an AEDP certified supervisor and therapist. She has a private practice in Stockholm, Sweden. Address correspondance to annika@medbo.se.

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that is, in a relationship with a “safe enough” attached other. In the state of emotional isolation a part of the patient’s self, or sometimes the entire self, exists in a state of shutdown, with little to no ability to reach out, seek safety or comfort from others, or receive any help that may be offered.

An essential part of the therapeutic process, therefore, is about creating a space where the patient feels safe enough to allow core aspects of the self to emerge. Fosha (2013) states that the relational safety must be employed in the “search-and-rescue mission for and of the patient’s felt sense of self.” We engage to “find” glimmers of the hidden self, encourage and support these glimmers, and then gradually help the patient be able to take in, and hold onto, the new experience of feeling their Self. It’s a slow process that requires repetition and patience.

This article illustrates how the attachment-informed therapeutic stance in AEDP (Fosha, 2000), combined with the approach that allows moment-to-moment phenomenology to guide the process, creates the interactive space necessary for the development of the Self. This process inevitably leads to reactivation of very early attachment needs which is when engaged with therapeutically an opportunity for healing. In the case featured below, this reactivation took form at the level of the early adaptive function of imitation, one of the most important interactive features for learning and survival (Meltzoff, 2017).

Three vignettes from my work with a patient, whom I refer to as Ellie1, are used to illustrate the therapeutic process involved in finding glimmers of Ellie’s Self helping her to experience and reclaim her True Self. The various challenges encountered in the therapeutic process with Ellie required of me, as the therapist, to deepen and refine my understanding, as well as further develop my AEDP stance and skills in working with clients who have minimal access to a sense of Self. Crucial to my understanding of Ellie’s therapeutic needs – of how to work therapeutic with what is ‘not there,’ is Eileen Russell’s (2021) conceptualization of the agentic self as a core affective state. She proposes that the sense of agency, will, and desire are themselves core affective experiences AND they may be absent in our clients when “neglect, exploitation, and oppression of any kind leave holes in the development of self” (Russell, 2021).

The work with Ellie led to my development of a new, deepened, and expanded area of intervention within State 2 work, in order to specifically address what was missing – her undeveloped sense of agency. The two new “triangles of experience” I developed will be used to help track the process and evolution of Ellie’s growth.

It was important to first create an expanded space for the agentic Self to be identified, then felt, and filled in and formed. Creating and sustaining this expanded space is challenging for

1 Patient name and identifying information is disguised to protect confidentiality.Transformance: The AEDP Journal Volume 13 ©AEDP Institute 2024

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therapists when working with clients such as Ellie, for whom the diminished sense of self and agency impairs their engagement in the therapeutic process – in Ellie’s case, she could not speak. Such fine-tuning of presence and enhanced listening is beneficial even for patients less traumatized than those I refer to in this article. Such ‘doing’ of AEDP, requires ‘being’ present for the patient (Lipton, 2021), right brain-to-right brain, and moment-to-moment tracking that experience, balanced with left-brain understanding. It is a bottom-up, inside-out learning that builds trust in the therapeutic process. Moreover, it greatly promotes agency – our innate capacities to be who we are, as well as to genuinely be together.

My work with Ellie was critically informed by AEDP’s clinical application of infant research. AEDP plays a significant role in the “bridging” between infant research and adult treatment and is especially helpful in working with patients such as Ellie, who suffer with a debilitating undeveloped sense of self. I explore and illustrate how AEDP’s therapeutic stance, devised from observations of secure attachment promoting parent-infant interactions, enhanced Ellie’s capacity to engage in the therapeutic process and establish therapeutic trust. This stance, together with tracking the phenomenology of the patient’s moment-to-moment experience, can guide the therapeutic dyad on the journey that begins from emotional isolation with no felt sense of Self and arrive at the felt sense of existing as oneself, and as oneself in-the-world with others.

PART IEllie: working without words

There is nothing such as an isolated individual. Organisms survive only in relation to an environment, influencing that environment and in turn being influenced by it (Regina Pally, 2005, p. 208).

At some point, early in the therapy, Ellie became mute. She reverted to just nodding (“saying yes”) or shaking her head (“saying no”) in response to my words. Of necessity, we needed to begin there, in order to “find” her. Years later, she described, “I needed the nonverbal thing. My words felt false, but that which came from my body felt right. I wasn ́t in contact with the words AND my body. When I talked, it felt like the contact was broken.”

I never experienced Ellie ́s muteness as a defensive withdrawal. Intuitively, I felt there was something “right” in her turning mute. Although silent, it was intense, and I felt her desire to connect through her nodding or the shaking of her head. She was present, there, on the edge of what was possible in that moment, but it was something more than that. The muteness seemed like an entrance to her true Core Self, an invitation to BE with HER. A fragile NEW space. It was her way of being ME/I with YOU from a place of awakened healing and self- righting drive.

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Diana Fosha says, “Lodged deeply in our brains and bodies lie dispositions for healing and self-righting that surface under conditions of safety; they are there for the awakening from the first moments of the first session onward” (Fosha, 2021, p.28). The “mute part” in the process with Ellie was her nonverbal response to safe enough conditions with me, and it was the beginning of the journey to rescue and support the emergence of her Self.

Attachment trauma and the emotionally isolated Self

Working with attachment trauma and neglect (errors of omission), and the emotionally isolated Self – the result of the trauma (Fosha, 2000), has always been an area of interest to me. AEDP opened a new arena and landscape for this kind of work and developed a new platform for me to work from.

It is slow work and requires patience, from both the therapist and the patient. I see the need to deepen our understanding of these processes and to develop our ways of working therapeutically with this group of patients. Understandably, therapists can easily get lost in the quietness/silence stemming from the patient ́s lack of experience with self and shutdown states, when “facial expressions are masked, and words are withheld behind walls of silence” (Pando-Mars, 2016, p.9); however, this may result in unintentionally leaving the patient alone with the painful fear that there is no way out of their emotional isolation.

Right-brain-to-right-brain communication

Ellie suffered from deep neglect in her early life and childhood. She never experienced the ”nonverbal thing” in a way that allowed her to sufficiently develop and grow. Yet, she knew she needed “the nonverbal thing.” She explained that what came from her body felt right. Her need embodied what infant researchers have discovered about the earliest forms of interaction: that the bodily aspect of communication is an essential component of the capacity to communicate and understand emotion (Beebe & Lachman, 2014). Beebe & Lachman (2014), highlight how the nonverbal interaction plays a key role in attachment formation and they draw a link to adult treatment, noting that “nonverbal communication is remarkably similar across the lifespan.”

While Ellie knew she needed the nonverbal ”thing,” and it felt right. I, as her therapist, also sensed something right in her becoming mute. AEDP therapists are trained to be on the lookout for glimmers of transformance – the innate motivational drive to heal, self-right, and “strive toward maximal vitality, authenticity, and genuine contact” (Fosha, 2008, p. 282; 2017a). This involves seeing the patient through an adaptive lens rather than a pathological one (Fosha, 2000). This knowledge informed my approach to Ellie’s muteness and allowed me the freedom to lean into my own right-brain sensing and knowing, thus attuning to her glimmers of healing and self-righting, rather than feeling stuck or puzzled by her silence. I

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was able to remain open to “learning the nonverbal, moment-to-moment rhythmic structures of my patient’s internal states” (Schore, 2016, in Foreword to Marks-Tarlow, p. 13).

My work with Ellie emerged through a place of “no words and no content.” The AEDP approach and stance helped me stay in a kind of extended nonverbal openness and listening beyond what I was used to, and I developed an increased tolerance for “the tension between knowing and not knowing.” (Lipton, 2021, p.149). Schore emphasizes that right-brain-to- right-brain communication is critical for the development of the self and for the regulation of emotions throughout life (Schore, 2019). He discusses how unresolved trauma, particularly early relational trauma, is stored in the right brain and can lead to various forms of psychopathology. He argues that effective therapy must address these trauma-based, right- brain processes to promote healing. He also discusses the importance of therapists attuning to their own right-brain processes to enhance their effectiveness. (Schore, 2012; Schore, 2019).

Recognition

Ellie needed my “independent subjectivity,” my recognition and the experience of mutual influence (Jessica Benjamin, 2005), all crucial aspects for early self-development. Tronick introduced the concept of the ‘dyadic expansion of consciousness,’ where both the infant and caregiver co-create emotional and cognitive states through their interactions and where both grow and develop as a result of their exchange. He highlighted how this mutual regulation of emotions is foundational to the development of the self (Tronick, 2007).

Although Ellie deeply needed the experience of mutual regulation and mutual influence, this was also something that, in her adaptation to such severe neglect, she had learned to stop needing. She both lacked a reference inside herself for these kinds of experiences and simultaneously feared the new experience. This condition turned out to be one of the greatest challenges in our work together.

The findings of the Still-Face Experiment (Tronick et al, 1978) are relevant to our work with patients suffering attachment trauma. This well-known psychological study conducted by Dr. Edward Tronick in the 1970s, examines the infants’ reaction to emotional and social disconnection from their caregivers. In the first stage of the experiment, the caregiver (usually the mother) and the infant sit facing each other. The mother is first instructed to interact with her infant as she normally would – smiling, talking, and responding to the baby’s cues. In the next stage, the mother is asked to stop responding to the infant and instead maintain a neutral, expressionless “still face” while continuing to look at the child. Then, after 2 minutes of “still face” the caregiver is instructed to return to normal. The infant’s profound response to the mother’s sudden emotional unresponsiveness while in “still face,” embodies the excruciating experience of ‘nobody there.’

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In the early 2000s, at a workshop in Sweden, the infant researcher George Downing compared the “still face” response between securely attached and insecurely attached infants. The securely attached infants reacted with the well-known pattern: surprise—trying to get the mother’s interest back—distress/anger—sadness—despair—panic/fear while the insecurely attached infants did not react, typically lowering their gaze to their own lap. The insecurely attached infants had already learned to protect themselves from the excruciating panic/fear response that the emotional unavailability of the mother gives rise to. This explains the fear- based risk aversion that neglected patients have for taking in new experiences with another.

Along with the developing right-brain-to-right-brain presence with Ellie, addressing the significant therapeutic challenges and fears also required a developed left-brain understanding on my part, informed by infant research, which became increasingly essential as new phenomena emerged.

A phenomenon that occurred late in the process with Ellie further contributed to my understanding of the profound importance of nonverbal communication in the development of the Self. While reviewing a video-taped session, I noticed that Ellie imitated me in the way infants do. It was a spontaneous, unconscious mimicry of my body movements.

Agency, will and desire – the missing link

Even though the degree of Ellie’s pathogenic shame was reduced and felt safety with me was deepened, she nevertheless struggled to hold onto these new secure attachment experiences, as if she didn’t know how to do it. On this matter, I resonated with Russell’s (2021) observation that “something essential is missing from the sense of self that is not simply going to emerge fully formed, even in the safest, most secure therapeutic relationship.” This insight provided me with a crucial comprehension of Ellie’s lack of agency, will, and connection to her desire, and moreover that the missing link in our work – the missing aspect of her Self, must be centered. In Part III I will describe how we went about recovering and developing this missing aspect of her Self. But first, I would like to review a set of key concepts in AEDP (Part III picks up on page 12).

Part IIOverview of AEDP theory and methodology

6 Key concepts in AEDP

1. AEDP is a non-pathologizing model that works with trauma and attachment trauma (Fosha, 2000, 2021), from a fundamental understanding of psychopathology as a result of aloneness in the face of overwhelming emotions and as the by-product of internal working models born out of insecure attachment experiences. The AEDP therapist’s first task is to foster secure attachment from the get-go, and to employ interventions to undo this kind of unbearable

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aloneness. Through its attachment-based approach, AEDP “places the therapeutic relationship front and center in its mission to heal relational trauma and transform the Self” (Piliero, 2021, p. 269). The AEDP therapist ́s genuine affective engagement and responsiveness is crucial, and the stance brings forward the therapist ́s deep warmth and genuine care for the patient.

2. AEDP has a strong foundation in developmental research and research on transformational affective change processes. From this knowing, the “doing” of the therapy is based on the moment-to-moment tracking of the phenomenological manifestations of affective experience, in the patient, in the therapist, and in the interaction between patient and therapist (Fosha, 2021). This approach not only serves as a foundation for developing secure attachment, but also encourages mutual openness for exploration, trust in the process, and creates a space for the patient to discover and build trust in their own innate (unbroken) capacity to heal and grow. The moment-to-moment tracking helps to identify “subtle and not so subtle nonverbal cues of affective shifts” (Hanakawa, 2021, p.107) in the patient, therapist, and dyad. These phenomenological shifts are what therapists base their interventions on.

3. AEDP is oriented toward healing, guided by the foundational principle that healing is an innate, wired-in, biological process, ever present in all of us (Fosha, 2021). Transformance is AEDP ́s term for the innate motivational drive to heal, self-right, and flourish (Fosha, 2008, 2017a). The concept of ‘honoring defenses’ is crucial to the therapeutic process, involving the recognition and respect for the adaptive functions that the patient’s psychological defenses have served. This approach together with the understanding that there exists in all humans a fundamentally integrative neurobiological core self (Fosha, 2013, 2021) are important guiding concepts in the work of helping the deeply neglected patient come out of their emotional isolation.

4. AEDP fundamentally focuses on experience. It is a mind-body therapy that works “bottom- up,” with an intensive focus on present-moment, internal experience, and the felt sense of affective experiences as they arise in the body during the here-and-now of the therapeutic encounter. In doing so, the AEDP therapist strives to “make the implicit explicit and the explicit experiential” (Fosha, 2021, p. 33).

5. The use of the therapist’s Self (Lipton, 2021) together with the focus on “making the implicit explicit and the explicit experiential” are key interventions in the work of helping the neglected patient take in/receive new experiences.

6. A key component of AEDP methodology is its innovation of Metatherapeutic processing, or metaprocessing – the processing of positive affects or changes for the better. It helps the patient solidify the change they have experienced. A frequent refrain in AEDP trainings is simply, “First, you must have the experience, but then, you must also know that you have had the experience.” When working with deeply neglected patients, we can add, ‘and, you must be able to take in the new experience.’

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The phenomenology of the four-state transformational process

The process of healing and change unfolds through four distinct states, each with its own unique phenomenology. In AEDP, these have been mapped and tracked to guide the therapist—and is known as the phenomenology of the four-state transformational process (Fosha, 2009). I will illustrate each of the four states with Ellie’s process.

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The Phenomenology of the Four-State Transforma5onal Process in AEDP, Including the Maladap5ve Affec5ve Experiences (I.e., the Pathogenic Affects and the Unbearable States of Trauma5c Aloneness)

Copyright 2020 by Diana Fosha

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Patients often enter therapy in State 1, connected to their suffering. Often, the emotionally isolated patient enters therapy with no connection to either their suffering or to who they are. Only a vague yet pervasive sense of not being well.

In State 1, side by side with the suffering and its manifestations, there are manifestations of transformance. Transformance is described by Fosha (2008), as “the overarching motivational force, operating both in development and therapy, that strives toward maximal vitality, authenticity, and genuine contact” (p 292). These manifestations or glimmers of transformance indicate that the client’s inherent drive for healing and growth is already at work. The therapist’s role is to help nurture and amplify these transformance glimmers to facilitate a softening in the defenses or an opening to the isolation, which can lead to a State 2 experience.

In the process with Ellie, I intuitively sensed that her “muteness” – instead of being a sign of resistance or pathology – was one of those glimmers of transformance.

State 2: Adaptive Core Affective Experiences AND Maladaptive Affective Experiences

State 2 refers to the phenomenon that occurs when defenses are lowered, allowing the patient to access their affective experiences. State two consists of two categories of affective experience – core adaptive experiences and maladaptive experiences.

Core adaptive experiences are: “categorical emotions of sadness, anger, fear, joy, and disgust; coordinated relational experiences; receptive affective experiences; intra-relational experiences and their associated emotions; attachment strivings; somatic ‘drop-down’ states; experience of agency, will and desire; and authentic self-states” (Fosha, 2021, p. 44).

Maladaptive emotional experiences, such as toxic shame, fear, and unbearable aloneness, lack adaptive action tendencies, cannot be processed, and are not inherently transformative. They require transformation, which sometimes leads therapists to leave the maladaptive field of experience too soon. However, I want to emphasize that the maladaptive experience is still crucial – it holds the neglected truth and a split-off part of the Self, and the maladaptive experience might, for the neglected patient, be the (yet) only ”road” to their inner emotional life. Without being recognized, witnessed, and felt in the presence of a safe Other, the split-off divided self cannot be unified, and the True Self cannot emerge. This is where the journey— from ”no self to core self”- must begin. As SueAnne Piliero describes it, “It’s here, in these deep, dark, shame- and terror-filled, warded-off places within the human psyche, where the deepest healing needs to take place” (Piliero, 2021, p.274).

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Intra-relational Parts work is a vital therapeutic intervention when working in the realm of State 2, particularly when working with maladaptive affective experiences. Parts, or child parts, are fragmented aspects of the Self that haven’t been integrated due to deficiencies in early attachment with caregivers. This approach helps the patient develop a new understanding of themselves, recognizing that their feelings and beliefs about themselves or others can stem from old memory feelings (parts) of unprocessed (and/or unformed) experiences, and discern the old from what is happening in the here and now.

The understanding of “parts” is crucial in the work of ‘finding’ the wounded Self. The wounded Self often emerges as an image of a younger Self, ‘the little me,’ as it did for Ellie, who found her wounded Self as a dirt-covered, barely alive little girl in the mud. When given the space, the creative and resilient right brain can begin to work its magic, showing us what happened (the wound), and what needs to happen (to heal the wound and develop the emergent Self). Androff and Russell (in preparation) term these spontaneous images “emergent imagery” and describe how they can occur “unscripted.” Emergent imagery that occurs within right brain-to-right brain communication is an entry into both affect and the unconscious.

In the session transcripts I will demonstrate my use of these techniques. The transcripts will demonstrate the necessity to engage in extended work with State 2 maladaptive affect with Ellie before she could enter the transformational and healing realm of State 2 adaptive affective experience. Simply said, the patient needs to know they have a Self, and have a felt sense of that Self, before they can feel about, and for, the Self.

State 3: Transformational Experiences (feelings of mastery, pride, mourning the Self) and State 4: CORE STATE and The Truth Sense

State 3 is characterized by the emergence of the transformational affects associated with experiences of healing, transformation and/or change for the better (Fosha, 2021, p 45). It ́s about taking in, deepening and expanding the experience of change or healing that the patient just went through.

State 4 is the phenomena emerging when the patient finally has access to the true core self The fears, doubts or forces against accessing the True Self have been transformed. This state is characterized by a deep sense of calm, clarity, and coherence within the Self.

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Introducing new triangles and expanding State 2 workState 2 work between maladaptive affective and adaptive affective experience

AEDP is a model, not a method. The work is grounded in the moment-to-moment tracking of fluctuations in the experience of the patient, dyad, therapist, and process. We track the felt sense of affective experiences as they arise in the body in the here-and-now of the therapeutic encounter. The therapist uses these fluctuations to guide the choice of intervention (Fosha, 2021, p 31). I want to emphasize the importance of this focus on following the patient and the process. Nothing more effectively enhances the patient’s sense of agency than the experience of being continuously responded to. One of my patients, when reflecting back on the process, exclaimed: “It (the model) really followed…WE followed my body. Not even I knew…it just emerged kind of. It feels like such a beautiful model – to be able to follow from inside what you didn ́t even know existed.”

According to the same principle, the AEDP therapist uses the four-state transformational process as a map, not a manual (Kranz, 2021), where the phenomena guide and orient the therapist as to whether they are on the right track with any given intervention. These distinctions make AEDP an open space for development and exploration. It was by following the phenomena that occurred during these processes, that I was able to identify some new patterns that enhanced my understanding of attachment trauma and of what can be developed within the therapeutic relationship. The patterns occurred in State 2, between maladaptive and adaptive experience. Between, because it happened in a state of openness to new experience (”Self at best”), not in maladaptive affective experience, but still many steps to go before reaching core adaptive affective experience.

The new triangles:

Through tracking the phenomena that occurred, along with my own and my patients’ experiences of the process, two triangles of experience gradually emerged that correspond to two phases of this expanded work in State 2.

Figures 1 and 2 (below) illustrate my therapeutic work within each phase of State 2: The Triangle of Finding and Rescuing the Self represents Phase 1 work. The Triangle of the Emerging Self represents Phase 2 work.

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PHASE 1. The Triangle of Finding and Rescuing the (Wounded) Self. ”Do I exist?”

In this phase of the process, glimmers of the truth are unfolding. The patient begins to recognize and accept that ‘something happened (or didn’t happen) to me,’ followed by the realization that the neglect did not reflect upon the patient, but upon the parents’ deficit – in the words of a patient, “It wasn’t me who couldn’t form an attachment; it was them, my parents, who couldn’t.” The patient also begins to understand that the initial false self- attribution of fault or deficiency was a necessary survival measure to protect the attachment bond to an insufficient caregiver. These realizations are necessary for the patient to begin to fill in the missing parts of self. Delineating a separation of Self from the qualities of the caregiving one received (or didn’t) is, in and of itself, an undoing of pathogenic shame.

The work is about tolerating the previously unbearable truth – of ‘nobody there’, and/or, of having been used as a surrogate (Russell, 2021). It’s a beginning step in the process of separating the True Self from the neglectful caregivers. The survival strategy – to preserve the attachment bond at the expense of the True Self – was necessary and adaptive back then, but in the here and now, it prevents the individual from being who they are, by compromising the inborn ability to feel, communicate, and connect (Frederick, 2021, p 190).

This part of the process entails “feeling the holes.” As one patient described: ”It was like an unfolding, it was painful, about finding the wound. I didn ́t know where we were going, and it went on in the darkness.” Even though the patient can be processing deep core state experiences and having deep insights about their wounds and its consequences, they may not necessarily be solidly in the core affective adaptive area of experience. They may be close to

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Finding, forming and transforming the Self Medbo, A. 15 shifting to the next part of the work but the patient may still have one foot in emotional

isolation.

For example, one patient had an experience of seeing straight into the ”split” inside. She stated, “It ́s actually about a splitting. I had to split myself. Split-off the truth. I never saw it like that before.” She saw the split-off part of her truth while feeling the deep pain of what the splitting had done to her Self. The realization of the splitting marked the beginning of ability to her bring the parts of the self back together. This moment of realization gave rise to a profound core state experience, wherein she declared, “ I saw my soul!” Although being in a deep and clear Core State experience, there was no release of adaptive action tendencies and no emergence of resilience. This was a glimmer (or sparkle) of her True Self, but she still had one foot in the emotional isolation while beginning to sense the first vulnerable feeling of truly existing in her own right.

PHASE 2: The Emerging Self. ”Who am I?”

The patient is now ready to take the first steps out of emotional isolation and experiences glimpses of a new felt sense of being free to be who they are. The focus of therapy is now about “birthing,” developing and exploring the emergent Self. The patient who described the ”unfolding” in phase 1 describes her experience in phase 2: “It was like the same unfolding, I didn ́t know where we were going, but it was now going on in lightness”. The process is about “filling the holes” and forming the unformed experience.

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Finding, forming and transforming the Self Medbo, A. 16 Being “on the other side.” “This is who I am.”

Once the felt sense of existing and the right to be who one truly is, has been sufficiently integrated, there is a shift in the process when the patient finally enters the adaptive affective field of experience. These experiences are now transformative, and the processing of (adaptive) emotions to completion can begin. Different patients have similarly described this shift with words like: “This is the first time I experience that what we are doing is healing.” They describe emergent experiences of resilience, and they start to report a sudden emergence of memories of (traumatic) situations and relationships that previously lacked meaning. But now, when seen through “new eyes” these memories become deeply clarifying and further explain the depth of the wound and the emotional isolation. AND through the new access to their core emotions and the truth of what happened to them, the old trauma memories can now be processed to completion.

PART IVEllie: working within the new triangles – between maladaptive and adaptive experience

At the beginning of therapy, Ellie was intensely focused on not losing my attention. She wasn’t yet ready to risk feeling anything within herself. However, beneath her focus on me, in the moment-to-moment tracking, I began to notice a more subtle reaction from Ellie—barely noticeable moments of freezing or going silent in response to my mis-attunements or misunderstandings2. Through my recognition of and taking responsibility for these ruptures (micro-ruptures), Ellie slowly began to develop a budding sense of having boundaries that were recognized and respected. This marked a beginning in the ”filling the holes” in the development of her Self.

With this growing, yet fragile, sense of a boundaried Self, she could start to articulate what her freezing or going silent was about. She explained, “She (referring to her child part) gave up, she didn’t feel understood.” Together, we realized that, at this stage of development, Ellie needed me to understand her perfectly. Although her adult part understood that perfect understanding was impossible, she couldn’t stop her automatic disengagement, or “giving- up,” when she felt misunderstood. Her need in this early phase of the development of her Self resonates with the amazing quote from Winnicott in a 1949 paper, “…. in the development of every individual, the mind has a root, perhaps its most important root, in the need of the individual, at the core of the self, for a perfect environment” (Winnicott, 1949, p. 247).

In the same paper Winnicott also claims that the need for a good environment, which is absolute at first, quickly becomes relative. The ordinary good mother is good enough. If she is good enough, the infant becomes capable of compensating for her deficiencies through mental

2 Tronick & Gold (2020) found that in typical healthy parent-infant pairs, on average, 70 percent of the interactions are out of sync, 35% out of tune, 35% seeking to restore coordination.

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Finding, forming and transforming the Self Medbo, A. 17 activity or understanding and develops a growing tolerance in relation to both “ego needs and

instinctual tension” (Winnicott, 1949, p 246).

Ellie’s need to be perfectly understood and her declaration of “giving up” was an act of “mental activity and understanding” from the core of her SELF, marking the first step in developing her sense of self, separate from me/the other. It was an early form of differentiation, saying: “I have a need that isn’t understood by YOU.” A first experience of being *I* with you, rather than an I submerged in “you”, or a differentiated true “we”.

All these “giving-ups,” combined with my active efforts to reconnect us, formed the essential foundation for the development that later took place. Ellie needed these repairs, “in the countless moments of interaction,” to “fill” in one of the earliest holes in the development of her Self (Tronick & Gold 2020, p. 39). Tronick & Gold found that without the opportunity to move through disruption to repair in early interactions with caregivers, infants develop behaviors consistent with sadness, withdrawal, or disengagement. They also observed that these infants seemed to struggle with holding themselves together – “either their movements were disorganized, or they collapsed and became very still. Both responses suggested that they felt helpless and ineffective.” These findings explain Ellie’s fear of losing my attention (as if losing my attention meant “there would be no way back”) and her later “giving-ups,” which stemmed from a place of having no expectation of repair. But/AND the ”giving-ups” were, in themselves, a development of her ability to stay present in her own experience and a new step of differentiating her Self in the relationship with me. And they didn ́t become toxic because I took them as signs for the need for repair.

When Ellie finally reached the adaptive affective field of experience, she explained in a session: “I ́ve realized that I ́ve started to tolerate the fact that you don ́t understand me perfectly.” Beyond being an incredible testament to her growth, it also clarified what we had been doing and why. It embodied two of the three organizing principles for development of attachment described by Beebe & Lachman (2000) – ongoing regulations, and disruption and repair of ongoing regulations. The third organizing principle: heightened affective moments (Beebe and Lachman, 2002), later became integral to the process of building the Self as Ellie’s receptive affective capacity increased.

PHASE 1. Working in The Triangle of Finding and Rescuing the Self: two case vignettes

Case vignette 1: Meeting patient at Phase 1; Finding and Rescuing the Self phase, glimmers of core, spontaneous Self.

When I first meet Ellie, she is in her late 20s. She is seeking therapy due to a profound sense of not belonging and a fear of social situations. She hasn’t been able to complete any studies and recently resigned from her latest job due to her social anxiety. Ellie can’t share much about her past, other than that her parents divorced when she was 8 years old. Her mother

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struggled to cope with the divorce, and when her father met a new woman, her mother became deeply depressed. Ellie mentions that her mother is emotionally cold and rejecting, and her father emotionally distant, with little capacity to be present for his daughter.

This vignette illustrates the first part of the process, the finding and rescuing of the Self. Ellie is still not connected to her suffering, nor to who she is. There are glimmers of contact with her core Self but with frequent slips into maladaptive patterns. Ellie alternates between withdrawal and struggling to stay connected. Shame and fear easily take over. She is deeply afraid of feeling anything within herself. Although she has come out of her muteness, it is still difficult for her to talk, to stay with, and share her own experiences. We will see how challenging it is for her to allow anything to emerge from within herself, and how terrifying and shame-inducing it is. However, by holding the space and inviting her back, and with her effort to stay present both in herself and with me, we eventually reach some precious moments of contact with her core, spontaneous self.

We will observe how my intention and persistent focus is on encouraging any part of HER to come forward, while also holding space for the difficult experiences. It’s important to note that I recognize both the glimmers of emergence AND the painful truth of what is holding her back—the lived but unfelt reality of nobody there, of not being seen or heard, and the experience of her BEING as something dangerous. I want to emphasize that my acknowledgment and holding of these two aspects of her Self—the wounded Self and her True Self, and the ”unbearable pain that lives between the two” (Piliero, slides, 2020)—are what finally allow Ellie, even for a brief moment, to feel seen, not alone, and safe enough to allow a glimmer of her emergent Self to appear.

THERAPIST: Just let yourself land [Inviting and encouraging patient to be in her own experience]

PATIENT: Mmmm (some confusion or hesitation in her voice, while nodding, nodding, nodding)

THERAPIST: Give yourself some time and space… Space for yourself. You are here for your sake. WE are here for your sake. We are doing something important [Holding the space for her to be in herself and confirming her right to be here and to be present in herself]

PATIENT: Mmmm (chuckles, nodding, still some hesitation in her voice)

THERAPIST: And I ́m wondering, [Invitation to explore] where are we? In this important thing. Where are you in it? It ́s controlled by you, from within you. Or we WANT you to lead (from inside) and then sometimes I take the lead to help you (patient nodding)[Entering Phase 1; Triangle of Finding and Rescuing the Self]. So, if we try to find our way into you [Inviting her, holding the

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Finding, forming and transforming the Self Medbo, A. 19 structure, clarifying our work, holding space for anything that would like

to come out from within her.]

PATIENT: Yes, needed! [Receiving therapist ́s invitation to help, taking a step into the new; Finding and Rescuing Phase]

THERAPIST: Yes, I ́m doing it right now to help you check inside where you are at right now

[Helping her stay on track. Balancing, moment to moment, between leading/guiding and following her.]

PATIENT: Yes (nodding, nodding)

THERAPIST: I don ́t want to take over but I want to help you……[Clearly communicating therapist’s own mind and intention to make her more accessible to the patient.]

PATIENT: THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT:

Yes (nodding, anxious breath).

Do you need some extra help today? [Offering a ”helping hand”]

Yes, I think so [green light, she wants the help]

Completely ok. Some days it ́s just more difficult [Normalizing to lessen shame reaction.]

Yes (yes now means ok) (nodding)

To find the way in…deeper inside. I think, last session, we were talking about that it has started to happen things ”out there.” You described you can see you have developed, or are growing… or that you understand more about yourself?[Linking to last session, reminding her about that new things ARE happening and giving her a menu to choose from.]

Mmm….(nodding) Both?

Yes both (smiling) Oh no my good (looking away, anxious sigh) Yes. No… Yes [She takes a step forward; one more step into Phase 1. Puts words to her own experience which immediately activates shame and fear; slips into maladaptive field.]

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PATIENT: THERAPIST:

PATIENT:

THERAPIST:

PATIENT:

THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST:

PATIENT:

No (shaking her head, arms doing a gesture showing how uncomfortable she is) [gives up, shame reaction takes over]

You don ́t need to know (yet) but something is happening?! (patient beginning to tear up) You are feeling something? (patient nodding, nodding) What are you feeling? (care and tenderness in therapist ́s voice) [holding space; mirroring, platforming, offering organization to her disorganized experience; Inviting her back to area of Finding and Rescuing her Self]

(patient looking away, crying, deep sigh) Oh but….no., I think… No but…sad [glimmer of core feeling, glimmer of finding her Self]. Oh my god, ahhh [One more try to put words to her experience, she is struggling hard, shame/fear takes over again; back into the maladaptive experience.]

Just stay a little with the sadness (patient nodding). Let the sadness have a space here. In you and here with me [Holding space for her feeling and reminding her of that I/therapist is here to help her; offering direction because the patient needs it in this moment.]

Mmmm….No. Yes. No…. (looking away, deep sigh) I think it ́s just…Yes. Just….no I don ́t know. [Struggling, shame/fear comes in the way.]

Yes try! It is…? [Pushing her gently]

I think…no (looking away) [struggling, giving up]

What do you think? Even if…[Therapist’s persistence communicates her desire to know the patient and the patient’s mind; that she is important, and so her feelings, thoughts and reactions are also important]

yes (looking away, chuckles)…

…it gets wrong we can change direction. [Therapist tenuously letting her know that she will not give up on her/the patient and giving her some space to ”play” with it]

Yes. (hands in front of her face) Yes. I do know that. Actually [In contact with the part who trusts therapist and a glimmer of a true sense of her Self; a moment of amazing organization and coherence, in the new experience, of finding her Self]

THERAPIST: Yes. But even if you know it in your head it ́s something inside that has a hard time now [therapist feeling “the hole”]. And we want to be with the hard (as well) (patient nodding, looking away, crying) [patient feeling the hole]. It ́s

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PATIENT: THERAPIST:

THERAPIST:

PATIENT: THERAPIST:

THERAPIST:

okay to wobble as much as you need. To go back and forth (patient crying, nodding) [feeling the hole] So, you think something! (patient nodding and chuckles) [Letting patient know she will not leave her alone with the hard, and then helping her to move on]

Mmmm

And it ́s difficult to bring forward what you think? [feeling the hole] (patient nodding)[feeling seen in her hole] Because you are so unused to being met in what you think. Being heard (patient nodding, nodding)[feeling seen in her wound]. Is that why it gets so difficult? (patient nodding) [Seeing and understanding her struggle and linking it to the historical roots. Making meaning of the struggle and undoing of self-blame; filling in some of the developmental holes.]

And it is telling us so much about how massively it must have been, how much you were met by that (patient gaze upward, nodding)[feeling seen in her wound]. That ́s why it still so hard, even though one part of you now knows… has some trust that I will not react as your dad or mom (patient nodding, looking in therapist ́s eyes, short smile)[glimmer of relational safety with therapist] And no matter what, we need to do this until you CAN do it. That ́s why we are here. It ́s extremely heavy and painful…for you.

Mmm (nodding)

But I feel that I WANT to be here and want to do this over and over again, because I WANT you to be able to feel free to BE (you). And I have patience. We can do it over and over again (patient nodding and still crying). [Pushing with my/therapist ́s genuine wish and will to be there for her.]

This feels like such a deeply meaningful building. It IS happening things out there now. Which you understand has to do with ”this” (the work we are doing together). And we are now so deep inside of you, into what is the very beginning of something new. To be a SELF. And every now and then we take a trip back to the old to understand one more level about what WAS. Sometimes you are in the new, taking new steps and it ́s scary and difficult. and it ́s just so NEW and lately we have also taken steps back to (patient smiles, a very short smile)….(into the old). [Reflecting back the process, how I/therapist experience it and understand it/guiding her/us in the process, holding space for and recognizing emergence]…what ́s the smile about? [Something happened, a shift, patient smiled, and therapist reacts immediately to hold space for and nourish this fragile little ”gift”, glimmer of core self; in Phase 1, Triangle of Finding and Rescuing the Self]

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PATIENT:

THERAPIST:

PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT:

THERAPIST:

PATIENT: THERAPIST: PATIENT:

THERAPIST:

I don ́t know. No, but yes… [struggling, now without giving up] That you say it…or that you see it. Or yes. [feeling seen/found, both feet now in area of Phase 1; finding and rescuing the Self]

That I see it…make you? You smiled. [This is so emergent. Therapist assumes patient having no capacity to deepen the sense of feeling seen yet. So, just trying to help her stretch the moment of being in contact with something new and core.]

Yes.A quick smile. You were happy? (patient nodding, one hand upward as to try to

hide her face)Yes. Oh my god. Yes (looking away, nodding) [Struggling but staying with

the ”yes” to the experience of being happy.]

What makes you happy? If we help you stay with it one more while, it ́s so important.

I don ́t know. Yes… (chuckles, looking away) Then…. I am not alone…if you…see it. (looking into therapist ́s eyes) Yes… [Feeling seen, now deepens to a new experience of not being alone; Huge statement — I am not alone, a moment of experiencing being found]

No, exactly. And right now, your body takes it in. It ́s so lovely with these little smiles. It ́s so good! Your body is reacting, right? (patient smiling, tearing up again) [Still holding the space for what emerges. Therapist reflects back what she witnesses and feels is happening in the moment, focusing on patient ́s body to help her stay in the experience]

Yes.

Is it okay that I see it? [Inviting her response to therapist ́s reflection]

Yes, really! Yes, it is. I just think it ́s a little hard because I guess it ́s about that it ́s not yet completely okay. (looking away, crying) [the new good experience is a “chock” for her psyche] Yes. No. [Daring to reveal her ambivalence, glimmer of some resilience]

Could it be about that it ́s both, that…? You are moving back and forth, it ́s not okay, some shame there and at the same time, you CAN let your body be spontaneous and express it and I ́m seeing it. It feels SO real and genuine…

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PATIENT: THERAPIST: PATIENT:

THERAPIST: PATIENT: THERAPIST: The process

and there is some deeper closeness between us, and you are there, you are taking it in, and then you leave it for a while and then back in it again. And it ́s exactly where we need to be. It ́s here where it ́s happening, right? We are doing something new. That you didn ́t get when you grew up. I and you. There you are, the spontaneous you.

Mmmm

Just as you are.

Yes, it feels like that. It ́s like when you compare it with an infant. It FEELS… like that…I mean they are doing like that…I mean. [The chock has been regulated and the new experience is now in the foreground; Phase 1, Triangle of Finding and Rescuing the Self]

Yes!Kind of give you a little smile.Yes, and that ́s so in the here and now. So present. So genuine.

For an extended period, the work continues in this manner. In retrospect, I understand that we were engaging in ongoing regulations, and rupture and repair of ongoing regulations. Ellie needed me to guide her back to herself repeatedly, over and over again.

She still can’t share much about her childhood, but there are two scenes we can use to gain a better understanding of what happened – and what “didn’t happen” – to her. One scene involves the 8 years old Ellie, who, frightened by a dream in the middle of the night, asks her mother if she can get into her bed. She is allowed to get into the bed, but she senses the terrifying truth, that her mother is not psychologically present; she feels completely alone in the world. The other scene involves the 10-year-old Ellie, who often fantasized about being adopted, riding her little bike to a woman in the neighborhood who made her feel seen. One day, when she returns home from her bike trip to the neighbor, she is met by her father, who says, “What are you doing? The neighbor woman doesn’t want kids running around in her garden.”

This experience left Ellie in a state of deep shame, which not only prevented her from seeking attachment with the woman in the neighborhood but also stopped her from fantasizing about being adopted. The shame kept her from going against her father, in order to “maintain the (secure) connection with her primary caregiver at all costs” (Frederick, 2021, p. 192). In therapy with me, she gradually began to recognize and accept these behaviors and fantasies as

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adaptive strivings and a form of transformative strength. The shame she felt for longing for different parents is slowly transforming into a new understanding – an acknowledgment of both the deep lack of emotionally available parents, and the strong inherent drive of the little girl to keep seeking what she intuitively knew she needed.

This understanding opens the door to her wounded self. In a profound session, she finds her inner child, represented as a dirty figure, barely alive in the mud. In deep pain, she expresses, “I never realized I was this damaged.” This experience leads to a profound sense of relief. Discovering her wounded self allowed her to feel ”found” – meaning, ”maybe I do exist.”

Through working with her younger parts, we begin to distinguish the present from the past and separate the child part from the adult part. Ellie needs my support and deep care, although it is still difficult for her to fully accept it. But I trust the process. Two years into the therapy, she says, ”This is the first time I hear you,” and a year later, she dares to look me in the eyes for the first time. Even though she cannot verbally respond to my attempts to be there for her, I understand that she IS receiving my listening and acknowledgment.

Levels of undoing aloneness – pushing with connection

The only way to come out of emotional isolation is through relationship. There is a beautiful quote from Alan Sroufe, “Before there is a self, there is relationship… and it is from that relationship that the self emerges” (ISC International Conference, 2021. David Elliott). Through the work presented in this article we could add or make a distinction, saying: “In the beginning there is a neurobiological core self (Fosha, 2000, 2021) in a need of a perfect environment (Winnicott, 1957)….and it ́s (then) from the influencing and being influenced by a good enough environment (Pally, 2005) that the FELT SENSE of a differentiated whole self emerges.” Working relationally “tends to reactivate insecure attachment learnings” (Frederick, 2021, p. 194), especially when working with the isolated self who never experienced a good enough environment. Karen Pando-Mars (2016), states that the AEDP therapist ́s offering of relational accompaniment to the insecurely attached patient can actually escalate the discomfort and increase the defensive strategies (p.23). The patient who has learned not to BE will require significant support to tolerate and take in the genuine connection with the therapist, gradually overcoming the painful reality of unmet needs, disavowed feelings, and unprocessed memories (Frederick, 2021). At times, we need to gently guide or actively help these patients toward connection.

Case vignette 2: Expanding receptive affective experience of being seen, intrapsychic focus (still in Phase 1: Triangle of Finding and Rescuing the Self ). A heightened affective moment.

In the next vignette we jump a bit forward in the process. I intuitively felt that Ellie needed to use me more, to feel my being with her, for her to be able to take the next step in her

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development of self. I was “feeling the hole in her,” the lack of someone to lean on, the fear to BE and having her needs met. I use my therapist Self, self-disclose her impact on me.I tell her tenderly, while looking her in her eyes: ”I ́m here for you. When you are sad, I want to comfort you, when you manage to do something new, I feel delighted for your sake. You have an impact on me. Our interaction awakens feelings in me for you.”

Although this intervention is about helping her take in her impact on me and my deep care for her, it still needs to become an intrapsychic experience. She needs support to begin accepting and stop fearing the care and love she never received and stopped seeking during early childhood. This process is about increasing her receptive affective capacity and activating her attachment/seeking system -the beginning of “filling the holes.” It is through the felt sense of being “in the heart and mind of another” (Fosha, 2000, p. 57) that the (felt sense) begins to emerge. If you have never felt seen or cared for, you may struggle to feel you exist or care for yourself. And as McCullough (2003) states, “Nothing that isn’t received can be processed!” Ellie needs help to internalize and feel her own experience of having an impact on me.

This vignette illustrates my interventions to maintain the focus on her internal experience while helping her regulate the overwhelming emotions that arise at the edge of what her psyche can tolerate.

THERAPIST: Feel into it [Inviting her to feel, having an experience to my/therapist ́s words]

PATIENT: (Nodding, anxious breathing) Yes exactly.

THERAPIST: Just close me out if you need to while feeling it in yourself. [Encouraging her to connect to her own experience. So important in this phase of finding her Self to give space for her own experience.]

PATIENT:

(Nodding, crying, anxiously sighing) Yes exactly. Yes. I ́m getting so over …overwhelmed. I just need to… (moving her arms and hands downward to regulate the strong emotion, a movement she has seen me do many times to dyadically regulate her emotion) [She is imitating therapist, a beginning of internalizing therapist ́s care and comfort; Being on the edge of new experience/a heightened affective moment, close to her window of tolerance]

THERAPIST: You are doing it [Championing her for doing it and encouraging her to stay attuned]

PATIENT: I just think this is so BIG [Regulating the experience by putting words to it]

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Finding, forming and transforming the Self Medbo, A. 26 THERAPIST: It ́s so big. Yes. I understand that. So, just take it in this little. [Helping her to

PATIENT:

THERAPIST:

PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT:

stay with it by titrating experience]

Yes (nodding, gaze upward)

Keep me outside to be able to feel it inside of you (yourself). We exercise your capacity to take it in. And you need that [Guiding her and giving space for her own experience]

Mmm. yes. (nodding, crying briefly)You kind of get an injection now, and it ́s a little painful. [Regulating by being

playful, encouraging her to move on, psychoed ”a good pain”]

Yes (nodding, still crying)But it is good. It will protect you. Yes

It will help you grow. So just stay with it, just in YOU (yourself). Close me out, and just feel into what ́s it like inside of you… to get all this from me… [again, a very important intervention of intra-psychic focus in this phase of the process with a patient who never had the space to BE herself]

But…mmm ohhh.Just a little [Titrating and encouraging her to stay with it]

Yes. exactly….ehm. I think it calmed down a bit [Coming out of the affective wave]

THERAPIST: So, when you felt it (how was it?) [Processing/metaprocessing the experience]

PATIENT: It just came….was super super super super-strongly… It kind of felt like a volcanic eruption in my body, and I think [hesitating, some anxiety for expressing such a strong feeling]

THERAPIST: because you think…? Volcanic eruption is about something is coming up…[Encouraging her to keep on going.]

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THERAPIST: PATIENT:

THERAPIST:

PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT:

Yes, let it come out…in words. [gently pushing]

Yes. I just realize you helped me understand what actually happens… I didn ́t…I haven ́t taken in all that you do, kind of. I have just blocked it. I think I felt like this is not anything that I can receive, kind of. I ́m not worth it…actually [metaprocessing her experience of receiving therapist ́s care and feelings for her; naming the shame/ felt sense of unworthiness rather than acting from it/ manifesting it]

So, what was this volcanic eruption about. [Asking for more specificity.] This is so hard, so difficult for you, but I ́m here. [Affect regulation, undoing aloneness] It ́s SO difficult but you can back off whenever you want. [Inviting her agentic self, reminding her that SHE can change the intensity.]

Yes

But like you said….you haven ́t been able to take it in. You need my help to take it in. [Framing the work/the process, seeing and owning her need of therapist]

Yes really.

So, what was the volcanic eruption about? [Helping her back on track]

I think maybe an insight about…

A deep insight. Together with a feeling… an experience? [keeping it emotional, experiential]

Yes. Yes…About?About? [She loses the thread, short moment of dissociation]The experience, you said an insight. [Helping her back to her experience] Yes.About what?

About that we… That… That we ́ –r–e…doing….it. (Grimacing, all facial muscles engaged.) [Patient struggling hard, fighting for letting out her own experience]. Oh I ́m sorry… [apologizing, wanting to take it back] But, yes.

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Maybe an insight about that we ARE in contact [Inner fight is over. Now talking with clear voice, standing up for her own experience of BEING and of being in contact with therapist. A short moment of having a relational core experience in Phase 1: Triangle of Finding and Rescuing the Self. It is not possible yet to deepen experience]

PHASE 2: Entering The Triangle of theof the Emerging self – between maladaptive and adaptive affective experience.”

There is now a clear shift in the process. Ellie is beginning to have new experiences of presence within herself and with me in the room. In one session she expresses, “This is the first time I feel connected to myself AND to you at the same time.” She is safe enough to be vulnerable in a new way. It ́s the beginning of “feeling and dealing while staying related” (Fosha, 2000). Ellie experiences tremulous affects3 for the first time and realizes that ‘fear can be a good fear.’

Once I was equipped with Russell’s insight that “neglect, exploitation, and oppression of any kind leave holes of development of self” (Russell, 2021, p.244), I was able to understand the nature of the support Ellie needed from me in order to take a next, new and very important, step forward. My understanding helped to undo Ellie ́s shame for “not knowing how to do it.” Instead of believing that her feelings and behavior result from her own inadequacy stemming from defensive personality characteristics, she could now understand them “as a response to what, for most of our evolutionary history, would have meant actual death” (Sieff, D. F, 2019, p. 30). Most of all, that “the holes” are not who she is. This is the “essence of resilience,” as defined by Russell as the “self’s differentiation from that which is aversive to it.” (Russell, 2015)

Through my understanding, she began to recognize and accept that the absence of a space to BE during her childhood, and of what she had to sacrifice (her felt sense of being) was the only means of survival. It was at the level of ‘life or death, you or me.’ Later in the process, when Ellie finally entered the healing phase of her journey, she could see things with “new (adult) eyes” and shared a deep truth she had not been able, nor dared, to reveal before. She spoke about how her mother had used her as an extension of herself, and the mother’s disappointment and subtle punishments whenever Ellie expressed her own self/identity. We now understood how Ellie had learned not to BE, and how this had prevented her from developing her own self, instead creating these “holes.” My understanding represented another step in the process of undoing her aloneness.

3 Tremulous affects in AEDP refers to emotional states characterized by feelings of vulnerability, uncertainty, or shakiness that arise when a patient begins to experience positive emotional shifts or transformations. These affects often occur as the patient starts to connect with more adaptive emotions or begins to feel new, unfamiliar feelings of growth, healing, or connection (Fosha, 2000).

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The next case vignette illustrates how the patient’s deepened connection with her own needs opens for a next step in the differentiation of her Self from her (internalized) mother. This is what is needed for Ellie to finally take her first step out into feeling she exists in her own right and that she can be and exist, have her own needs and wishes, without anybody else breaking.

PHASE 2: Triangle of the Emerging SelfCase vignette 3: The birthing of a whole and differentiated Self.

Ellie is now entering into the next phase between maladaptive and adaptive affective experiencing. She is developing and exploring the Emergent Self, and taking the first steps out of isolation, into a felt sense of existing.

The following vignette illustrates Ellie’s imitation of me as a first indicator of her emergence from a maladaptive into an adaptive affective experience. The imitative gestures might have been interpreted as a demonstration of a maladaptive state, but this behavior is now emerging as an expression of her unformed self. It is a precursor to the developing differentiation of Self through a deeper connection with her own needs and emotions.

The vignette illustrates the deep and moving breakthrough session in which Ellie, for the first time, experiences that she exists, has a felt sense of existing. She describes a physical experience beginning in her upper body and then spreading down through her whole body. It’s like a kind of birth, where I guide her through it – not just with verbal interventions but also by using my body and movements.

I wasn’t aware of my participation in this part of the nonverbal interaction until I reviewed the session afterward. It is then that I suddenly recognize a new phenomenon in the nonverbal interaction. Ellie is imitating my movements several times, in the way infants do. Meltzoff and Marshall, known for their research on infant imitation, argues that imitation in infants is not just a demonstration of memory but also a sign of the infant’s ability to understand and internalize the actions and intentions of others. It’s an adaptive function that enhances learning and survival, and it is used for social-communicative purposes. They state that through imitation, infants become like us. (Meltzoff & Marshall, 2018)

The emergence of the imitating phenomenon in the nonverbal communication with Ellie reinforces the idea that nonverbal communication is ”remarkably similar across the lifespan” (Beebe & Lachman, 2018). It also highlights the power of relationship and the innate drive to heal, grow, and develop aspects of Self that never had the opportunity to be nurtured when provided with the “right circumstances.”

The vignette demonstrates two main interventions. One is to support and help Ellie stay with, deepen and expand the emergent felt sense of her needs and will. Ellie experiences for the

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Finding, forming and transforming the Self Medbo, A. 30

first time a transformational spiral, i.e. the experientially processing the experience of transformation, giving rise to yet another round of transformational affects (Fosha, 2021). The stretch and deepening of the felt sense of her needs and will, along with the right to them, deepens into core state experience of “This is who I am. I take responsibility for my Self, and this is who I want to be.” As this experience of Self lands sufficiently enough there is a sudden opening in the process of becoming separate in the relationship with her mother. She can for the first time feel two feelings at the same time. In next step she can be angry at her mother without the fear that her mother will fall apart. From this new space of being separate from her mother she is now open to take her first steps into the felt sense of existing.

My second intervention is to emotionally, verbally and nonverbally guide and support Ellie ́s becoming/birthing while taking her first steps out of emotional isolation into existing by using my therapist Self and my body to support. WE are now level by level filling “the holes” in the development of her Self.

THERAPIST:

PATIENT: THERAPIST:

PATIENT: THERAPIST:

PATIENT: THERAPIST:

PATIENT:

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So, your words, “I needed it and now I have the will…” [State 2 Core affective experience, patient connected (for the very first time) to her need and will. Phase 2, Core affect still emergent], what does it feel like? To hear yourself, your own voice, say that. [Slowing down, helping patient deepen and stretch experience, metaprocessing and deepen felt sense of her own need and will]

Yes (smiling). That I needed it, feels very nice to say. [Patient in a dropped down open space, reaction of post breakthrough affects]

So just stay with that. [Slowing down, help to stretch, expand and install the experience]

Mmmm (gaze upward signaling taking in her own experience)“I needed it,” just feel what it feels like. [Repeating her words to help her

take it in one more level]

YesJust like suck in that feeling. To be able to say “I needed it.” [Staying with and

deepen experience]

Yes (short moment of gaze upward again) It feels, in a way, that I ́m standing up for myself. [State 2 expression of agency, will desire; the experience of the agent self, still in Phase 2; Birthing of the Self]

Yes! [Delighting in the patient’s new sense of Self with the right to BE]

Finding, forming and transforming the Self Medbo, A. 31

PATIENT: THERAPIST:

PATIENT:

THERAPIST: PATIENT:

THERAPIST:

PATIENT: THERAPIST:

PATIENT: THERAPIST:

PATIENT:

THERAPIST:

And it is very very nice. [ Spontaneously metaprocessing experience]

What does that feel like in your body to stand up for yourself? Stay with the feeling, describe it, own it. [Slowing down, helping patient stay with and expand the experience]

(Chuckles) I ́m feeling more competent or kind of more grown up. Or this is who I am, I take responsibility for myself. [State 2: desire/ will for self. This part can begin to dream]

Yes!It ́s very nice. It ́s what I want. I want to be like that (swallowing, signaling

tremulous affects) [Expanding the experience of desire/ will for Self]

Yes. So just stay a while more in the feeling. Feel into it, breathe it in. Let yourself feel it in your whole body. [Holding space for the patient to stay with, deepen and expand experience]

(Short moment of gaze upward, swallowing, struggling to stay in this new experience) Yes.

If it ́s possible. [Tracking] To feel “I needed it.” You are saying it, that you are standing up for yourself. [This is so new; Therapist wants the patient to stay with experience and giving space for more to unfold. Therapist feels the birthing and holds the space for it to unfold]

Mmm… Yes, absolutely. [Green light]Be with yourself and just feel into the experience. [Giving space for her own

experience.]

Yes. Absolutely. It feels very calm. It ́s a kind of calmness (imitating a movement with her arms I use to do to help her calming down) Like this…this is what I needed. [The very new experience of being connected to her core needs, will and desire is landing]

Yes. It ́s just so clear and right (recognizing patient holds her breath) Breathe. Don ́t hold your breath (gentle, soft voice). [Inviting patient to be even more fully in her body]

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No exactly. It ́s good you remind me (chuckles while taking a deep breath) [Saying yes to Therapist ́s guidance and recognition]

Finding, forming and transforming the Self Medbo, A. 32

THERAPIST: I can feel in my body, for your sake, how nice it is. [Self-disclose to make Therapist ́s connection explicit and being with her in the new that is happening]

PATIENT: Yes.THERAPIST: I needed it! [Repeating her words again to hold the new emotional space

PATIENT:

for her]

[Shift gears, the new experience of connection with her needs gives rice to a new force to separate her needs from mother ́s needs] Mmm…. In a way… you can be angry and at the same time understand (the other/mother). It ́s as if I…I don ́t think I have allowed myself to feel it fully. That it can be… it can be two feelings… that it can be two feelings at the same time [The new core experience of her agentic Self opens for emergence of resilience and a new experience of differentiation, a new letting go of the need to protect the (M)Other]

THERAPIST: And it can be ONLY about anger too. [Therapist mis-attunes, misunderstands patient, things go too fast for therapist here]

PATIENT: Yes.THERAPIST: But it sounds like it ́s important to you to have some kind of understanding.

PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT: THERAPIST:

[Therapist beginning to get it]

Mmmm

Of your mother, but (you) are angry.

Yes.

AND are angry, not “but.” [Now therapist getting it right]

Yes exactly.

And are angry. [Repeating to let the patient really know “I got you”]

Yes.

So, what does that feel like? To be able to feel two feelings at the same time.

[Metaprocessing experience. Therapist back on right track]

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Exactly. [Confirming being at the same page again]

Finding, forming and transforming the Self Medbo, A. 33

THERAPIST: PATIENT:

THERAPIST: PATIENT:

THERAPIST:

PATIENT: THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST:

PATIENT:

To let it be like it is.

Yes. Yes exactly. I ́m laughing at myself… (laughs a little nervously) [some light shame or embarrassment comes online, or/and some tremulous affects]

Why? (tender voice)It ́s maybe because it gets a little uncomfortable. Ehm… [Owning her

reaction, while now knowing that “fear (tremulous) can be a good fear”]

So just keep the laughter to the side. (Make a sweeping motion with my arm showing, keep the shame to the side) [Helping her put the shame to the side]

Yes. Yes exactly (chuckles)It ́s a lighter kind of shame, isn ́t it? Yes. Precisely (chuckles).

Keep it to the side. Take your self seriously. [giving space for her new being in connection with her core Self, helping her back to the new experience, back to the area of Phase 2; birthing the Self]

Yes. Yes exactly

This is new.

Yes. Yes really (taking a deep breath signaling relief)

So just feel it in your body what it feels like to both understand and be angry at the same time. [back to experience, help to deepen experience]

Yes exactly. Yes precisely. [patient present in her body again]Breathe it in. Let it be. [helping her to deepen experience and stay in her

body]

Yes. Really. Yes, it is… very nice. Because it feels like I can….I actually think it is the very first time I feel… I can be angry (tears in her eyes) [post breakthrough affects]

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Finding, forming and transforming the Self Medbo, A. 34

PATIENT: THERAPIST: PATIENT:

THERAPIST:

PATIENT: THERAPIST:

PATIENT: THERAPIST:

PATIENT:

THERAPIST: PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT:

I mean without…ehm… (hesitating)Without what? [Encouraging her to move on]

Yes. Ehm… I think I have been just so… I have felt mom being so fragile and that made it difficult to be angry. It ́s difficult to be angry at someone who is fragile. [Separating the fear and protection of mother from her feeling of anger]

Yes, very difficult. Especially when it ́s your mother who “holds” your survival

[honoring defenses]

Yes. …

That is what she should have done. When you are a child that ́s how it should be.

Yes. Yes. Really (eyes upward signaling taking in)……Yes

So again, what does it feel like, for the very first time, to feel you are angry, without being scared she (mother) will get destroyed? [metaprocessing the new experience]

(clear voice, no tears, no chuckles) Yes, just that! I really don ́t feel it now. What I feel now is more like “okay, this is my feeling,” that ́s how I….[The naturalness of core state when something that was voluble gets integrated; no longer disruptive or unnatural]

wow [Silent wow to not interrupt the patient ́s experience.] feel. And it ́s my right to feel it. [Declaration of Self]Yes!And…yes…ehm… nothing happens to the Other. [New truth] No!

Ehm…because it ́s my feeling. (Chuckles) Yes. So just keep away the laughter.Yes. Yes [reconnecting with her experience]

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Finding, forming and transforming the Self Medbo, A. 35 THERAPIST: Yes. Breathe it in! This is SO important [”drawing” her back to her

PATIENT:

THERAPIST: PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT:

THERAPIST:

PATIENT: THERAPIST: PATIENT:

experience]

Yes really. Yes, I agree. This will make it easier. very much so (gaze upwards, chuckles)

Yes!ehm…to just….yes [Wobbling]To be who you are. [Helping her back to trusting her experience] Yes exactly. Exactly. With all my feelings. Yes. [Reconnected]Yes. Without anybody else breaking. [Repeating her new truth] Exactly.Just breathe. This is so important. [Helping her stay with experience] Yes. Yes really.And nothing dangerous happens.No really not. Really not.Nobody breaks [repeating her new truth]

And it ́s really at a much lighter level. I think it ́s now more… I breathe a little fast and hold my breath a little. I ́m feeling like I ́m here! (chuckles, swallowing, small sense of tremulous affects) [Deepened experience of presence]

I ́m feeling that too. That ́s why I want to help you do it one more bit. Because then it gets even freer. [Moving my/therapist ́s upper body as an invitation to reinforce my/therapist ́s words; This is one of the movements that Ellie later will imitate]

Mmm. Yes, exactly. Yes really.And you feel it for the first time. [Framing her experience and what we do] Yes exactly. Yes really.

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Finding, forming and transforming the Self Medbo, A. 36 THERAPIST: Let it land… [Holding the space, therapist feeling something new and big is

happening]

yes exactly…

in your body.

Yes. And I feel it ́s the first time I feel it in my whole body. That it ́s ok, it ́s true…ehh [patient in a deep new experience, apparently moved, shivering]

What does it feel like in your whole body right now? [Therapist feeling deeply moved by the patient ́s new openness and wants to help deepen the bodily experience]

I think it is….even though…but it IS a huge calmness (doing the calming down movement with her arms again). I mean…ehh. I DO feel I own it, kind of (clear voice) [Emergence of agency]

Aahhh (wow) (moved, in awe) Yes…ehh

It ́s landing, for real. In YOUR body. (Therapist using her arms to mirror the landing) [Mirroring and sharing therapist ́s experience of what ́s happening in the patient]

Yes.

and it ́s calm.

Yes.

So, what does it feel like to be YOU right now? [Inviting patient to deepen the experience of existing]

Mmm.Can you feel…do you feel you exist? [tracking]

Yes absolutely. It just feels so much lighter. Ehm…I kind of feel quite free from here (showing with her hands that she can feel free from belly and up). And up. But I feel in the other part… I still feel….(Chuckles, tears in her eyes) [On the edge, tremulous affect]

PATIENT: THERAPIST: PATIENT:

THERAPIST:

PATIENT:

THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT:

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Finding, forming and transforming the Self

Medbo, A. 37

THERAPIST: PATIENT: PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT: THERAPIST:

PATIENT:

Feet on the floor [regulating tremulous affect] Yes, exactly.It feels so str….[Tremulous affect]strange?

Yes

Just because it ́s new. [Naming and regulating tremulous affect]

Exactly, precisely.

So do it in small steps so it doesn ́t get too much. This is SO good. Do you get that? [Titrating experience]

Yes.

You feel it, don ́t you? [Tracking]

Yes absolutely.

So let it land here. Breathe it in and feel like a new platform here. [Mimicking patient ́s hands showing that she can feel free from her belly and up]

Yes.Do you feel it?Yes absolutely (crying)

You exist to here (belly and up). [Therapist not focusing on patient’s tears. Just holding patient in the big experience and inviting patient to deepen the felt sense of existing]

Yes exactly. I ́m feeling quite free up here (upper part of the body, imitating the movement she saw therapist do a little earlier, chuckles and grimacing, tears in her eyes) and then…I don ́t know I guess it ́s something that still blocks it a little that makes it…

THERAPIST: (smiling tenderly, deeply moved, tears in her eyes) Yes, but….

PATIENT: So ,I don ́t dare to do it fully (still crying)Transformance: The AEDP Journal Volume 13 ©AEDP Institute 2024

Finding, forming and transforming the Self Medbo, A. 38 THERAPIST: Does it feel okay to do it just a little, little bit more? [Encouraging her to

move on]

PATIENT: Yes. Yes absolutely (present, calm)THERAPIST: So, feel your feet on the floor. [Therapist letting her own feet sliding on the

floor]

Yes. Yes.

You have no shoes on, very good. Let your feet slide a little on the floor so that you feel your feet. [Inviting her feet to be felt, doing the movement to join patient in her experience]

Mmmm They exist.

Yes precisely (gaze upwards, taking in feet exist) Yes, they do. Oh, my god, I ́m sorry. Yes, they really do. (crying, chuckles) [On the edge, tremulous affect]

Mmm. Yes, do it this little. Hold it thin. [Titrating, regulating tremulous affect]

Mmmm

It ́s a very big feeling. [Confirming that this is big]

Yes precisely. Yes exactly.

And you can feel it to here. (Hands on belly)

Yes. So…I just think I ́m getting moved. I think it ́s just about that. [Dropping down, State 3 experience of being moved, healing affect]

Aaahhh. [Slowing down, responding tenderly to patient ́s reaction]that makes it…yes.So just stay with that feeling right now. [Helping her stay with healing affect] Yes absolutely (gaze upward, taking in healing affect). Ehhh

PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT:

THERAPIST:

PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT:

THERAPIST: PATIENT: THERAPIST: PATIENT:

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What moved you? [Specify experience to deepen and stretch]

Finding, forming and transforming the Self Medbo, A. 39

PATIENT: I think I ́m moved because you are, kind of, helping me. And ehhh…yes. yes. Yes precisely. [Wobbling, helping herself back to experience, validating experience; initiating the validation of relational experience and connection]

THERAPIST: I ́m too very moved [Slowing down, self-disclose, staying for a while in a mutual experience of patient ́s new capacity to take in being helped]

PATIENT: Yes. It feels absolutely that it ́s possible [referring to her own new experience of existing]

THERAPIST: Yes, you are doing it now [focus again on patient ́s intrapsychic experience]

PATIENT: Yes exactly. And…eh

THERAPIST: (having a sense that patient doesn ́t know where to now go) So, is this the first time you feel you exist? [helping her back to the big new experience]

PATIENT:

THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST:

PATIENT: THERAPIST: PATIENT: THERAPIST: PATIENT:

(gaze upward) Yes, I think so. In the whole of me [in it again, expansion of experience]

Wow [silent voice to avoid disturbing the patient in her experience] It sounds so crazy! I ́m feeling a little insane. [Tremulous affect]

Yes, but we understand… I do understand it fully [Normalizing tremulous affect]

Yes

It ́s about the felt sense of existing. You needed to close it down, freeze it, the connection with your Self.

MmmYou are not insane…no… (taking a deep breath)you are just doing something that is very big and very right and like finally! Yes really! Ehm

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Welcome into life, kind of.

Finding, forming and transforming the Self Medbo, A. 40

PATIENT: Yes precisely (smiling, calm again) THERAPIST: YOUR life

PATIENT:

THERAPIST: PATIENT: THERAPIST:

PATIENT: THERAPIST:

PATIENT:

(gaze upward) Yes exactly. Yes, thank you [receiving therapist ́s welcoming her into life]

If you again…

yes…

feel into your body. Do you still feel it ́s blocked here? Or do you feel it a bit more? [tracking, inviting her back to the experience in her body]

Mmm. it feels…yes. Yes exactly. Yes, I do feel it a little more. Yes. I do feel iin my whole body [landing in a whole experience of existing in her body]

We have now been here for a long time. This might be the sign of…this enormous expansive experience…. the experience might have come to an end. So now we can maybe just embrace it, the experience and what happened here today [Recognizing an end of the emotional wave, holding patient and helping her to embrace the big, shared birthing experience]

Mmmm. Yes… [imitating therapist ́s movement, hesitates, let her arms fall]

THERAPIST: Yes, do it. It can be nice. To embrace yourself and keep yourself a bit together

[Encouraging her and validating her new connection with Self and the birthing of Self-care]

PATIENT: Yes, my god. Yes, it IS coming more and more…now I ́m feeling… I ́m feeling more and more comfortable

This vignette illustrates how Ellie, now feeling safe enough in her emerging Self, can release her early survival strategy of protecting her mother. Her emergent Self is established enough for her to face the truth and see both herself and her mother as separate individuals. Letting go of the early insecure attachment bond to her mother, and the need to prioritize her mother’s needs, frees her from the necessity to sacrifice her own needs, her Self, and her existence. This allows her to enter a new space where her unique Self can begin to fully exist, and this newfound freedom activates the early adaptive function of imitation, one of the most important interactive features for learning and survival (Meltzoff, 2017).

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Finding, forming and transforming the Self Medbo, A. 41 Conclusion

In this article I explore and illustrate the use of a fine-tuned AEDP stance, and the benefit of following the phenomenology in work with emotionally isolated individuals. Commitment to the AEDP stance and to tracking the phenomenology through AEDP’s moment-to-moment processing has led to my insights and opened new areas of work in State 2 and in between maladaptive and adaptive State 2 phenomenon. The transcripts demonstrate that bottom-up processing, i.e., nonverbal, right brain-to-right brain, moment-to-moment experience, (balanced with left-brain understanding), promoted Ellie’s agency and built her relational capacity to trust in the therapeutic process and in our innate capacities to BE, as well as to be together. Additionally, it is a demonstration of Fosha’s assertion that this approach fosters motivation for both therapist and patient to explore and learn. She states, “Phenomena keep us humble and always learning” (Fosha, 2021, p. 31).

By closely tracking and staying grounded in moment-to-moment experience, I was able to learn, experientially, what Ellie was asking for and needing from me, and what interactions she best responded to, especially during when she couldn’t convey her experience in words. AEDP’s foundation in infant research helped me to identify when she felt met by me, and to identify markers of growth. For example, I recognized that her imitation of me was a form of communication rooted in our evolving secure therapeutic attachment, indicating she was in the earliest stages of developing her sense of Self. In fact, all the phenomena that occurred when Ellie was given intersubjective space informed my understanding of the work, and what needed to be identified, felt, and developed.

The new triangles I presented in this article, The Triangle Of Finding And Rescuing The Self and The Triangle Of The Emerging Self, represent an overall formulation of how to find, form and transform the unformed Self within the AEDP framework. It is not until a felt sense of existing, of being as one’s True Self, is sufficiently established that the healing and processing journey can begin. It ́s an experiential journey in depth, and in many, many steps. Like one of my patients so beautifully explained, “Everything contributed to this (the birth of my Self). Every single word, every feeling…every single tear.”

When I asked Ellie, now finally in the adaptive affective realm of experience, what it felt like to feel whole, she answered, “It feels like I have become a person.”

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Finding, forming and transforming the Self Medbo, A. 42 References

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Fosha, D. (2021). ”We are organized to better than fine”: Building the transformational theory of AEDP 2.0. In Fosha, D (ed), Undoing Aloneness & the transformation of suffering into flourishing (pp. 377-414). American psychological association.

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