Transformance Journal Volume: Volume 6 Issue 1

Editor’s Letter: Ideas for Getting Unstuck

By Gil Tunnell, PhD

Gil Tunnell

As exemplified in the previous Transformance  issue on applying AEDP to couple therapy, AEDP is continuously expanding, not only with new techniques and paradigms presented in this issue, but rapidly expanding all over the world. An international issue is in the works.

As I read these papers one last time, I realized that four articles focus on techniques to help AEDP therapists when we get “stuck,” i.e., when we reach an impasse where AEDP therapy is not working the way we think it should. In this issue, Jerry Lamagna presents his intra-relational parts model within an AEDP frame (he has a three-DVD set of training tapes available on this website).  Hilary Jacobs Hendel writes about the judicious use of touch in AEDP (after she had submitted her article here, The New York Times in March 2015 published her article describing AEDP entitled, “It’s Not Always Depression, Sometimes It’s Shame.”  This article generated much interest in AEDP and led to Random House offering her a book contract.  This Fall, the Times published another article by Jacobs Hendel, “The Healing Power of Hugs,” which is relevant to her article here).  Both Jacobs Hendel and Lamagna utilize portrayals and “parts work” yet offer very different approaches to working with pathologic affects and undoing aloneness.  Also in this issue, Judy Silvan discusses the use of body movement in AEDP to unblock energy and core affects.  Hans Welling offers a delightful short read on how he addressed an issue most of us have experienced: therapist impatience.   Up close and personal, he describes his own impatience as an AEDP therapist and the steps he took to “self-correct.”  He offers guidelines to the rest of us impatient folk.

Also in this issue, David Mars continues his expansion from individual AEDP, to AEDP with Couples, to his two-day innovative Community Healing Workshop.  On the second day the couple he has treated is live on stage, interacting with an audience of therapists who are empathic and supportive as they bear witness to the couple’s growth.  (A three-DVD set of this workshop held at Seton Hall, NJ (Training Set 2) is available on this website.)

Finally in this issue, I review Eileen Russell’s masterful new book, Restoring Resilience, which greatly expands the concept of resilience and teaches us how to capitalize on it at each stage of AEDP treatment.   Although neither Mars, Lamagna, Jacobs Hendel, Silvan nor Welling explicitly use the term resilience, there are numerous implicit examples in their case transcripts of unearthing resilience in their work with individuals and couples.


Expanding the Ordinary to Extraordinary: A Review of Eileen Russell’s Restoring Resilience

By Gil Tunnell

Restoring resilience:  Discovering your clients’ capacity for healing.  By Eileen Russell.  New York: W. W. Norton., 2015, 356 pp.

Eileen Russell’s new book Restoring Resilience is a major contribution to the psychotherapy literature. It is the best professional book I have read in a long time.  Rich in new, jargon-free theory and filled with clinical vignettes that illustrate working with different forms of resilience, the author begins with a comprehensive review of the literature on how clinicians, philosophers and poets have thought about resilience (later she cites relevant research on resilience, mostly on children). Russell is clear from the start that she is not talking about the everyday, ordinary notion of “resilience,” but rather a multi-faceted concept that manifests itself in different ways at each stage and state of the therapeutic process.

Russell believes resilience potential is hard wired yet needs to be nurtured and practiced.  First and foremost, she writes that resilience always operates “on behalf of the Self,” whether it exists in its more restrictive mode that results in defensive functioning (in the service of survival and protection of the nascent Self), or in its fully expansive mode such as in transformance, Fosha’s (2008) seminal concept of the individual’s hard-wired striving for healing, growth and expansion of Self.  Early in the book, Russell says that the “essence of resilience is the Self’s differentiation from that which is aversive to it” (p. 5).  This seems to be a simple sentence the meaning of which, frankly, I did not grasp immediately. Later I came to understand how and why Russell defines resilience this way: Her definition encompasses the complexity of resilience in all its facets.  Indeed, our therapeutic efforts might be described as attempts to help the patient minimize, mitigate and sometimes mute the parts aversive to the Self.

Although Russell’s ideas on resilience can be useful in any psychotherapy approach (from psychoanalysis to cognitive behavioral therapy), Russell applies it primarily to Accelerated Experiential Dynamic Psychotherapy (AEDP, Fosha, 2000).  She “slices and dices” the concept of resilience in a number of ways relevant to AEDP.  Taking a long view, she describes the arc of resilience as it appears in the stages of treatment when the patient is in different modes of functioning:  “self-at-worst” (resilience as “potential”), “self-in-transition” (resilience as “promise”), and “self-at best” (resilience as transformance/“flourishing”).  Similarly, Russell maps resilience onto each of the four intra-session AEDP states (defense, core affect, transformational affect, and core state).

More than demonstrating what resilience looks like in its various facets, Russell describes numerous clinical interventions that can be used to nurture it.  In my view, this is why the book is so important: The author goes beyond helping the reader identify resilience in all its forms, but provides explicit clinical interventions appropriate for cultivating each form.  For example, in early treatment, she writes that it is insufficient simply for the clinician to note the patient’s resilience privately or even share his thoughts on the patient’s resilience with the patient. Instead, Russell invites therapists to get curious about resilience, become more adept in spotting it, get the patient curious about it, and, together with the patient, mine it and bring it into the light.

Russell notes that resilience is implicitly embedded in Fosha’s concept of transformance (“the overarching motivational force operating in both development and therapy that strives toward maximal vitality, authenticity, and genuine contact,” Fosha, 2008, p. 292).  Russell goes to great lengths to explain that resilience is also present in its more buried form in the patient’s defensive functioning in real life and shows up in therapy in State One AEDP as resistance, the polar opposite of transformance.  Resilience in the resistance means that, although the patient is interacting with the therapist in “top of the triangle, self-at-worst” mode—defensive, oriented toward basic survival and protection, preserving the status quo and conserving energy that might be better put toward enhancing growth—the patient has nevertheless shown up asking for help (resilience potential) and is actually doing the best she can do, struggling in a compromised mode of “self-at-best-under-difficult-circumstances” (my phrase). Russell cites interventions designed to harness the patient’s resilience potential in State One (see below for examples).  Finally, in keeping with the idea that transformance strivings are always present even in the resistance, Russell seems to be saying that if the parts aversive to the Self can get out of the way, both resilience and transformance can come on board full throttle.  Of course, that is the work of therapy.

Many of us in AEDP make some positive statement of affirmation to a new patient at the end of a session, sometimes pointing out how well he coped in surviving difficult, often traumatic circumstances.  Russell goes beyond affirmation:  While acknowledging the wounded-ness that made defenses necessary, she helps the patient isolate and identify “the part” that doesn’t want to shut down (the resilience potential).  In early State One work, she is particularly empathic, doing what she calls “pressuring with empathy”—“the explicit use of the therapist’s emotional reaction, more specifically the explicit self-disclosure of her own feelings of compassion, warmth or appreciation, to help the patient feel at a deeper level” (p. 94, originally cited in Russell & Fosha (2008), p. 181).

In contrast, interventions around resilience in later treatment (when the patient is in States Three and Four, experiencing transformational affects and core state) are qualitatively different.  Here the patient is often feeling positive affects (joy, gratitude, mastery). Yet many patients have trouble “taking in” such positivity.  Russell suggests we linger and hang out there. To help healing truly “sink in” and deepen, therapists should metaprocess these feelings, e.g., “what’s it like to feel the joy,” and “to experience the joy with me.” In short, we should not view the positive feelings as a mere by-product of good treatment.

In traditional insight-oriented therapies, resistance is the primary avenue the therapist utilizes to help the patient gain insight into his defenses and thus develop his full potential.  These therapies confront and interpret patient’s defenses under the premise that once defenses are no longer needed and conflicts resolved, the patient will “somehow” thrive based on the insights achieved. (Russell reviews research that demonstrates this outcome—insight leading to growth—so often does not occur.)  In contrast, Russell and AEDP, while recognizing defenses, nonetheless try to bypass them and instead focus from the get-go on the patient’s resilience and transformance drive. Rather than strip away defenses, which, after all, are learned and acquired, we provide the patient a more “bottom up” experience, capitalizing and building upon the individual’s innate resilience and transformance drive.  It seems to me that building up “the good stuff” that’s already there might be easier and more efficient than trying to extinguish deeply ingrained, tenacious learnings that remain fiercely protective of the Self yet now stand in the way of healing, expansion and growth.  Easier or not, AEDP is almost always a more positive, and less fraught, experience for both patient and therapist.

In summary, it is difficult to capture in a short review all the insights this book offers (e.g., the distinction between resilience potential and resilience capacity, how to work with resilience when the patient is in “self-in-transition” mode when the therapist becomes a “transformational other”).  By the end of the book, Russell has demonstrated that resilience is anything but ordinary. She encourages us to discover and exploit it in all its forms.  Her masterful book Restoring Resilience provides a rich buffet of something for everyone: sophisticated theory, numerous moment-to-moment transcripts, and comprehensive scholarship.  Like her topic, Eileen Russell’s book is extraordinary.


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

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

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


Making Good Use of Suffering: Intra-relational Work with Pathogenic Affects

By Jerry Lamagna, LCSW

Abstract. The unbearable psychic pain of pathogenic affect presents a formidable challenge to AEDP-trained therapists. As an experiential re-iteration of abandonment in the face of overwhelming distress, it sometimes renders patients incapable of engaging interpersonally, thus limiting the effectiveness of dyadic regulation. Because of the overwhelming distress and the dysregulation that results, pathogenic affect is generally seen as a clinically undesirable state that blocks therapeutic change.  In this paper, the author suggests an intra-personal approach to working with pathogenic affect that involves helping the patient shift from a threat-based response to their overwhelming inner experience (i.e. fighting, fleeing, freezing or fawning) to an engagement-based response characterized by “tending and befriending”. This is accomplished by helping patients to differentiate their present day state from the archaic pathogenic one and then facilitating moments of open-hearted contact between them. It is proposed that the affects that manifest from such types of self-engagement (i.e. mutual resonance, recognition, compassion, understanding appreciation and tenderness) constitute a distinct affective change process that when experientially tracked, can be used to fuel and reinforce transformational experiences.


You have heard about the art of happiness, but many of us have not heard about the art of suffering. But there is an art. We can learn how to suffer — how to handle the suffering inside of us . . . and that is an art to be learned. If we know how to suffer, we suffer much less and we can make good use of the suffering. Yes. It is like an organic gardener. She knows that the garbage produced by the garden can be useful, so she does not throw away the garbage. She keeps the garbage and transforms it into compost in order to nourish flowers, vegetables . . . suffering plays an important role in in making happiness . . .

Thich Nhat Hanh (2013)

Accelerated Experiential Dynamic Psychotherapy (AEDP) (Fosha, 2000a, 2000b, 2002. 2003, 2008, 2009a, 2009b; Fosha & Yeung, 2006; Lipton & Fosha, 2011; Russell & Fosha, 2008) is a therapeutic approach that poses particular challenges for patients who struggle with self-regulation. With its emphasis on affective experiencing, it is a model that encourages these individuals to attend to the very aspects of body and mind that have been avoided in order to function. Many well-intentioned AEDP trained therapists have invited such patients to sense into their body, only to discover that rather than the therapeutic response they anticipated, the patient descended into a psychobiological state of hyper or hypo-arousal marked by intense anxiety, shame, cognitive disruption and aloneness. In some such situations, clinicians may discover that the potency of AEDP’s intervention-of-choice for addressing intense affect, dyadic regulation is considerably weakened by the virulence of the pathogenic affect. Mired in this afflicted state, the patient’s receptive capacity becomes too compromised to take in the therapist’s presence, support and care.

In this paper, I will propose an “intra-relational” approach to addressing the challenges of working with pathogenic affects. Here the suggested clinical focus will be on helping patients to “tend and befriend” the pathogenic experience in ways that 1) reinforce contact with the present moment, 2) ease the experience of inner aloneness, shame, anxiety and pain, 3) develop capacities for self-regulation, self-reflective capacity and self-compassion and 4) activate core affect associated with moments of self-to-self resonance, affirmation, appreciation, care, understanding and wholeness. Differentiating from and then approaching one’s inner distress in this manner can offer our patients a new experience (as the Thich Nhat Hahn quote suggests) of turning the perceived “garbage” of pathogenic experience into “compost” for transformation. This is done by helping the dissociated despair, aloneness, pain, anger and hurt from the past to explicitly exist in the heart and mind of the patient (Lamagna & Gleiser, 2007; Lamagna, 2011; Gleiser, 2014).

AEDP: A Model for Transformation

AEDP is an integrative model of treatment that blends relational, psychodynamic and experiential treatment approaches with a metapsychology informed by affective neuroscience and attachment theory. Its main goal is to evoke, experientially process and integrate states associated with adaptive affective responses/impulses (“core affect”) —— states that have been blocked from consciousness due to repetitive attachment failure or trauma. The accessing, tracking and re-integration of these core affects serve to activate innate self-righting mechanisms, action tendencies and internal resources that support optimal psychological functioning. In addition, the positive movement engendered through the experiential work fuels additional rounds of processing — this time focused on the felt sense of change itself. The resulting “metaprocessing” (Fosha 2000b) of transformational affects (State Three) like pride, mourning, hope, and gratitude, ultimately brings the patient to core state – an experience of ease, calm, wisdom, and balance (State Four).

AEDP’s views on transformation and psychopathology are very much organized around the polarity of safety/connection —- threat/aloneness. In optimal attachment environments, children experiencing meaningful emotions are able to use their bonds with their caregivers to amplify positive affects and dampen negative ones. Regardless of the valence of the emotional experience, the child ultimately feels some positive affects in having their feelings received and responded to by a receptive and caring other. In pathogenic environments, children’s emotional responses are repeatedly responded to inadequately —— with errors of omission (i.e. neglect, withdrawal, distancing, denial) or with errors of commission (i.e. physical or emotional punishment, blame, ridicule) (Fosha, 2002). There is, in effect, a recurrent pattern of ruptures to the attachment bond — ruptures that do not get repaired adequately, if at all.  Fosha (2002) writes:

These disruptive reactions on the part of the attachment figure . . . elicit a second wave of emotional reactions: fear and shame, the pathogenic affects (Fosha, 2001a). What should feel good ends up feeling bad; whereas transformational affects motivate further emotional experience, the pathogenic affects spur the exclusion of emotional experience (p.13).

In other words, in AEDP it is the distress of one’s experience plus the absence of the regulating other (“unbearable aloneness”) that together give rise to most forms of environmentally-based psychopathology (Fosha, 2000; 2002).

Fosha has suggested that years later, when these individuals enter therapy and connect with categorical emotions like sadness, anger, fear and joy or with longings for interpersonal connection, they are conditioned to also feel some form of pathogenic affect as an experiential re-iteration of earlier disruption-without-repair experiences. For most psychotherapy patients, the arousal of emotion triggers mild to moderate levels of inhibitory affect (shame or anxiety) called “red signal affects” which in turn, trigger defense mechanisms that preclude the activation of deeper, more distressing emotions. In some patients however, accessing emotional experience brings on intense forms of unbearable psychic pain (Fosha, 2002).

Described with terms like “self-at-worst” and “compromised self” in AEDP literature (Fosha, 2002; Fosha & Yeung, 2006), pathogenic states are viewed as being nonconductive to change-for-the-better and are therefore to be mitigated (“undone”). This is most often achieved through the therapeutic relationship where as in healthy attachment, inner distress is soothed through direct contact with a safe, caring, supportive other (Lipton & Fosha, 2011). AEDP work here involves explicitly tracking the felt sense of the therapist’s presence, empathy and care and its moment to moment impact on the patient’s state. This quintessential AEDP approach offers the patient the possibility of counteracting the pain, shame, anxiety and unbearable aloneness of pathogenic experience with a new corrective experience.

However, several problems can arise when employing this approach. First, there may be times when the patient’s psychic pain is too acute to allow for meaningful interpersonal contact. Second, while relationally counteracting pathogenic affect can offer a new healing experience, for patients who have difficulty internalizing the therapist, it may not offer much help in dealing with their psychic pain between sessions. Skillful AEDP therapists need to learn different ways of approaching pathogenic affects in order to best respond to what is emergently occurring for the patient.

Intra-relational Affective Change Processes    

Intra-relational (I-R) AEDP is a variant of AEDP originally developed for clinical work with severely traumatized patients (Lamagna & Gleiser, 2007; Lamagna, 2011). Its aim is to promote a patient’s sense of inner safety, security and harmony and (as in standard AEDP) to evoke core affective experiences that promote adaptive psychological functioning.

Working with affective change mechanisms engendered through intra-relational work, clinicians and patients experientially process core affects that arise with meaningful contact with inner aspects of the patient —- affects associated with resonance, recognition, warmth, openness, care and compassion (Lamagna & Gleiser, 2007; Lamagna, 2011). And as when processing categorical emotions (anger, sadness, fear, joy) and relational experience, processing core affects related to intra-relational contact propels the patient through additional rounds of transformational work (State Three – transformational affects and State Four – core state). Such moments of positive self-to-state contact can be particularly helpful when working with patients who are not yet capable of tolerating affects related to painful events from the past.

The Power of Differentiation: Moving from Being In to Being With

A sensing and the object sensed, an intention and its realization, one person and another are confluent when there is no appreciation of a boundary between them, when there is no discrimination of the points of difference or otherness that distinguish them. Without this sense of boundary — this sense of something other to be noticed, approached . . . there can be no emergence and development of the figure/ground, hence no awareness . . . no contact.

(Perls, Hefferline & Goodman, 1951, p.118, italics added).

That which we are looking for, is that which is looking.

St. Francis of Assisi

During moments when our patients become consumed by pathogenic experience, there appears to be little differentiation between the felt sense of who they were in the past disruption-without-repair experience and who they are in the present moment. This “confluence” of past and present, as Perls et al. suggest, interferes with their capacity to maintain enough emotional distance to both experience their affective state and reflectively make “contact” with it.

Initiating intra-relational affective change processes begins with the therapist helping the patient experience themselves as separate from the pathogenic affects that threaten to overwhelm them. Techniques drawn from other approaches can be used to foster separation between the patient and their pathogenic experience, e.g., psychodrama (“mirroring” and “role playing,” Moreno, 1997), gestalt therapy (“empty chair,” Perls et al, 1951), psychosynthesis/dis-identification (Assagioli, 1971), internal family system therapy (“unblending,” Schwartz, 1995), and Buddhist psychology (“R.A.I.N technique” – Recognize, Accept, Investigate, Non-identification, MacDonald, 2001).  Moving from enmeshment with psychic pain to differentiation from it creates the conditions for the formation of a dyadic field within the individual and a multi-layered relational field between patient, therapist and the afflicted inner aspect of self (Lamagna & Gleiser, 2007; Lamagna, 2011). Experientially tracking the sometimes subtle changes-for-the-better that occur with differentiation and maintaining the separation are crucial in the early stages of the work.

Clinical Illustration: Intra-relational Work with Pathogenic Affect

Linda is a 60 year old, married, white, female who presented for treatment two months prior to the vignette below. She came to therapy depressed, anxious, “fragile” and on the verge of leaving her husband of 20+ years. This was precipitated by upsetting incidents with her grown stepchildren during the holidays that left her feeling hurt, dismissed, angry and unsupported by her husband. This experience evoked deeply painful feelings associated with her problematic attachment to her alcoholic, emotionally abusive mother, her abandonment by her father while a young child and recurrent relocations during her childhood. As the oldest child, Linda admitted to having a lifelong need to view herself as strong and independent. In order to do this, she dissociated any and all affects associated with pain, loneliness and vulnerable.  This edited transcript of a session illustrates intra-relational affective change processes in the context of pathogenic affect and AEDP’s four-state model of change.

Pt: I don’t know why but I’m terrified. (voice shaky)

Th: Yeah.

Pt: I don’t know why. It doesn’t make sense . . .

Th: Um hmm. You are feeling terror now?

Pt: Yes.

Th: Where in your body? [patient invited to track sensation]

Pt: I was thinking about it when I was driving down here. It’s like a really, really empty stomach if I had to feel it. It’s like a hunger or the opposite . . . like the dry heaves . . . up in here. (gestures to mid-abdomen)

Th: It feels like an empty space?

Pt: Yes . . . hollow.

Th: Uh huh.

Pt: (anxiously) I don’t know why I’m doing this. [defenses come to the fore]

Th: Is it possible that this is coming from a young place —- that this is an old feeling in some ways we are re-experiencing?

Pt: I guess so, but I’m back to the same thing – I’m going through the motions at home . . . Doing everything I’m supposed to keep going. (pause) I’m very surprised by this.

Th: The depth?

Pt: After everything happened (the precipitating incidents during the holidays), I anticipated the mourning of something; the death of something. Someone. Me. (with increasing agitation) I just can’t understand why I’m feeling this so deeply.

Th: Can we just accept for the moment that we are and that we can bring everything to bear to heal this today? Together . . . [encouraging the patient to stay with her experience. Use of “we” and “together” to emphasize my presence, support and willingness to help her regulate her experience].

Pt: (getting more distressed) It just hurts so much. (tears up) It’s still so close — that feeling . . . (pause) and I feel afraid of it.

Th: Yes. Let me help you with that feeling. [Acknowledging her struggle, I again emphasize my readiness to help.]


Pt: I don’t know what I’m feeling. It’s too hard for me (increasingly agitated, gasping with tears in her eyes).

Th: [inviting her to take in my presence so as to initiate dyadic regulation]

Pt . . . can you just check in with me for a second? Can you feel me here with you?

Pt: [She’s not registering me.] It all hurts too much. I miss my mother. (breaks into sobs).

Th: (softly) Yes.

Pt: (sobbing) I missed so much.

Th: (slowly, with softness) Yeah, you did. Keep breathing.

Pt: I keep telling myself I’m doing well. I have this wonderful world around me . . . (sobs)

Th: [For the third time, I try to make her conscious of my attending to her distress.]  Can we work on this together? I really want to help you today.

Pt: (sobbing)

Th: First. Can you check in and see that I’m here with you? [Seeing that the relational option isn’t working, I shift focus.]   See if we can ask this distressed part of you if she would be willing to separate out — just a little bit. And if she won’t, it’s okay. We’ll figure out other ways of helping.  [Here I employ the unblending technique from internal family systems (Schwartz, 1995).]

Pt: I’m just surprised it’s so deep.

Th: Okay. Do you have a sense whether there is a willingness for the distress to step back? Did you feel any shifting in your body?

Pt: I’m just able to breathe. (seems slightly calmer)

Th: [I invite her to experientially track the felt sense of this small positive shift.]  Just notice that you can breathe now. (long pause)  What are you noticing now?

Pt: I just want to know why. (calmer but still employing intellectualizing defense)

Th: The why question isn’t going to get us out of this.

Pt: (laughs nervously) I know.

Th: So ask the why question to move to the side. [looking to bring focus back to body] Check in with your body.

Pt: (sighing)

Th: Is the distress up, down or about the same?

Pt: I can breathe. That’s the best way I can say it. [This is a small but positive shift that would be helpful to seize upon.]

Th: Well, we did ask for breathing room . . .

Pt: (laughs)

Th: Right?

Pt: Yes.

Th: That’s what we got. (pause)

Pt: (tears up)

Th: Some feelings coming?

Pt: (first with derision, then softening) This sounds so soppy! (tearing up) It means I have to trust you.   [Here the patient provides a possible clue as to why efforts at dyadic regulation failed and differentiation is working only marginally at this point.]

Th: Yes, a little bit.

Pt: And I have to trust that I’ll be okay.

Th: Is there in willingness to try trusting me for a few minutes?

Pt: Yes.

Once a sufficient degree of differentiation is achieved (i.e. an absence of defensive or inhibitory responses like self-attack, shame, anxiety, urgency to “fix and forget”, minimization, figuring things out, etc.), the aim is to establish empathic contact between the patient-inner aspect of self. Any and all approach/engagement-based affects like sympathetic sadness, warmth, tenderness, interest, concern, compassion and subsequent associations become the focus of moment to moment experiential tracking. This class of core affects becomes the “fuel” that will propel the patient through additional rounds of transformational work.

Th: Can we bear witness to these old feelings with one foot in 2013? That requires some space here. [Intra-relational work uses distinction in both time and space to assist in the process of differentiation.]

Pt: Um hmm.

Th: Notice how you feel towards her. Someone who wanted love more than anything. See her with your mom over there [I gesture to the chair in the corner of the room to reinforce differentiation/space.] (pause) If it feels like it’s too much, you let me know.

Pt: (pause) It’s sad.

Th: Are you feeling her sad or sad for her?

Pt: Feeling sad for her. [This is a good sign as it indicates current feelings about the past experience rather than a triggering of feelings from the past experience.]

Th: [Sensing differentiation, I encourage empathic contact.] Sad for her? Let her know that and let her know why.

Pt: (patient cries) I’m telling her I want to hold her and rock her.

Th: (softly and slowly) Hold her. Rock her. (pause) We are so sorry it was like this for you.

Pt: I’m feeling . . . (becoming agitated again)

Th: Your feelings or hers?

Pt: Her feelings.   [Here the space between the patient (“I want to hold her and rock her”) and the part of self bearing the pathogenic affect begins to collapse. Differentiation needs to be re-established to keep the process moving forward.]

Th: See if she would be willing to step back just a little bit.

Pt: (crying) This is so hard.

Th: I know it’s hard. I am going to help you through this. See if she is willing to trust you. [empathy and reinforcement of my presence and readiness to help with affect regulation]   All I need is 15 minutes. Are you willing to give me 15 minutes? I guarantee that if you give me 15 minutes, you’re going to be in a different space when you leave here. [I offer this “guarantee” with confidence only because I have seen differentiation work successfully for this patient in a previous session.]

Pt: Umm. (smiling)

Th: Is there a willingness to try?

Pt: (nodding)   [To reduce any additional re-triggering of pathogenic affect, I educate the patient about the goal of differentiation and invite shared reflection on what triggered her shift back to the pathogenic experience.]

Th: About 10 minutes ago or so you told me you were feeling sad for her. And it was your feelings in 2013 about what she experienced back then.

Pt: Um Hmm.

Th: And you felt compelled to hold her and rock her.

Pt: Um Hmm.

Th: And as you started to rock her, what was it that happened?

Pt: It was just me wanting it for myself. It was me wanting to be held. It was me wanting to say “mommy”. [This indicates a merging or “blending” (Schwartz, 1995) with a child state.]

Th: Was it you saying “I’m here”?

Pt: It started out with me saying “I’m here” to her and ended up with me saying “I’m here” to the world (cries)

Th: I see. So when you hugged her, you became her?

Pt: Yes.  [The patient explicitly confirms that she had slipped back into identifying with her younger self.]

Th: Okay. Can she see that when that happened the hug went away?

Pt: Um hmm.

Th: Is she willing to stay separate enough to experience that? She needs to keep all of the pain in her body and allow you to be with her rather than you becoming her. Is she willing to try it as an experiment?

Pt: Um hmm.

Perhaps all the dragons in our lives are princesses who are only waiting to see us act, just once, with beauty and courage. Perhaps everything that frightens us is, in its deepest essence, something helpless that wants our love.

Rainer Maria Rilke, Letters to a Young Poet

Buddhist psychology (Brach, 2013; Kornfield, 2008) and internal family systems therapy (Schwartz, 1995) have observed that compassion, self-understanding and love naturally manifest when an individual achieves a state of differentiation unfettered by defenses, shame, anxiety and in this case, unbearable psychic pain. Like these approaches, intra-relational affective change processes make use of this differentiation from these states form the past to further the process of change. For I-R work, affects associated with interest, openness, tenderness, love, harmony and compassion become the focus of moment to moment experiential tracking. As positive affects come to the fore and are deepened, metaprocessing is employed as well to catalyze, reinforce and integrate the emergent changes in the patient’s relationship to inner aspects of him or herself. Continued processing yields further movement through state three (transformational affect) and state four (core state).

Th: Keep seeing her through your eyes. (long pause). How you are feeling toward her? [This question is employed in internal family systems therapy to assess “self energy” – a state of curiosity, calm and compassion. In I-R, discovering that the patient has entered this open hearted state prompts experiential tracking of affects linked to the felt sense of openness, tenderness, empathy.]

Pt: (softly) It’s too bad. (empathy arises)  [The affects linked to this empathic contact constitutes core affect just as it would if being offered by the Th in relational change processes.]

Th: Yeah. So sorry it was that way for you then. We are here now. We are here now. (long pause)   [After a relatively short time processing feelings of empathy, the patient suddenly moves from State Two core affect to State Three transformational affect.]

Pt: It’s out of nowhere.

Th: Is your heart open or closed?

Pt: Open………..because I admire her.   [The patient moves into feeling a sense of admiration/mastery for having survived the difficult challenges of her childhood —an indicator of State Three: Transformational affect. We track and metaprocess the shift.]

Th: What do you admire about her?

Pt: To keep on going.

Th: Tell her that.

Pt: To have a normal life. To try and separate all that neurotic, sick stuff.

Th: Do you get that she wanted her mother’s love more than anything?

Pt: (slowly) Yeah. Yeah.

Th: Let her know we understand that. It’s normal.

Pt: Yeah. It’s not selfish. (long pause)   I’m okay now. I can see it. I can breathe. It’s not taking my life away. It sounds so dramatic but these are the only words that make sense.

Th: Okay. Let’s go with them.

Pt: It may sound corny but I like who I am. I like how I made it in spite of this. [State Three transformational affects -mastery]

Th: Just notice. Feel that admiration.

Pt: It’s funny. I’ve never been able to think about my childhood without being very dismissive or I guess feeling it so much I couldn’t breathe.

Th: Right. So what’s this like? [metaprocessing of emergent, new experience]

Pt: It feels “handle-able”.  (we both laugh at her new word)

Th: And when it feels “handle-able”, how do you feel towards her?

Pt: I feel sorry but not overwhelmed. I feel admiration, I have to tell you.

Th: Yes!

Pt: I don’t know how I did it.

Th: You feel respect, admiration, appreciation, gratitude?

Pt: Um Hmm. (nods)

Th: What do you feel drawn to do?

Pt: Acknowledge it. All of it. Me. What it really was.

Th: Let’s make room for that.   [The patient shows signs of entering State Four core state as demonstrated by markers like calm, ease, and the emergence of an integrative, “big picture” perspective.]

Pt: I think there is a moment of clarity coming (giggles) I always found myself worrying about what others felt – how others suffered — how it was worse for someone else.

Th: And now? [inviting attention to the new experience of the moment]

Pt: And now  . . . it’s not that I don’t care. It’s just that it doesn’t matter for me. There is nothing I could do about it. And I shouldn’t have that burden.

Th: Can we ask her (the part) what it is like for her to have you and I bear witness to her in this way today? [metaprocessing]

Pt: It makes it mean something. That it is not imagined. And it’s not self-pity and it’s not . . . It is . . . It was.  [The patient sees her pain placed appropriately in the past and as it really was — not through the lens of dismissive defenses and not consumed by the feelings themselves.]

Th: I like your correction. (both laugh). It was, yes. It really was. See how it sits with you to allow that . . .   [inviting attention to the new experience that is unfolding in the moment]

Pt: I don’t have to fix it. I didn’t know I thought that, but I guess I did somehow.

Th: What’s it like to know you don’t have to fix it? [metaprocessing]

Pt: It’s so freeing. For this moment, I can think about it without getting sucked into a hole.  [The afflicted sense of self and associated pathogenic affects now appear to be integrated, neutralizing its negative impact on her.]

Th: What does that say?

Pt: It takes away some fear that I’ve always lived with.   [With the pain neutralized/integrated, the fear and perceived fragility dissipate.]

Th: What’s that like? (pause) What do you get to feel more when there is less fear?  [metaprocessing — attending to the new]

Pt: Stronger.

Th: And in this moment how are you feeling towards her (the afflicted part of herself) and her empty stomach and all that?

Pt: I see it in perspective. It was sad. It was hard. Sometimes it was terrible. Sometimes it was okay (smiles)

Th: Right.

Pt: I still had fun. I still found meaning.  [Again patient indicates an integrative transformation of her pathogenic experience. Good and bad are both there and available as part of her true experience.]

Th: This is big. This is big.

Several days after this session, the patient sent the following email message that indicated that the shift observed in session held:  “This may sound corny but as I sit here listening to the rain and enjoying it, I want to let you know I’m doing well. Churchill said “If you’re going through hell, keep going . . . thanks for helping me through.”


Accelerated Experiential Dynamic Psychotherapy is a clinical approach whose primary focus is on creating the conditions that facilitate change-for-the-better in our patients. Though at first glance pathogenic affects may be seen as a formidable challenge to this goal, the activation of intense pain can also provide an opportunity to heal, accept and integrate heretofore overwhelming experience resulting from chronic trauma and neglect. Intra-relational work does this by differentiating the patient’s past pain and aloneness from their here and now experience, and with the pain brought to a tolerable level, facilitating moments of meaningful connection between the patient and inner aspects of self. This contact, when unfettered by defenses, shame and anxiety, evokes intra-relational core affects associated with self-to-self resonance, appreciation, care, compassion and understanding, which, when experientially processed, fuels the patient’s movement through AEDP’s four state model of change.


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Brach, T. (2013). True refuge: Finding peace and freedom in your own awakened heart.  New York: Bantam Books.

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Fosha, D. (2000b). Meta-therapeutic processes and the affects of transformation: Affirmation and the healing affects. Journal of Psychotherapy Integration, 10, 71-97.

Fosha, D. (2002). The activation of affective change processes in AEDP (Accelerated Experiential-Dynamic Psychotherapy). In J. J.  Magnavita (Ed.), Comprehensive handbook of psychotherapy. Vol. 1: Psychodynamic and object relations Psychotherapies (pp. 309-344). New York: John Wiley & Sons.

Fosha, D. (2003). Dyadic regulation and experiential work with emotion and relatedness in trauma and disordered attachment. In M. F. Solomon & D. J. Siegel (Eds.), Healing trauma: Attachment, trauma, the brain and the mind, (pp. 221-281). New York: Norton.

Fosha, D., & Yeung, D. (2006). AEDP exemplifies the seamless integration of emotional transformation and dyadic relatedness at work. In G. Stricker & J. Gold (Eds.), A casebook of integrative psychotherapy (pp. 165-184). Washington DC: APA Press.

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

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Fosha, D. (2009b). Positive affects and the transformation of suffering into flourishing. In W. C. Bushell, E. L. Olivo, & N. D. Theise (Eds.), Longevity, regeneration, and optimal health: Integrating Eastern and Western perspectives (pp. 252-261). New York: Annals of the New York Academy of Sciences.

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Lipton, B., & Fosha, D. (2011). Attachment as a transformative process in AEDP: Operationalizing the intersection of attachment theory and affective neuroscience. Journal of Psychotherapy Integration, 21 (3), 253-279.

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The Community Healing Workshop:  A Final Treatment Phase of AEDP for Couples

By David Mars, PhD

Abstract.  This paper describes the nature and purpose of a unique new approach to both teaching the AEDP for Couples method and to assist the couple present on stage in the second day of the workshop to integrate and metaprocess the arc of their therapeutic experience.   This integration of AEDP into a large group format of therapists, using the Seven Channels of Experience in I-statements that reflect their internal experience to the couple, gives the couple the experience of being seen, heard and known by a large group of therapists who come to be felt as True Others.  The paper describes the three foundations of the Community Healing Workshop:  AEDP,  Process Oriented Psychology, and the witnessing discipline derived from Authentic Movement.   Process Training Language is introduced with its attention to moment-to-moment tracking and “sliding in time” to cultivate the immediacy of present experience that is very useful in generating safety in group processing,  metaprocessing and guiding healing portrayals in trauma treatment.

Description of the Community Healing Model:

This article describes the two-day Community Healing Workshop I developed for particular couples who are in the last stage of AEDP for Couples treatment.  The unique element of this process is that the couple is live on stage while interacting with a large audience of therapists as the arc of the couple’s transformational journey is shown on video.  The purpose briefly is to integrate and stabilize for the couple the transformative process of their treatment and to offer the therapists a deep experience of the AEDP for Couples model (Mars, 2014), using the seven channels of experience to metaprocess both the experience of the couple and the audience.

On the first day of the workshop I teach the theory and practice of the AEDP for Couples model to the audience, without the couple present.  The audience learns about the seven channels of experience and how to speak in Process Training Language, which is detailed at the end of this paper.  Part of the goal of the first day is to prepare the audience to offer a secure base for the couple when they arrive.  I show video clips of early work with the couple whom the audience will meet the next day.  These clips illustrate key change moments in the initial sessions and give the audience of therapists opportunities to practice I-statements linked to their somatic experience.  This also gives the therapists an exposure to integrating this particular way of perceiving, receiving and expressing in a new way that is applicable to both couple, individual and group psychotherapy.  By the time the couple arrives on the second day, a container of safety has been established that is palpably resonant with the secure base and the manner of accessing and expressing internal experience that I have established in treatment beginning in the first session of AEDP for Couples.

Three Foundations for the Community Healing Workshop:

The first foundation is the practice of Authentic Movement in which the skill of witness consciousness (Adler, 1996, 2002; Pallaro, 1999) is cultivated to access deeply embodied tracking of somatic experience.  I studied Authentic Movement with Janet Adler for ten years and taught Authentic Movement for eighteen years.  This whole-body witnessing is oriented to an individual or a group of Authentic Movement practitioners being held in a deeply respectful and contemplative atmosphere of safety.  The movers’ gestures, micro-movements, body attitude (Birdwhistle, 1970), even stillness is closely tracked by the witness or witnesses, whose eyes and all senses are open.  Any subtle sounds or breath changes are tracked closely by the eyes-open witness(es), as the mover(s) follow their internal movement impulses with their eyes closed without music.  Following the movement period, a spoken witnessing period follows in which the mover speaks first of his or her experience.  If invited, the witness then gives a moment-to-moment account of the recall of the experience of witnessing the mover.  The witness uses I-statements and “shifts in time” (Mars, 2011, 2014) by speaking of “what happens” in the present-tense, reliving and recounting a coherent narrative of his or her experience of the whole range of the mover’s non-verbal expressions during the entire the movement period, whether it lasted ten minutes or two hours.  The language form is specific to the witnesses’ embodied experience and seeks stays clear of positive judgment (praise) or negative judgment.  This language form was strongly influenced by John Weir in the form of speech he named “percept language” (Weir, 1975).

The second foundation of the Community Healing Workshop is the Process Oriented Psychology of Arnold Mindell (1985a).  Many World Work and Process Work (Mindell, 1985b, 1992, 1995) workshops have been held around the U.S. and the world, seeking to train therapists and to contribute to the healing of interpersonal, cultural and inter-racial wounding.  I studied Process Work and more peripherally World Work for a ten-year period.  However, there are important differences between the Community Healing Workshop and Mindell’s work.   

John Mizelle, a long time Process Work and World Work facilitator and my esteemed past teacher of the work, wrote the following specifically for this paper:

World Work and Process Work workshops allow significant dysregulated affect, accepting it as an inevitable fact and a frequent starting point. Mindell follows Jung in adopting a teleological view of human development, i.e., that human consciousness moves toward wholeness. He believes that phenomena—signals—that occur outside of the identity of the individual and/or the group often point toward that development, and that, when awareness is directed to such signals, that development is revealed and facilitated.  Therefore, Process Work exhibits a wide and deep tolerance for behaviors that are disturbing to the identity of the person and/or group.  It is believed that the disturbing signals will reveal either the wisdom at their core, or their limiting, dysfunctional nature, if given welcome and room to show themselves (Mizelle, 2014 written communication).

In contrast, the Community Healing model works to bring forward transformance drives (Fosha 2008) and regulated core affect and then to moves into adaptive action tendencies (Fosha, 2000), which guide the transformative process forward in a context of deeply held safety.  While shadow aspects of self are recognized as being important in AEDP for Couples and in the Community Healing Workshop, the intention is to regulate those dysregulated aspects of experience, in a way that establishes and maintains safety from the “get go”.

World Work allows projection and judgment to build for a significant period of time during workshops to “stir the pot” of amplified emotions in the audience of participants and thus to bring the problems, conflicts and intense energies that are the subject of the day or weekend in a pronounced manner into the foreground.

The Community Healing context works instead to convert projections and judgments even before they are expressed into vulnerable and somatically expressed I-statements of owned experience about the self, rather than projections or positive or negative judgments about the other.  Thus we incubate an atmosphere, an expressed intention and a language form that is mindfully expressed as Process Training Language, so each individual’s experience is explicitly owned and worked through rather than being attributed to others as introjects into the field (Mars, 2012, 2013, 2014).  If dysregulated affect emerges, as in any session of AEDP for Couples (Mars, 2008, 2011, 2014), the workshop facilitator gently, but firmly intervenes and helps the speaker to convert the projection, blame or judgment into embodied I-statements that express internal experience in any and all of the seven channels of experience.  These channels are sensation, emotion, energetic, movement, auditory, visual and imaginal.  The intent is for the deeper meaning of what is expressed to be received with a mutual softening of defenses in an atmosphere of slowed-down safety (Fosha, 2000; Mars, 2012, 2013, 2014).  In this way attachment bonds are strengthened. World Work and Process Work facilitators occupy a different set of six channels of awareness:  proprioceptive, kinesthetic, auditory, visual, relationship and world.

In my experience of Mindell’s work, the increase of awareness comes initially from the amplification of polarization of sides of issues and culturally charged situations, so that they reach an intense crescendo of amplified amplitude of expression, which may then break through to a surprising resolution.  By contrast in the Community Healing model, the transformative experience comes through the increase of receptivity to subtlety and nuance in the audience of therapists and in the couple members who are the focus of the Community Healing Workshop.   The focus in the Community Healing Workshop is on increasing the capacity and sensitivity for perceiving, receiving and expressing experience expressing experience (Craig, 2009a, 2009b), rather than on increasing the amplitude or intensity of the experience.

World Work takes on the difficult challenge of engaging live encounters with participants, who in many cases have never previously met the facilitators or each other prior to the workshop.  This stands in sharp contrast to the Community Healing Workshop, because the couple already has an established and secure base with the therapist.  The entire course of the work of the couple has been edited from a series of videotaped sessions to feature moments of change over the course of months and up to two years of treatment.   The intent of the Community Healing Workshop is to show these change-moments in treatment on a large projection screen with the couple present on stage with an ongoing, open and carefully held conversation between the audience of therapists and the couple about the process of transformation.

Finally, the expressed intention established on the first day of the workshop is for the audience to assist the couple to integrate and metaprocess treatment work that has already shown significant beneficial effects in a private clinical setting.  This presents a very different set of conditions than the challenges of the World Work or Process Work Workshops.

The third foundation of the Community Healing Workshop is Accelerated Experiential Dynamic Psychotherapy (AEDP, Fosha, 2000) with its four states of transformational process.  The context of AEDP’s focus on empathic attunement, orientation to affective neuroscience and attachment studies and seeking  to establish a secure base beginning in the first session (Fosha, 2005)  are all deeply held and made palpably explicit in the Community Healing Workshop.

Four Purposes of the Community Healing Workshop

First, the Community Healing Workshop serves the couple through metaprocessing and deeply integrating their therapeutic work.  Second, the experience gives the therapists in the workshop the opportunity to practice whole-body witnessing through the seven channels of experience directly with a live couple.  The therapists present have the experience of being, seen, heard and safely accompanied by me and their colleagues while “stretching” their internal working model in a surprisingly intimate large community setting (Mars, 2011, 2013), by perceiving, receiving and expressing in channels of experience that may be new to them. The experience of making these stretches that exceed the permission-set of the internal working model (Mars, 2011), and thereby expanding the therapist’s self-at-best in the presence of his or her peers has been reported in evaluations and back-channel responses to amplify the capacity of the therapists to go into new arenas of trusting and valuing their own somatic awareness, courage, spontaneity and transformance drives (Fosha, 2008).

The third purpose for the Community Healing Workshop is for videotaped training materials to be produced that provide a medium for therapists and interns who were not present to learn the AEDP for Couples model by experiencing the workshop after the fact.  Each workshop to date has been professionally videotaped by a crew of four videographers.  The ethos of the Community Healing Workshops has been to bring the transformational work of each couple not just to the therapists who are physically present on that weekend, but also to interested therapists anywhere in the world through the DVD series or streaming video produced.  There is obviously an increased element of exposure for the couple here.  How can a couple sustain the fact that their intimate process of treatment and, in fact, their trauma histories would be so exposed to view well beyond the day of the workshop?  So far, both the couples who have volunteered for workshops coming up in the future and those who have participated in the Community Healing Workshops in the past have described an overarching desire to serve the healing of other individuals, couples and families.  This is a profound extension of transformance drives that has helped couple members who have described themselves as shy, or “very private” to feel a new confidence and strength of purpose and ease at sharing in order that their suffering can serve the world and reduce suffering for others.

The fourth purpose of the Community Healing Workshop is to become a microcosmic healing medium that symbolically addresses macrocosmic problems of world-wide dysregulation and hardening of defenses and the resultant reduction of compassion.  I find that with couples who have suffered physical, sexual and psychic abuse, as well as neglect and abandonment that interlocked for years with the historical trauma and neglect of his or her marital partner, I perceive them sometimes to have a need to be held by a larger container than I can offer alone.  In these cases the “world channel” (Mindell, 1985) of community ideally needs to be addressed, because the attachment injuries and deprivation from which they are recovering are not just theirs or from their families of origin.  Those injuries are byproducts of multicultural influences across decades and centuries and from multiple sources around the planet. As just one example, the hardening effects, distortions of the capacity to be attuned, to love and be loved, to affectively self-regulate have been greatly disrupted and complicated through the unspeakable cruelty in two World Wars, plus wars in Vietnam, Iraq, Afghanistan, the Middle East, Africa and more recently again in Asia.

These world events have created wounds that are physical, psychic and relational and have triggered the heightened development of defenses against the experience of loving and being loved.  Over generations, these world events have set in motion affect dysregulation and dissociation, and have contributed to addictions to substances and resultant violence and dysregulation in the community and in the home around the globe.  These world channel events have changed the character and capacities of millions of couples’ respective lineages in profound ways.  In my view the Community Healing Workshop meets that world channel dimension by “inviting the world in”, represented by the audience of therapists who can play a part in making peace with the world through the compassionate help and loving regard of the combined couple and the therapist community present.

In the Community Healing Workshop, there is a “level” aspect of the work that is profoundly humanizing to the role of being a therapist and to that of being a couple. There have been many reports from therapists of experiencing a relief in the lightening of the load of responsibility of practicing couple therapy.  Following the workshops, couples have described witnessing the arc of their healing process as being more palpably real, held more coherently in-a-state-of-flow and accessible by the witnessing of each member of the couple in a state of recognition (Fosha, 2013) both during and after the workshop.  Core State, an enhanced condition of open, relaxed spontaneity of knowing in the couple, in the therapist-participants and in me as the facilitator have been evident in the review of the DVD’s produced from the three Community Healing workshops held to date.

There is a sense of an expanded capacity of all the workshop participants to cohere as a group organism to meet and experience self-at-best together that seems to enhance learning and create a collective relaxation of defenses in both the therapists and the couple.

The Issue of Safety

The reader may understandably ask the question, “How can there be sufficient safety for a couple to be physically present on stage as they share their trauma and couple treatment work on video with a very large group of people they have never met?”  While nothing in life is guaranteed, there are a number of contributing factors that have generated safety for the couple and for the audience of therapists as well.  The first is that deep transformance drives are engaged from the beginning by the couple in their expressed longing to grasp more fully what brought them from their distressed condition when they came into AEDP for Couples treatment, to the place of loving and being loved in which they have so recently arrived.  Couples to whom I have selectively offered the Community Healing process have expressed an immediate and enthusiastic “yes” to the opportunity to engage the process.  Then over a period of months leading up to the Community Healing workshop, I check with the couple to invite them to be explicit about any questions, anxieties, excitement, dreams, etc. that are “cooking” in the background about the workshop that is coming up. I might say, “How is the imagining of the Community Healing Workshop sitting with you these days?” or “I am wondering if you would update me on the experience of knowing that the Community Healing process is coming up in just two months.”  Couples with whom I have explored these questions have been remarkably relaxed and excited about the opportunity to serve their interests in obtaining help in metaprocessing their work. The couples have also been enthusiastic that the therapists will be attending to cultivate and refine their therapeutic skills to work with other couples in treatment.   Participating couples so far have each expressed before, during and after the workshop a sense of being honored to receive the skillful attention of so many therapists.  In addition, often these couples have already had the experience of coordinated treatment with a team of one or two individual AEDP therapists who have conducted treatment right along with the couple treatment.  In this way these couples are already accustomed to a team approach with AEDP and so adding seventy or more therapists to the team is not so foreign!  Plus in the coordinated treatment model, DVD’s of AEDP for Couples treatment sessions have already been shared with their individual therapists, thereby normalizing the sharing of their treatment with clearly beneficial effects.

Another factor in generating safety is the fact that the couple members who have been invited to participate in the Community Healing workshop have been watching their DVDs between each session from the first session of their treatment.  They have already cultivated a larger perspective and trust in their treatment process by experiencing and then metaprocessing each session with each other at home via DVD between each live session over the entire course of treatment. This trust is deepened by the fact that the DVDs they witness together at home are videotaped with split screen technology, so both the therapist and the couple are visible on the screen at the same time.  Through their own cultivation of tracking channels of experience through viewing ten, twenty or more DVD’s of their couple and trauma treatment work, they have a deep sense of trust in my attuning and accompanying them in our progressively mutual tracking of seven channels of experience.

They also describe their memories of the moment-to-moment process of the specific ways they can see in “DVD retrospective” what they could not perceive at the time of the sessions.  They notice in the DVDs that I am scaffolding, tracking and accompanying them step-by-step in each phase of treatment, even if for a period of time at the time of the session, he or she was triggered into an enactment of prior trauma or over-activated into a state of dissociation.  Paradoxically perhaps, the repairing of mini-ruptures and mis-attunements in this way has brought the greatest increase in verifiable trust (Mars, 2011) as part of the preparation for the couples presence on stage. The “thickening” of bonds brought about by dysattunement followed by repair is described by Edward Tronick (2015).  It may be that the process of these couples viewing their DVDs and witnessing their experiences between sessions of what they see, hear, feel, sense and recognize that generates a greater sense of my being a True Other (Fosha, 2005), not only to each of them as individuals, but to the couple relationship that then holds them more securely in the workshop setting.

The experience for me, as the facilitator and originator of the Community Healing Workshops, is that at each step I intend to move first and foremost from the transformance drive of my longing to be service to the couple.  Long before the workshop is scheduled, the couple is “pre-selected” by the spontaneous, natural and repeated experience of my spontaneously “seeing” and “hearing” the couple in the imaginal channel in a future Community Healing Workshop.  This imaginal channel of experience cues me up from my unconscious process becoming conscious when I track my imaginal visual and auditory imagery.  After months of this experience, I mention the potential of such a workshop to the couple at the moment when one or both individuals describe a sense of disbelief and even distrust of “how far I have come with you in so short a time.”  “How can I really trust that we (or more often “you” referring to the partner) are not going to backslide?”   I suggest the potential of the workshop when the couple members are already in a stable, yet forward-moving place with each other, in which they are coming in with self-generated repairs of bumps-in-the road that earlier in treatment would have triggered damaging enactments that would have plunged them into the well-worn ditch of their historical trauma.

Spreading the Healing Affects Around

Part of what I love about the model of Community Healing is that we are all brought together to witness nothing less than the miracle of the love of two people in the accelerated process of healing the capacity to express love and to receive love.  In this synergistic process I derive my deepest confirmation that we heal ourselves one family at a time with a widening circle of health-giving influence.  By multiplying this widening-circle effect by each therapist present at the Community Healing Workshop offering their heartfelt, attuned witnessing to the couple, the couple takes in a relieving of historical or even present day unbearable aloneness and a transforming of shame and passivity into confidence and vitality.   At the same time, as therapists offer their spoken witnessing of the couple’s transformative process of healing on video and live on the stage, they expand their capacity and confidence to participate in metaprocessing as a whole body expression of empathy with the individuals and couples they treat.  Thus, in the Community Healing Workshop, we multiply this widening circle by each therapist present and collectively touch our individual and couple AEDP treatment work.  We generate a quantum transformational effect that spreads in ever widening circles like the proverbial pebble thrown into a pond.

When Community Healing Workshops are held in regions in which the channels of experience are not familiar, multiple assistants come to help set the relational and somatic atmosphere for the witnessing of the couple.  Before workshops and trainings I have also forwarded the Process Training Language (Mars, Wolk, & Pando-Mars, 2013) as an email attachment to all the participants who have registered (see addendum below). By preparing the atmosphere of safety for the workshop with such a handout, we strengthen the awareness of how to use witnessing language, but more importantly the capacities to become more adept at opening the somatic perception and reception that precedes expression.  When our speech is reflective and transparent about our internal experience, we can co-create an atmosphere that “we are all in this together.”

The potential aloneness of “being the only couple on stage” is palpably eased when the first audience member joins the couple with an attuned I-statement that is spontaneously evoked about his or her own relationship.  As more dialogue emerges between the couple and the audience connected to change moments in the couple’s videotaped work that we have just experienced together, more drop-down happens into State Two (core affective experience).  Then State Three (metaprocessing the experience of transformation) and State Four (relaxed, open knowing, compassion, generosity and coherent and cohesive narrative (Fosha, 2000, 2013) can move into expression.  These state shifts in the group of seventy or more therapists become more evident and powerful and are reflected in the couple.  The couple is quite acclimated to embodied speech, so being joined by the organismically regulated core affect of so many therapists has to date generated an experience of being deeply met on familiar ground, since these practices of perceiving, receiving and expressing in seven channels of experience is part of every session of AEDP for Couples.  What was originally a stretching of the rules of the internal working model of the couple by feeling, seeing, hearing, sensing and energetically tracking core affective experience, becomes more normative through the audience of therapists accompanying the couple in somatic bottom-up processing.  By the couple being affirmed, deeply accompanied and delighted in by the community of therapists, an experience of being received and held surprises the unconscious with receiving affirmation and reflection in the here and now of what was needed in early life.

The embodied experience of support and honoring in the context of the former carefully concealed secrets of abuse and neglect being revealed in an atmosphere of shared productive suffering (Mars, 2014) is profoundly healing.  The resulting relief is unique for these couples and in one day, the dialectic of call and response with the audience of therapists “righting the wrongs” of much traumatic isolation and shame.  Words are not sufficient to describe the relief that comes from the deep surprise of being believed, met, seen and heard by a whole community of other safe others when one has been rendered invisible, ashamed and unbearably alone in a condition of historical helplessness held in implicit memory.

Transcript from a Recent Community Healing Workshop   

On November 15, 2014 Jane and Matt (not their real names) flew from San Francisco to New Jersey to meet at Seton Hall University for the Community Healing Workshop.  There Jane and Matt met Diana Fosha, Karen Pando-Mars, plus four AEDP for Couples Assistants.  Also present at the workshop as Jane and Matt entered was Anne Marshall, who is Jane’s AEDP individual therapist, who came to help re-create a secure base for Jane and Matt.  Seventy therapists from six nations and across the country engaged in the process described above.

On the second day, Jane and Matt are brought up on stage and introduced to the audience of therapists. I begin with a channels of experience meditation to deepen embodied awareness and to freshly engage the therapists in the somatic focus and the Process Training Language.  The meditation also has the purpose to help Jane and Matt to focus on slow abdominal breathing and to access each of the seven channels: sensation, emotion, energetic, movement, auditory, visual and imaginal.   Matt and Jane speak about the mixture of enthusiasm, optimism and nervousness they feel to be with us in the Community Healing Workshop.  Several audience members welcome them and give appreciation for the couple who have come to help facilitate the learning process of AEDP for Couples and to collectively metaprocess their experience of change.

As the audience of therapists views sessions eight through twelve with Jane and Matt,  we stop frequently to metaprocess the experience as we go.  Audience members and Jane and Matt express tears and joy together throughout the process of moving through the stuck places and from repeated breakthroughs and setbacks.  The themes of attunement, disruption and repair are vivid and powerfully evocative.  By session twelve it is clear that Matt and Jane have fallen in love with each other and that they have entered into a realm of intimacy and earned secure attachment with each other.  For a more explicit detail of sessions one and session eleven, see Mars (2014).   

In the last two hours in the Community Healing Workshop, we address the complexity this new-found intimacy may elicit fears of potential merger and loss of self in a couple that has spent three decades of enduring the distance, disconnection and dorsal vagal responses that are the by-products of Jane and Matt’s interlocking unresolved traumas.   A therapist in the audience asks if I have spoken explicitly to Matt and Jane about the issues we see that are becoming apparent about merger and loss of self:

David: Not overtly…we haven’t discussed this, but for me, it is all part of what makes this moment in the session so important. I want us all to just hold awareness of the possibility…we’re talking about individuation versus merger.

Matt:  Because I think it’s…I don’t know if it’s the same thing as me having been caught up with other people that I’ve trusted…that I’ve characterized…that I’ve trusted too easily. And it feels like the same thing. And I’m choosing YOU now.

Jane: Honestly, that’s the fear, to be completely truthful…like, oh am I the new Richard (Matt’s former AA oriented therapist) or the new whatever.

Matt: Well the difference is that we signed up for each other.  (Leaning toward Jane, smiling warmly)

Th: He’s really making a plea.

Jane: I know.

Th: I get that you don’t want there to be some way that you’ve seen in the past with Matt, where he gets into something that somehow…you perceived him as having lost himself.

Jane: Mmm-hmm

Th: …to people…and lost his own sense of autonomy. And then that makes you really angry and contemptuous toward those people.

Jane: Umm-hmm

Th: In a sense, they took him over.

Jane: Right.

Th: Am I getting that right………and that you don’t want to take Matt over?

Jane: Right!

Th: You want him…not to lose him into YOU…am I getting that right?

Jane: Mmm-hmmm.

Th: (to Matt) Not that that’s a risk that you perceive…I don’t know. Do you perceive there’s some risk of losing yourself into Jane in some way that you would lose who YOU are?

Matt: No, no.

Th: Can you tell her about this?

Matt: I think that I…….I don’t think that I would lose myself. In fact, if anything, I feel like in the last six months…eight months, I have become more and more myself…and that that’s been part of what has helped us to discover each other more in this setting. (turns to Jane) That, you know, in terms of how we’ve been together…how I’ve been with you…how I’ve been at work in this new work that I do…I feel as though who I am is becoming more and more defined. And so, I don’t feel like I’m risking…I mean part of…I know I just said…part of me feels a little ashamed,  ‘cause it feels like in some respects I’m like…you asked how do you know that you’re all-in or with Jane and it’s like, it feels similar to…I’m…I’m…I’m jumping both feet in with you and I’m hearing you saying what you need…I’m hearing you characterizing me and how I’ve been with you in our relationship and what…differently…I’m hearing it differently and I know that I’ve said…that I just said that I feel like I’m now just falling into…now trusting YOU but…you know what? I AM. (laughs).

Th: That’s the thing.

Matt: I am! And I…and I AM by choice and I…um…and I believe that uh…I believe it’s not necessarily misplaced, my trust.

Th: Yeah…and in fact…if it’s not misplaced, it is instead…to choose her and be all-in with her…

Matt: And I need to work on my neurons.  (smiling warmly)

Th: It’s true.

Matt: To…to find a different response other than “No, you’re wrong.”

Th: Mmm-hmm..

Matt: Because um…to the extent I’ve been able to entertain the notion that you’re not wrong in this setting…um…I’ve seen that you’re safe.

Th: Wow.

Matt: And that umm…

[00:14:24.23] Th: That’s quite a gesture, Matt.  (waving his hand toward his mid-section)

Matt: Yeah.

Th: You’re showing her, “You’re safe”…you said it twice…you’re safe. What does that mean? What does your hand show? You’re safe.

Matt: Well come on in…come on in….to ME.

Th: That’s huge…come on in to me. That’s a great statement of your receptivity to the person of Jane being received…so different from that…and getting bogged down or the dog refusing the bath…it’s something about your receiving her today that is so different in your voice resonance…so deep…I didn’t want to interrupt you, but it’s the way you’re speaking so whole-bodied…I trust this voice in you, Matt. I trust your voice. (turns to Jane) Do you know what I mean by his body resonance when he’s speaking today? Even in the work that he does…his self is coming more into his work…what is that new work that you’re doing that your self is coming more into?

(End of Clip)

David:  Can I have the lights up again please? Ok…so how is this passage for you, Jane and Matt, to be witnessing?

Jane: I still look like I’m not all-in at that time. I think I was all there…I’m not sure. I think still at that time, I was still…up until fairly recently, one foot in…NOT trusting, but not fully there either.

David: And how do you understand that, Jane, based on the fact that you were really urging Matt to be all-in with you?

Jane: Cause I was there before.

David:  Yes.

Jane: And I’ve been there…and waiting.

David:  Yes.

Jane: And it wasn’t a game…it was never a game…and so…I’ll be ready when I’m ready…(turns to Matt) and I wasn’t closed or unempathetic to whatever you were saying or feeling but…this is the time for the truth, right…from where I am.

David:  Yes. How about for you Matt?

Matt: I don’t remember quite talking so much. (blushing) [Appreciative laughter from the audience, of Matt’s previous self-effacing comment referring to his view of himself of not knowing or being able to speak of his own experience.]

David:  Because you’re a person who doesn’t find words easily.   (smiling at Matt with pleasure.)

Matt: I was struck by two things. One is that my conviction and certitude about my experience of letting Jane in, in fact, is the right move.  And…

David:  How do you know that’s true right now with Jane? Your certitude with her, being all-in with her is the right move…what validates that as true? That you can know in your body as true? Right now with her…

Matt: Um…I don’t know…it’s a…first word that just popped in is symmetry, but it’s a synchrony…a synchronosity (slip) that we have in our conversations recently and

David:  Thank you.

Matt: And then I also did notice here…what you just said about yourself…that I wasn’t catching there…in that moment, which was the um…it’s not a wall that you were putting up but it’s a…standing aside still…

Jane: Mmm-hmm.

Matt: And waiting. And I think in a subsequent session or two, we had the opportunity to examine that. (All laugh) And…and specifically, my needing to give you the space by  accepting that.

David:  Wow.

Matt: Why? I trust you now. It doesn’t happen just like that.

David:  Thank you. (turning to the audience of therapists) Any responses that you have, any embodied experiences that you’re sitting with…Dale?

Dale: I’m also usually not at a loss for words, but for the last half hour, I’ve been sitting…just a streaming energy in my feet and hands, which I’m feeling more intensively now…and I feel there’s a…I’ve received a gift from each of you and from David in this process. There’s some things I want to say of appreciation…where in the tape this morning, Matt, you talked about feeling shame, but you didn’t drop out and away from the shame and you were present and I felt strong in myself as I saw that in you. Just a lot of admiration…man to man…of your kindness and your presence. Seeing that in you brings out the best part in me. So I want to thank you for that.  (Matt beams at Dale, his eyes bright and moist)

And yesterday, we watched the tape of you and Jane and I struggled because…in seeing the fierce part of you (directed to Jane), that triggered me and I had struggled with liking you (Jane giggles) in that place and it was good for me to have that struggle. And I actually want to thank you for being YOU and showing that, because it gave me time to…although I could, in my…I’m confusing right and left at the moment because of the streaming, but in my intellectual mind I could say I understand where that comes from in you, but I couldn’t get it at first.  And so your commitment to being genuine…I mean you describe Matt as having integrity, but I see YOU have tremendous integrity. And as I see this part here, um…you know I’m…the Missouri license plate…the “Show Me” state…I’ll believe it when I see it…I mean, I like that in you. You know? I want you where the rubber hits the road, where you’re real with me and until my body can trust, I don’t trust. At least that’s I guess, the Jane in me feels that.

Jane: Thank you.

Dale: So I feel like a cheerleader for your integrity and your fierceness.

David:  Yes.

Jane: Thank you.  (smiling, beaming at Dale)

Dale: And I had an image during lunch that as people talk about the influence of watching the two of you…because there’s a parallel process for me, being with the two of you and David…um…seeing how you remind me of a couple I’m struggling with and recognizing in myself and my own marriage when my wife, you know…ok, she’s angry ‘cause she wants to be with me (chuckles)…and trying not collapse away or respond defensively. So all of those aspects I’ve had a chance to be with.

So the image I have is like the gifts that people are talking about…I’m trying to share with you now…I am sharing with you now. Um…I feel that there’s…what you’re providing with your courage is to me, like a rain of blessings and the sense of drops of water on so many of us, reverberating with what you are letting us feel, what I’m feeling in myself…and so many others are feeling as well (voice trembles) and will go home to their spouses and be different, or bring out the best and go back to my office and find a way of um…celebrating the fierceness that you brought, in service of connection. So…

Jane: That’s beautifully said.  (eyes glistening, brightly lit.)

Dale: Thank you.

David:  And will you tell about the beauty you experience in this…in what Dale is saying?

Jane: The validation, because there were so many years that I began not to trust where I was going or whether I was right…his mother was always, you know, pointing out things about me that were unkind or untrue or whatever, and no one was standing up for me and then I didn’t even know I was married to an alcoholic for 20 years…and then it was worse coming into recovery and I was wrong for not working the program and we were talking about that during lunch. So I…it’s really hard to start…where do you start to try to find yourself…let alone show the person you’re living with, you know.

David:  How about you, Matt? What’s your experience here?

Matt: Um…I appreciate Dale, your honoring the integrity in Jane as well and seeing that and…and riding through your own reaction yesterday to her.  (all chuckle)

David:  Can you relate to that part too?

Matt: It’s good, isn’t it? (all laugh)

Dale: It’s sorta like surfing and falling off the board, at times.

Matt: We’ve used some beach metaphors…not Normandy…but the waves (all laugh with tones of empathy and affection).

David:  What is the good in the end…Thank you. Yes…  Polly?   Sorry…go ahead…thank you for helping me keep track.

Andrea: I had the microphone twice and got cut off twice already.

David:  Oh…I appreciate your persistence.

Andrea: Thank you. Hi, I’m Andrea and am extremely grateful to both of you…um…your generosity in showing us your tapes and your generosity in being here and sharing of yourselves with us…I really appreciate it greatly. Jane, I really resonate with your journey to finding yourself and to you know…needing to be seen…that’s a journey that I’ve experienced as well and I want to honor that. Um…and I had a different reaction than Dale to your shame, Matt. I felt very protective of you in the earlier sessions…I felt a tremendous desire to like…you know…tell you that just because you made a mistake doesn’t mean that you’re terrible, you know. But then as I saw you showing up more and more, I felt less of a need to be protective of you, because it seemed like you were really able to take care of yourself and that was really lovely to see.

Matt: I think it was the Andrea in me that was coming out.  (broad grin, bright eyes., joy expressed)

Andrea: (laughs) Thank you!

David:  So who really IS next to speak? What’s the truth? Is it Polly now? Ok.

Polly: Something just clicked for me, Jane…when you spoke and you said something about people standing up for you…feeling stood up for…as I reflect, this whole day, I’ve been so sitting up…so in my uprightness and feeling curious about what that was about…and really like…I cannot sit back today. As you said that, it struck me, this witnessing experience that Esther commented on of being with the young one in you, standing at the chain link fence, watching your father’s truck go by and longing for what you longed for…for so long. I felt so…the justice of myself sitting up and standing with you to see that with you…and I feel so moved to be with you and witnessing that moment with you and validating that that was true. I’m enjoying the experience of standing up with you and for you…I thank you for letting us.

David:  (smiling) Thank you Polly. (turning to Jane) A lot of welling up…what’s happening with that big sigh?

Jane: Yeah…I wish I bought stock in Kleenex. No I just…I still see that fence (voice trembles)

David:  Yes…a lot of feeling here…and part of my gratitude, Jane, is that following this workshop, you’ll be working with Diana Fosha, and you will be having a private session with her as a follow-up to this. And what gets evoked here, what gets brought forward, there is a place to go on the way to keep the connection to what’s still needing attention and support to move through. (Jane nods and self soothes.) [I made a from-the hip-decision here to bypass processing the trauma memory of the six years “behind the fence” as a six to eleven year old in the workshop setting, feeling the greater safety for Jane to work that out dyadically with Diana.]  Another person here?

Jack: Hi, I’m Jack.

David:  Hi. (smiling and nodding)

Jack: I had the honor of having lunch with Jane and Matt and um…one of the things that I want to come back to…we discussed a number of things, but I wanted to bring up something, because I think there are probably some other witnesses here who could be helpful…and that is…when I spoke about how I ran the family treatment part of a alcohol treatment program once and it was so difficult for couples who were going through a process of recovery when one person was going to AA and the whole emphasis was on their recovery and very little on the couple. In fact, I think it really created more of a wedge in the couple and a very painful disconnection and I think that it’s something that probably a lot of couples experience and when we were speaking about it, it seemed like this was something important for you to know that you’re not alone in that experience…that recovery is a very painful process for couples. So I’m bringing that up in case other people have witnessed that as well.

David:  Thank you Jack. (nodding, pausing, scanning the audience of therapists) How about one more comment…I guess we’ll have two.

Andrea: It’s me again…I have a question that’s burning that I have to ask Matt. In addition to Jane, to your persistence and allowing that to come forward and that helping the whole process of you guys connecting…at the beginning, I felt the same way as you did about the shame that you were feeling at the beginning of not being able to do what it is that you wanted to do as a husband. Help me understand how you got from one place to the other…from feeling so ashamed and going into that place of not feeling good about yourself to a place where you could stand up for yourself and speak from confidence and love and compassion…was it something in particular that David did as a therapist or something, you know, that your wife said to you?

Matt: There’s the long answer and there’s this…short answer, I think is probably the truest…is that in being able to look at the sessions again on DVD and watch them…that dynamic enabled both of us, I’ll speak for me…to step back and look at the interaction that I had experienced initially from a more detached place.  I saw the shame I was expressing and experiencing in that moment and I realized that it didn’t last forever. So what I told myself was, you know what? Hang with it, Matt…just hang with it and to bring you into in, David.  David’s got a tremendous way of inviting the conversation to continue along the most productive path and so he’d say, Matt, can you look at Jane when you’re saying that? In a kind way and so I was seeing myself experiencing shame before even noticing it and labeling it. So, that experience of seeing the video kind of gave me a check for next time, like what was said at lunch…that was kind of self-monitoring and so the next time it came up, and I was feeling it…I felt it…and I stayed with it and um…and it was a kind of trust…um…but it kind of harkens back to that persistence that we both share that this is not going to take me off track.

David: Yes. Thank you. Anybody else have anything else that’s cooking? Steve?

Steve: Wow…I feel so filled up. I have an image of many ribbons in the sky…not just for your love…what you’ve offered us today is going to have so many ripples…it’s going to help so many people…so I just acknowledge you for your heroism…it’s just truly inspiring.

David: (nodding) In back of you is Maria.

Maria: Yeah…it’s hard for me to speak but …last week I had a couple and it was so similar, but even more traumatic right now and whatever…but it’s so similar and I told them, before I had met you two…I didn’t know what was going to happen.  I said, I’m going to bring you in here with me.  I didn’t know in what way…and I am so hopeful that what you have showed me today and to have witnessed your work, David, with you and the whole process…I really hope I can bring it back to them next week…and that they will show up, both of them.  Everything that you have gone through is so similar…so thank you so much. And they have three little kids.

David: Yes…thank you. Yes. So I just want to make a comment. How about if we go maybe another 10 minutes with this process with Mat and Jane?  Then we’re going to wrap up our time with Matt and Jane at that point, and then we’re going to have a metaprocessing period for all of us.  The theme will be along the lines of how can we take this home.  How do we ensure that it takes root? How do we really do that successfully and maintain that connection with the work. (pause, listening, looking for an audience response and receiving the nodding of many heads) Thank you.

AUDIENCE COMMENT:  I just wanted to ask you all…I’m so curious about what your experience of being in therapy with David has been like. I feel this sense of safety in your relationship together. I actually have enjoyed seeing from the first session all the way to the end, the comfort that you all feel with each other. I see you up there now and you seem like…David’s sort of beaming and so incredibly proud, but there’s also this sense that you guys are all grown up, you know? I mean that in like the most, warmest sense I can…being a child myself (group laughs warmly). I guess I wonder…I would love to learn more about how this particular experience in therapy and your experience with this therapist has moved you and guided you to this process of transformation.

Jane: I’m going to let you go first again.

Matt: Well my experience of this time together in couple therapy with David has been…we’ve each, as we’ve said, done individual work coming into this couple work and I think that was a necessary condition for us to be able to do the kind of work we’ve done with David and be ready for this. There’s been a readiness that was hard earned…has been hard earned. And…and I’ve shared this with you David. David’s got a way of being with us…I’ve noticed David has a way of being with us (group laughs at his self-correction back to making an I statement) where I’ve noticed you be patient when I’m waiting to find the right words to say.  I’ve noticed you prod when I’ve needed to be prodded.  I’ve noticed you call us each, in gentle ways, on ways that we’re expressing ourselves that wouldn’t be productive. You listen…I’ve heard you listen to the words that we use…and the words that we’re not using.  The other piece that’s tremendous about this process is that I think we get to work on a little bit more is to find a way to say it in the positive…say it in the affirmative…because I’m understanding that’s overriding some of this other stuff and THAT’S deep healing…healing-for-the rest-of-time kind of healing. And that’s the only way I want to spend my time…my remaining heartbeats here. And I also, since I’ve got the microphone in my hand…I want to recognize…I’m glad you invited Anne (Jane’s individual therapist who also flew out to accompany the process with Matt and Jane) to say something…I want to recognize you, Anne, for the work that you and Jane have done together. And for the one session that you invited me in, not for couple therapy, but just to be an interpreter.  You and David…you, are our angels. And (to the audience) you ALL are angels. And I’m sorry for the connotation there, but my experience of this session is that the openness…the truth that we’re living together, the witnessing that we’re providing for each other. Steve, as you’ve described the ripples and others have shared with me…the ripples of healing that are going to happen as a result of this…these are moments of heaven for me.  And…we get to live them in the living years. And there’s more to it…there’s more of the living years left and that’s so hopeful. And so that’s what it’s been for me.

David: Wow.

Jane: How am I going to top that? (group laughs with affection, empathy) Well, I bought a seesaw right? And that meant two things…it’s a seesaw that you see in a park…it’s not just a seesaw…it’s a long story, but the short of it is about balance and joy. (sighs, voice trembles) And I’m only inviting the people I like to come play on my seesaw…cause life is too short…not to be judgmental.

David: (pause, letting it sink in) Thank you. Wow…

AUDIENCE COMMENT:  A couple of comments…first of all today, your fantasy you mentioned  earlier David of having a circus…I want to thank you for not being the center ring…or even the ring leader…that made the circus a lot more meaningful, because you certainly could’ve done that and had a right to but…Matt and Jane, I want to stand not so much for you, but with you and the image I have is the last scene of Les Mis…that always brings me to tears. When the people stand together, redeemed, alive, departed…I wasn’t going to share this, but when you mention the heavenly…that’s a sacred moment to me, because it’s a manifestation of transformations through wars, through abuse of children, through lives and through death and through illness…everybody stands and they march together, waving the banner…saying, we’re going to go on…we’re going to keep this going and all that we have through transformation…and it was transformation, not just the 15th…if we had only seen the 15th session, this place of hope, I call my hope within, would not be full because…Yesterday I came very depleted (pauses, sighs)…but today I’m full again and so I stand with you and I know we do, too…to march together to a new future and if those sessions had been edited like you wanted, [referring to a disruption earlier in the day caused by my mistakenly sharing a raw, out-of-sequence video clip that took Jane off guard by seeing and feeling how dysregulated she was in that particular session]  I wouldn’t be filled. Because the evidence of transformation would not be there…but it is…and the two of you stand in the place Jean Val Jean for me before all of us in that line up marching forward…thank you.

David: Wow…powerful. (pause…looking into the audience) Thank you.

Karen P-M: I’m just thinking of that place of wanting that piece edited out and I can understand totally wanting to end in one place, but the buoyancy of seeing that place, from what we’ve seen in the transformation…and then to watch that moment where there’s this settling and understanding of where statements can just jump out…and like back to Esther’s comment about making that hard choice, and then just also holding what I…I’ve just been on the edge of my seat with tears and chills and filled…and just so, so moved, that it’s all the fabric…it’s all one for me, actually at this point and I don’t hold any more special than the other, because I see you two here. I’m so proud. And…I think my marriage is going to be even more interesting after this, too. (all laugh)

David: I do too! Thanks baby! (big smile to his  partner Karen in the front row) This is good!  (all laugh again)

Mark: My name is Mark and I’m totally awestruck by your work David and by the work you guys have done…it’s just been amazing to watch and when you guys look at each other now…and you smile at each other…I just light up in my heart…to see the growth you’ve made, the commitment to your marriage…the commitment to your kids…it’s just lovely. And I think…in terms of my own work, I’ve been…I sort of moved away from couples work over the past year or two and I think this is really…you guys will be in my office now…giving me that energy and really giving me that hope, so you’ve done a tremendous thing coming here.

David: .Thank you Mark. (smiling, nodding)

AUDIENCE COMMENT:  I have learned so much from the two of you about love…these two days…and I’m very grateful and I, too, have been watching little gestures…one in particular I noticed when you were sitting next to each other on stage upstairs and Jane, your foot rubbed up against Matt’s leg and I watched the expression between the two of you…your eyes met and you looked at each other, and it was very, very sweet and there’s a tremendous sweetness I feel in your relationship. I also wanted to comment on…I’ve been to other workshops where clients have come and done work and there’s something different about the way that this experience has been than any other experience I’ve had watching the work. Because you’re up there as equals…you’re not the clients on stage that are being looked at…you’re teaching us and you’re part of us and we’re learning from you and there’s a humanity to the way in AEDP we treat our clients as fellow humans that we’re on a path with, rather than as this artificial boundary, which I just haven’t seen today and it’s wonderful to see. So thank you.

David: Thank you. So on that note, I want to begin to bring…do you want to say something Sandy?

Sandy: As we are all sharing our tears together, I was thinking…what are those tears? So I think of the six-year-old Jane…meeting the six-year-old Matt as well and the teenager Jane, the teenager Matt…and the six year olds and teenagers in all of us…our longing to be noticed…a longing to be seen…a longing to be nurtured…and watching you guys grow…the mid-wife that Diana talked about the first day…as the mid-wives and watching you guys grow and watching David nurture you guys and watching how Jane stood up for herself and validated herself and nurtured herself.   And Matt stepped up to the plate…and then seeing how David…the delight in you…like the proud mid-wife, the proud parent…look at my son!  Look what he did! (group laughs, beaming) I think I’m amongst AEDP therapists and I’m proud to call you guys my colleagues…I’m proud to call myself an AEDP therapist (voice trembles)…I appreciate the power of reparation…one of the first things that Jane said, when you first came on stage this morning was…”I guess it’s not really a pleasure to be here,” because of what brought you guys here…yet, you guys have made so of much an impact on all of us. And the power is going to transcend. And being grateful is not enough to describe where I’m coming from…where how you have built me up…builds the six year old in me and the teenager in me…up…and the clients that I will be seeing…thank you.

David: Thank you Sandy.

Jane:  I do just want to say that people…it’s like at a funeral…oh hey, how ya doing? Oh good to see you! Then you stop…does anybody see you? It’s not good…but it is good to see you…so there’s a kind of weird separation and that’s kind of what I was going with, in a way…it is a pleasure to be here…it is a pleasure to be here, even under the circumstances of how we got here. And we’re just like everyone else that doesn’t talk about it. You all know. People don’t talk about and hopefully that’ll change cause you guys will all go out and start changing it.

David: (smiling, nodding to Jane)Is there anything in closing Matt that you want to say, in wrapping up your time here with us? (group laughs, beams at Matt) Just checkin’.

Matt: I don’t know what else to say, really. Thank you.

David: Alright…there we are…how about if we just all stand to be with Matt and Jane as they’re going on to their next step of their  evening.

AUDIENCE COMMENT:  Could we bow to them?

David: Let’s do!   (All bow)

Some Results of the Community Healing Model

The morning after the workshop, I asked Jane and Matt about their experience of the six hours of metaprocessing of their therapeutic process with the audience of therapists.  Matt went silent for a short while, then he grinned broadly and said, beaming at me, “The best description I can come up with is that I feel little bits of heaven happen all through the day.”  Jane smiled broadly with a sense of comfort and happiness expressed in Matt’s words, “I couldn’t say it better myself!”  At six weeks and again at nine months later in follow-up sessions, both Jane and Matt described and showed themselves to be very much in love and in a stable state of inspired contentment.  They describe how much fell into place that has stays in place that is in sharp contrast to the state of the anxious disorientation preceding the Community Healing Workshop that are the tremulous affects of being in a new and unfamiliar place following a series of transformative shifts.  As described earlier in this paper, this stabilizing integration of quantum change is one of the four purposes of the Community Healing Workshop.

The reports of the other four couples following Community Healing Workshops have indicated that they gained the felt experience of intensified confidence and wellbeing through the process.   Couples also show signs of enhanced earned security of attachment  (Roisman, G.I., 2002; Lamagna & Gleiser, 2007; Fosha 2009a). The changes have been shown in more coherent and cohesive descriptions of self and of the life of the partner and in the clearly increased harmony and confidence in the couples’ dynamics both within and between follow-up sessions.  The four couples who have engaged in the Community Healing Workshop to date have emerged with a sense of feeling lighter, more met and at-one with his or her partner and with the audience of therapists (Mars, 2011, 2012, 2013, 2014a).


Process Training Language for the AEDP for Couples

Community Healing Workshop

The purpose of Process Training Language is to engender safety, connection and intimacy as we share our experiences throughout the workshop and in working with clients and especially couples.  Through these ways of generating more conscious and “vulnerably owned” communication, we aim to reduce to a minimum the tendency of social speech to evaluate, judge and interpret.

Although using this language may feel awkward or unfamiliar at first, I encourage you to try it on.  My experience is that this method of communicating is highly effective at creating access to the richness of “bottom-up” experience that lies beneath our social habits of interaction and provides a means to give witnessing that is more deeply received and taken in.   This way of accessing somatically constructs new experiences, which change the brain productively.   These skills apply to our intimate relationships, and to expanding the capacities of therapists and couples to connect safely and more deeply within the self and one to another.

Key Points:

Speak in “I” language.

Social Speech Example:  During the morning of the workshop, a member of the audience of therapists wants to give support to the couple who has just done some moving work in the live session.  “You are so good at saying what you feel.  You really know how to stay with your partner and reflect each other in a great way.”

While this statement is “positive” and generous, it is also an evaluation, and can only leave the couple members with the option to accept this “praise” as true about themselves, or to reject what the witness is saying, depending on how they judged themselves.  Both options take them out of core affective experience.

An Alternative: “I feel so humble, as I see you with your partner. As I hear you make statements that reflect her, I feel myself relax into a deepening of my sense of trusting you myself.  I feel inspired”

With this statement, the couple members are not invited to agree nor disagree with the witness’s comment, because the witness is speaking solely of his/her own experience. The couple members are held on level footing with the therapist who is speaking, and are free to take in this reflection and explore their response to having touched-in withthe therapist who speaks in this way.

Use present tense.

This one can be a little bit of a mind-boggler, but it’s worth it! This part of the language comes out of the Authentic Movement tradition.  Here we can bring forward the intention to activate the portions of the brain and the body that experience in the present moment, even if that moment is brought forward as a memory from the past. This brings greater aliveness and intimacy into the sharing.

Social Speech Example: During a moment when a participant shares with the whole group, “I had a really hard time earlier in the workshop in staying present. I just wasn’t getting it and I touched into some old shame I had about being deficient.”

This is a vulnerable share, and certainly leaves room for empathy and contact. However, speaking (and tracking the body) in the present creates the opportunity for everyone in the room to come into the experience with the speaker. When we speak in the present, like we would when sharing a dream, we invite others into our immediate embodied experience.

An alternative:  “From the first moments in the workshop this morning, I find myself struggling to feel as though I get this work. I feel flooded and confused a lot.  I feel myself contracting…as if I should know all of this already, even though I know that a lot of this feels really new to me.”

Also: “As I slide back in time to when this therapy session begins, I am struggling to get the experience freshly with an open mind.  Now I feel relieved that I am finally being in the moment.”

Also: “I’m imagining I am sitting in the therapist chair (where David is sitting) and I realize I have no idea what to do. I’m totally stumped and feel this wave of anxiety rising right up from my belly to my heart.  I get this same anxiety in couples sessions in my office.”

Speak from Bodily Experience. (Seven Channels of Experience practice)

Using David Mars’ Seven Channels of Experience: Sensation, Emotion, Energetic, Movement, Auditory, Visual and Imaginal,  notice, identify and share from your immediate experience in “I statements”.  (See the Seven Channels attached below if you want more detail.)

Social Speech Example: In dyads reflecting about the experience of seeing the videotaped trauma treatment session in the morning, “I really agree with what is happening in the session. It’s like there’s a beauty in how effective this is.”

An Alternative: “As I hear David’s voice quality (auditory channel) I feel a speaking that somehow gets to my heart (energetic and/or sensation channel).

Also:  “I’m actually aware of heat (sensation channel) in my heart. This heat feels like it carries a kind of expanding energy (energetic channel”) that moves outward (movement channel).”

Also:  “I feel appreciation (emotion) for how the couple meets each other in this part of the session.  I hear something telling me (auditory/imaginal channel) that there is something real here.”

Also:  “I feel a bittersweet feeling…happy and at the same time shrinking away from you (combined emotion and movement channels) as I say this out loud.”

Rather than talking about evaluation and thinking, the conversation shifts into a vulnerability of inner reflection that reveals how both people are relating to an experience of stretching beyond the habitual that is “edgy”.

Generic Wording (Tactical Defenses): It, That, They, We, & You versus I

Social Speech Example: During a large group sharing on the day before the couple arrives: “It seems like we all want to help our patients…when you just ache with how much you can feel their struggle and want to be of help. It’s one of the beautiful and challenging things about AEDP.”

While this person is in touch with some very meaningful experience, she is subtly distancing herself from the immediacy of her experience by using the ingrained social speech of “you”, “we”, “that” and “it” instead of “I”. She is also blurring into attributing her experience to the whole group, which may or may not be true for other members.

An Alternative: “I’m aware of how much I want to help my patients, and I feel this ache in my heart for how much I feel so transparent in this work. I’m opening in new ways here today. I am grateful to be feeling so much compassion.   I am also a bit over my comfort level about all of this.”

Also: “ I feel confused and stuck in my head with all this language stuff.  I feel restricted from being spontaneous and I just want to say what I want to say the way I speak!  This feels a bit too-much-all-at-once to me“

“The Way I Feel You in Me” 

We have the opportunity in the workshop to “dream into” being the therapist, the male partner, the female partner and the therapist.  Rather than talking about them, the workshop participant feels into how each person is experiencing the other “within” him or herself.  This is going beyond empathy and toward unitive experience (Adler, 2002 ).  This is experiencing one’s self clearly and explicitly experiencing the intersubjective somatic field shared with another or others.  Some examples:

“The therapist in me feels…(this provides a way for the witness to step into his experience in the context of the therapist )…the courage to be vulnerable and confident at the same time.”

“As I put myself in the shoes of __________ who just took this stretch just now, I am noticing that I feel so free to speak the truth of what I am saying…kind of experimentally and yet with what feels true to me.”

“As I hear you say ___________, the therapist in me feels a little contracted and yet determined to trust impulse in the moment. ”

“As (female partner’s name) I am aware of my eyes gleaming in response to being recognized by my partner reaching out and touching my hand.”

The above is a brief introduction to these ways of perceiving, receiving and expressing in the AEDP Process Training model.*  I hope you will find yourself playing with going deeper into accessing and expressing new experiences with fresh reflections to go with them during the workshop.  These are all ways to bring forward stretches of bottom-up experience into your work with individuals and couples and your somatic connection to your self and anyone else with whom you communicate.

© 2013 Written by Jessica Wolk-Benson, MFT in collaboration with David Mars, Ph.D. and Karen Pando-Mars, MFT.*

* The Process Training model and the Channels of Experience have been developed by David Mars, Ph.D., AEDP Senior Faculty member.


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The Impatient Therapist

By Hans Welling

Abstract.  The author argues that an eagerness in the therapist to help the patient and go deep into emotion can cause unnecessary resistance and a feeling of invalidation in the patient.  Listening for the gifts that client give us may counter this attitude.  The author gives examples of where these gifts may be found.  In a clinical example an occurrence of impatience and its correction are illustrated.

As a therapist I am ambitious and impatient. Sometimes this is good because I work hard for my patients:  They have 100% of my attention and my wanting to help them.  But it can also get in the way when I want faster change, deeper emotion, more transformation, and I get frustrated. Worse than that is that the message transpires to clients that they are not doing good enough, which affects the safety of our relationship.  It’s a trap I’ve fallen into several times, discovering over and over that I was “doing it again”. Especially with patients with intense suffering and with demanding patients I am easily triggered into wanting to go too fast.

Two things have helped me.

First,  instead of focusing on where I want the patient to go, I focus on where the patient actually is. There may be defenses for sure, but I urge myself to focus on the wonderful deep and meaningful things the client is actually giving me. We receive without expecting:  It’s an open hand and a warm heart ready to receive whatever the clients want to put in there. There is something about my being aware of these defenses that, without even mentioning this verbally, promotes both safety and awareness in the client and in turn leads to opening up and going beyond these defenses.

The second is the radical notion of AEDP that everything the client does is adaptive, however maladaptive it may seem (Fosha, 2000). So if the client stops the process, changes the topic, or blocks, we notice it and accept it. If the client goes just so deep, or doesn’t want to work on something, that is very okay.  More than that, we must assume that the client has very good reasons for to doing so. We may just go with the client to the new direction he went, or we may make it explicit and welcome it by warmly inquiring,  “Hey, I noticed the tears stopped, what happened?”

The Dialectical Process

Linehan has made a similar point that there is an “inherent tension between validating a response versus trying to change that response” (Linehan, 1997, p. 367). She thus describes therapy as a dialectical process of both empathically focusing on the client’s experience and focusing on change.

Of course, we would like our patients to change in ways that diminish their suffering and promote their growth and fulfillment in life; however, that effort is often at odds with the need to feel safe and validated in their suffering. If we encourage the client to go beyond resisting or avoiding, we are implicitly saying, that  he  should change;  this is inherently invalidating of what the client is doing currently.  So we try to walk the thin line between validation and change.

Some clients are more sensitive than others and may detect the slightest signal of invalidation. Other clients come in with a strong conscious readiness to change and may even elicit in the therapist to show ways he could or should change. But also here there is the risk that the therapist may unwittingly be colluding with the self-criticism of the client.

Many times I still “go for the affect,” (as Diana Fosha calls it in her workshops) trying to bypass the defenses, but more and more, work with patients has become focused on recognizing the gifts that clients are giving to me spontaneously.  Here are some examples:

–Intense sadness announces the desire to change.

–Anger reveals protective resilience against pain.

–Unstoppable talking comes from the need to be understood.

–A question about my personal life may reveal a wish for closeness.

–The sharing simple facts and stories stems for the need to be heard and known.

–A subtle thank you at the end of the session is a huge relational gift to me and the tip of the iceberg of a client allowing himself to depend on me.

–A telephone call to a friend may show a big shift in relating to others.

–The “I don’t want to feel this pain again” is the first acknowledgement of that same pain.

–The vague smile that very shortly appears in the middle of a very sad story can be the beginning of shifting perspective and transformation.

–A patient reporting that “she wanted but couldn’t” is not a sign of failure but an opening for exploring anxiety and how this situation did not feel safe enough.

–A patient who apparently doesn’t want to talk about the pain of the father who abandoned him, is giving me a lot by telling me about his strength and the experience of how it was taking on life as a teenager without a father.

–The client who comes in with the huge defense,“I’m great, no bad feelings here,” is showing me right now something about a life of keeping suffering to himself. and having to show that he is happy.

However banal a story may seem I ask myself:  “Why is the patient telling me this?”  “What makes it important to her?” or “Why does he want me to know?”  However defended a client may seem, if I am perceptive enough, I can find meaning, underlying emotion, attachment needs, resilience or adaptive effort, informing me where to go next.  Rather then focussing on what the patient is not doing, I try to focus on and affirm what the patient is doing:  the connection, the trust, the wish to change, the honesty and the courage.

My wanting a certain change to happen and having a fixed idea of where to go, may often be useful.  And just as often, it can be an obstacle to really see what is happening with the client and where she really is.

This reminds me of Bion’s dictum of the proper attitude for starting a session as: “without memory or desire” (Bion, 1967). I adapted this slightly for my purpose into  “with memory, without desire,” as I find that the memory of what I have seen before in patients and in my own life helps me to recognize the gifts, potential and meaning of that is implicit in what the patients are offering me.

Case Illustration

Some of the work I did with Leonor taught me a lot about the importance of therapist patience. I think it illustrates the ongoing struggle I experience between my wish to help and how that gets me into trouble by losing sight of the patient’s experience.

Afonso, Leonor’s boyfriend , was killed instantly in a car crash. They had lived an exceptional love story lasting 12 years, starting when both were 14 years old. His life ended and her life collapsed. She returned to live with her parents, and had to stop working. She came to me one month after the accident and told me she needed help, that she could not do this alone.

Her main feeling in the beginning was that of horror and guilt, and of all the ways she should have acted to avoid his having to come home very late after work, when he was too tired to drive. She would obsessively try to find out details from of the accident, and replay the last telephone calls and the moment of the accident in her head. She would imagine how it must have been for him, what he must have felt and thought, trying to undo the fact that he had been alone in this last terrible moment. She kept as much of Afonso’s things intact as she could, and her room turned into a kind of mausoleum. She would visit Afonso daily in on the cemetery crying and having long conversations with him. After a few months, she tattooed Afonso’s face on her chest.

People around her worried about her and started to urge her to go back to her life and to think about the future, which would leave her furious, feeling misunderstood and alone. These reports were a warning for me not to make the same mistake. And although her reactions were extreme, I could relate to it as their love story was so truly beautiful and fully lived.

Being a psychologist herself, Leonor knew something about depression and at times would inquire if I thought she was depressed and if this mourning process was “normal.”  I said that by the criteria people might find her depressed, but that I didn’t care if this was a normal process or not. I told her normal people don’t exist anyway. Her whole love story with Afonso had been exceptionally intense, and so I said to her that we could only expect that her mourning process would not be ordinary or normal. I would show her how she was progressing by integrating and confronting herself with and all the aspects of this loss. She felt very validated and said she wanted to live this mourning as completely as she had lived the relationship. I was happy that she felt supported, and she acknowledged the safety and the enormous support she got from our work together. It was intense and painful but it was very real.

But there were times I doubted if I was doing the right thing. I questioned whether I didn’t allow (!) her suffering too much. Wasn’t there supposed to be a balance between supporting patients in their suffering, but avoiding to reinforce their pathology? Wasn’t I too much on the supporting side?  By the criteria, it was easy to label this as a pathological mourning (Welling, 2003). Wasn’t she avoiding experiencing his absence by keeping him so alive?

At those times I became impatient and I would, for instance, suggest letting more pleasure into her life, something she downright refused. Or I kind of hinted at the idea of saying goodbye to Afonso at which she reacted with shock. I felt we were getting in a struggle, that I was losing her and this was not the way to go.

I had to remind myself many times to really be with her in her experience at the place where she actually was and let go of my wish that she should be somewhere else. I wanted to be more attentive to the gifts she was giving me. There were all kind of subtle steps she was making;  all I had to do was notice them and make them explicit.

Every week she would talk about a different aspect of missing him: the conversations, his advice, him being when arriving home, watching movies together, his body, the planned children. At first I thought that missing was a way of not accepting his loss, but I learned to see how this was actually a process of facing the loss. She was doing the mourning piece by piece! Then I could make this explicit.

She would tell how terribly lonely she felt and now I would say how brave she was to face that Afonso was not there anymore. When she would say she would remember his hugs, and I could say that I understood how hard it was to have to live without them. When she said she was disappointed in her friends, who didn’t understand her like Afonso did, I could see that she was actually trying to receive something from them, even if their efforts disappointed her. I would bring it to her attention when there were days when she would come in lighter, which would then fill her with shame and guilt to be alive. I would gently remind her whenever she had initiated some activity she had never done since he died, after which she would make sure to tell me that it was not the same thing without him.

A year into the process after the holidays I got impatient again. I felt her process was kind of stuck, and her musings over Afonso were repetitive and didn’t seem to go anywhere. I told here that she had done a lot of work, that she had suffered enough, and that she might try to focus on things other than Afonso. Over a couple of sessions I felt we were getting into a fight again. I knew I had to change course and that I had gotten impatient again. As I was writing this article, I tried my own recipe: I tried to go back to seeing were she actually was.

After telling me how hard her week had been, I asked her if she wasn’t fed up suffering.  To my surprise she said, “No, I have a good reason to suffer.”   But isn’t there anything else you want for your life? No. But it was not a depressed “no,”  it was a determined no. I intuitively felt that this active renunciation of volition was important and I set up camp there. “Stay with that, what else can you tell me about this not wanting anything?” Somewhere in this session,  she spontaneously told me this seemingly unrelated story:  “The other day someone told me about the hole in the ozone layer getting bigger, and I thought I don’t care that the earth gets destroyed.”   I heard the anger in the content of this story and saw that she got activated emotionally while telling me this. I recognized that here was my gift. “So I see you are very angry at life for what it did to you,”  I reflected. “Yes, she said, it took away my love, my house, my job, and my dreams.”  “And if this is what life is about, then you don’t want it, you refuse to dream again,”  I conjectured. She agreed and we explored this anger and her rejection of life being so unacceptably unfair and cruelly random. I metaprocessed with her how it was to acknowledge this anger and refusal to live again here with me. She said it felt good and that she felt relieved. I felt this was pure, this is where she was and this is where we should be together and not try to be anywhere else. I felt free again of the urge to “do more” and we were on track again.

Soon after she proposed to be a day on her own in Lisbon, sleeping in a hotel like she used to do with Afonso to celebrate their relationship anniversary. Again, there was a gift here: She made a move towards autonomy. I just needed to make it explicit: “Wow, this is going to be the first time in a year and a half that you are going to spend a whole day alone with memories of Afonso. That requires courage!”

Now, three months after this article was written Leonor feels she deserves to enjoy the rest of her life and feels that she has her deceased boyfriend’s blessing to do so.


Bion, W. R. (1967).  Notes on memory and desire. Psychoanalytic Forum, 2 (3) 271 – 280.

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

Linehan, M. M. (1997). Validation and psychotherapy. In A. Bohart & L. Greenberg (Eds.), Empathy reconsidered: New directions in psychotherapy (pp. 353-392). Washington, DC: APA Press.

Welling, H. (2003).  An evolutionary function of the depressive reaction: the cognitive map hypothesis. New ideas in psychology , 21(2), 147-156.

I want to thank Netta Ofer and António Branco Vasco whose influence I sensed on several points in this article but are difficult to refer to specifically.


Attachment-in-Action: Movement-Inclusive AEDP as a Healing Catalyst

By Judy Silvan, LICSW

Abstract.   AEDP with a body activation component can enhance state completion and regulation. This paper discusses and demonstrates with two case examples how movement of energy is used as an affective change process.  Studied body movements are particularly useful and judiciously filtered into AEDP when other avenues of accessing, regulating, invigorating or integrating affect and energy are blocked. The therapist gently guides the patient through grounding or expressive body motions, attuned to the patient’s needs and introduced gradually. They are often done in tandem with the patient, while seated or standing. A solidly attached emotional container neutralizes the risk that movement of energy will incite shame or pathogenic withdrawal. Physical movements can (a) help “ground” the patient to prevent or reverse dysregulation, (b) soften defenses, and (c) deepen emerging affect.


“Play is the exultation of the possible.”Martin Buber

Growing up in an extended family laden with first-generation, traditional psychoanalysts, my early career veered into partisan territories. I was fascinated by Self Psychology in graduate school, and once in the field discovered experiential models such as neurolinguistic programming, hypnotherapy and psychodrama. My psychodrama teacher Dr. Ildri Ginn, a gifted Norwegian psychologist, invented a merger of psychodrama, (a foundation of ‘parts work’ including dramatic action), with bioenergetics, a movement-based psychotherapy.  She was instrumental in resurrecting a local bioenergetic training program in the late 1990’s. With a love for yoga with its grounding elements, and forever a fan of vigorous outdoor activity (cycling, swimming, walking, etc), I joined the training group with a sense of my body as ‘home’. I’d had little exposure to somatic or movement-based psychotherapy, yet felt inspired by my teacher, curious, and the bioenergetic training seemed like a path to follow with other colleagues who were innovative in their methods. Since studying Accelerated Experiential Psychodynamic Therapy (AEDP, Fosha, 2000), I’ve had a “click of recognition” (Fosha, 2009): Historically, what sings to me in any brand of psychotherapy, including my kinship with a movement-based model, is filtered into a deeply intuitive ‘attachment-in-practice’ lens. I was certified in bioenergetic analysis mid-career and gained a broad somatic and energetic clinical knowledge-base. I now theorize that carefully studied movement is at times a uniquely useful healing element in the context of the elegant, gentle, relational model provided by AEDP.

In my early years at family gatherings I professed employment of the body as a psychological healing entity to newly minted and older analysts, who barely listened with darting eyes. In retrospect, I see their awkward response was to the revolutionary notion, introduced by Wilhelm Reich in 1933 and now common knowledge, that the body could possibly be included in the concept or practice of psychological reparation (Reich,1933; Lowen, 1957; Van der Kolk,1994; Eckert, 2000; Fosha, 2000;  Levine et al, 2010). Ildri Ginn’s modeling suggested melding of the body’s movement of energy as a natural expansion of experiential and psychodynamic modalities, and this was pivotal in my development as a psychotherapist.

AEDP has vast capacities as an integrative model, while maintaining its own phenomenology and integrity, and is another radical divergence from psychoanalysis. While AEDP is a talk-therapy, it has a somatic value-base (Fosha, 2000, pp. 24-25). When direct use of the body is sought by patients and taught with proper care, the AEDP model allows for seamlessly adding an energetic and movement facet as one of a banquet of springboards to regulation and transformation. Before formal AEDP training, I leaned into an intuited, uneducated, and thus unreliable version of AEDP. Processing and internalizing AEDP’s rigor and scope initially took all of my focus and concentration. I nearly abandoned hope of refining body movement into my new knowledge base. Yet the glimmers persisted, and this matrix started to manifest in my work with certain patients.

Current Practice Matrix: AEDP with a Movement Element

In the bioenergetics world, I never had a permissive office venue for loud vocal expression, nor felt comfortable using prolonged physical touch or pressure. Both are common elements of classical bioenergetics as gleaned from studying with Alexander Lowen and others. On the other hand, through an AEDP lens with patients who choose to work with body movement, our dyadic attunement may lead to a careful exploration of the body’s energy towards a determined “YES!” (stand-alone, or as a precursor or follow-up to a determined “NO!”). At times permission to tenderly, firmly hold my hand on someone’s back during heavy sobbing, or a move towards them to touch our hands or feet or sit beside them during a moment of intuitive sensing, provides the attunement and security that is needed. These body movements, voiced expressions, and/or touch, are ideally avenues to a ‘state change’ (Malan,1997; Fosha, 2005). For example, gently dropping the arm with a soft fist, or some controlled kicking, while standing or even lying on a couch, can enable stuck affect to surface, open body constrictions, or integrate errant energy. Leaning one’s neck and ribcage back over the soft top of a chair can open the throat and support the diaphragm for fuller respiration, offering a release of laughter, sobs or other trapped core affect. Tracking energy, like all moment-to-moment AEDP tracking (Russell & Fosha, 2008), is a roadmap toward recognizing, integrating, or releasing collapsed, constricted or over-charged energy, and a path to healing and transformation. (Reich,1933; Lowen,1958; Rapaport & Gill,1959; Levine,1997).

Distressed energy is carried around in one’s adult body, often from a childhood or more recent traumatic event, or from complex family trauma (Levine, 1997). In AEDP, our dyadic felt-sense of safety leads us to soften and integrate this hyper or under-charged energy. When a person’s history and narrative revolves around shame through profound loss and/or betrayal in seminal relationships or sexuality, energetic exercises for releasing the blocked or un-integrated emotions are titrated specifically towards quintessential healing phenomena. The healing is based on the AEDP protocols (Prenn, 2011) of creating emotional safety through the field of secure attachment (Ainsworth & Bell,1970). A careful invitation to add movement may offer a down-regulation or an up-regulation of energy if needed by the patient’s nervous system in a given moment of clinical work (Porges, 2010). In turn the patient may feel more fully ‘seen,’ or less dysregulated if proceeded by a sense of invasion. Being dyadically together and including the body in this way can deepen trust and sparks one’s ability to ‘experience’.

AEDP has taught me that the most powerful use of body and direct energy movement thrives with a slowed-down introduction, with many pauses and check-ins to metaprocess. Gradually, if a person needs an energetic boost or regulation, we begin relaxed expressive body movement while seated together, understood as part of ‘talking’. For example, dropping the fore arms onto the side of one’s legs on the chair on an out-breath, and slowly repeating this gravitational movement several times with a light, open fist can be integrated into the clinical moment to arrest shame, transform fear, or calm an incipient sense of overwhelm. Time and again the resultant embodiment promotes a gentle surfacing of categorical affect, or State 2 (Fosha, 2000). Removing the shoes, and slowly pressing sock-bearing feet on a wooden massage roller while talking creates an internal state of solidity and body focus. Almost everyone can tolerate sitting facing one another while engaging the body in these ways, perhaps also verbally communicating, and working to maintain eye contact.  Eventually, after several weeks or even a year, a patient may seem open to standing together for active ‘grounding’, or for a studied expressive body-movement sequence (Lowen,1975).

Often, no movement (or even not speaking) at all is gleaned from dyadic attunement, and would not be considered or suggested with a particular patient. Strict adherence to an AEPD stance, as seen reflected in portions of the following transcripts, underlines that physical movement of energy can sometimes be a liability or cause dysregulation. AEDP repairs or revives whatever is dissociated or shut-down. So it is with all of AEDP: The dyadic connection and regulation, in particular, the therapists’ deft attunement to affective, expressive, aesthetic, somatic and energetic  markers, uses an educated right-brain intuitive stance as a basis for emotional safety. The safety is registered as healing through left-brain phenomenological recognition and transformational skill sets. Any addition of movement needs to be discriminate, and based on intuited and explicitly permitted capacities of the patient in a given moment (Fosha, 2000; Fosha & Russell, 2008; Prenn, 2011; Pando-Mars, 2011, et. al). All of these concepts can also transfer to couple or to group therapy situations (Mars, 2009).

Some people seek out a movement-based psychotherapy based on prior understanding of somatic psychotherapy, or based on wanting to release their body’s holdings or to relieve feeling ungrounded. An athlete or a person driven to lose weight may perceive movement in psychotherapy as a ’short-cut’, from an addictive tendency to perfect their body shape. In the latter case, an experience of attachment without movement can be feared as an expenditure of autonomy from which to control weight or sexual self-image. Body-shame and traumatic experiences previously expressed through dieting, binging, exercise bulimia, sexual compulsion or sexual avoidance become free to surface. Healing is accessed through carefully attuned AEDP, if the addition of movement is gradual and titrated to the tolerance peak of the patient. Emotional healing commences when the internal body-concepts are safely exposed, and the “true-self” (Winnicott, 1960) is given an opportunity to emerge. In relationship with a True Other (Fosha, 2005), movement is then re-experienced as neither harmful nor defensive. The body’s energy becomes modified, and an ability to experience unburdened vitality and authentic affect (including joy) can emerge with the body’s natural pulsations (Reich, 1933) in a relational therapy context.

When people seek body-oriented psychotherapy from the get-go, the desire is sometimes retracted after a few sessions, and requested and reintroduced once trust is solid in the relationship. (This describes the therapy trajectory in the second case below).  Motion-activated shame or dissociation is a crucial element for the therapist to scan and remain acutely attuned. The following transcripts both have portions where dyadic deconstruction of movement-induced ruptures occurs. The disruptions surface as an experience of “confusion” to the patient in both transcribed vignettes. The movements themselves, including dyadic repair around them, become central AEDP and energetic healing agents in unexpected ways.

In this matrix, the movements occur during a circumscribed portion of the session. We then sit down to energetically and verbally metaprocess. The movements lead to an Affective Change Phenomena or “deepening of rapport” (Malan,1997, p.20; Osimo, 2003, p.30), and can accelerate a healing event, through energy either coalescing, softening or releasing. For example, if introduced as a safe and soothing possibility during the beginning phase of a polyvagal shutdown, (Porges, 2009), the body-movements can reverse the energetic collapse and jump-start a revival as we see in case two. An individual can then return to a trusting, connected working state.

When the suggestion of a portrayal provokes an immobilization or shame state, a patient can also be offered carefully chosen physical activity. This might include grounding followed by a guided expressive release through the arms and/or legs. The tandem movement will likely decrease the sense of aloneness that often begets paralyzing anxiety or shame. Often no words are necessary for a few moments afterwards as both parties feel the energy shift  in ourselves, as a dyad, and in the room. When verbal communication resumes in the portrayal (during or after the movement phase), it arises from a deeper state. Delight, relief or pride can surface as a “transformative action tendency” when the patient moves out from under the crush of withdrawal, rage or overwhelming sadness (Fosha, 2009).

Case One[1]

James is a 46 year old, African-American, gay married male. He came to me years ago for couples therapy with his (then) partner who was an active gambler and drug addict. In the past he remained in relationships in a caretaking role. In this second treatment, he has a vital, sexually positive, mutual partnership, and has nearly erased his tendency to lose himself in an “enabler” role.  He is an underemployed standup comedian. We have a solid therapeutic connection, and while we have worked though most of what defeated his self-assurance in running a household, he yearns to move forward in his performance career. He inherited his parents’ house, and his new family lives there with him. Much to his pan-ultimate pleasure, he’s a few years into being a highly beloved stepfather to twin pre-teens, a girl and a boy, whom his husband of several years adopted in infancy.

By history, James experienced layered and complex trauma. He divides his childhood before and after his mother became ill (when both she and his father were over-attentive and “kept me on the shelf so I wouldn’t break”)  James was much younger than his two stepsisters, and grew up as an only child. During his pre-teen years, his mother developed an allergy leading to sudden severe brain damage and was nonfunctional from when he was 13 until her death when he was 40. His dad was an oppressive taskmaster with an OCD-personality style. He enforced zero discussion of the mom’s condition in or out of the home, enlisting James as his partner as primary caretakers. James has recognized previously occluded feelings of anger at his father and horror at his past, which involved feeding his barely conscious bedridden mother, then extracting the waste from her body daily, for over two decades. His father’s hubristic pride (Tracy & Robins, 2004) kept the mother from receiving the professional nursing home care she needed.

Thus James was prevented from having a relatively healthy adolescence, and along with being gay his emotional development was thwarted and burdened (Tunnell, 2006, p.139). Of note, his mom died eight years ago, and finally James and his sisters were able to express love to their dad who lived for six more months. The father’s frail state allowed him to receive love from James during these months. James’ own capacity to feel finally emerged, and he could enter therapy in earnest several years after his father’s death. The excerpt begins with James referencing his underpaid job as a historical tour guide. He yearns to free up what holds him back from his authentic acting gifts; his desire is to star in a comic television series to support his new family. He frequently states that working for this company is akin to “prostitution.”

(Talking about his job 5 minutes into the session):

Pt: The inconsiderateness…

Th: Where do you feel that? [visceral/energetic experiential inquiry]

Pt: I feel it in my ass (fists clenched)…

Th: Yeah… (mirroring his movement)… Do you feel it in your fists? [an attempt for Dyadic Attunement which backfires……]

Pt: I just did…

Th: Yeah.. (coaxing affect): Don’t lose it if you can, stay with it, with me…okay? (lightly tapping chair arms with loose fists) [joining him with emergent affect]

Pt: (fists push forward) I start to feel a little lost[confusion; red-signal affect]

Th: (gently) Do you want to stand up and feel your feet, feel your body? 

When moment-to-moment tracking reveals red-signal affect, I suggest we stand and ground together to help him regulate the affect. My “AEDP Decision Tree” (Gleiser, 2008/2015) guides me to channel his anger into a portrayal by following his affect and energy as our roadmap. Through our attuned relationship, I suggest he discharge some of the affect through his fists, which he experiences as also held in his buttocks.

The following movement and ensuing conversation is a composite of the transcript. The movement lasted approximately seven minutes before we sit. His energy, initially very present, quickly dwindles and he is left feeling confused. We make the disruption explicit, using AEDP interventions to course-correct and allow him a healing experience (Gleiser, 2008/2015). My hypothesis is that his spontaneous movement, while not concluded as planned, allowed enough energetic release and integration to enhance the subsequent rupture-repair sequence.

Pt: (Both stand up, James takes off watch, begins walking in a circle, fists move up and down) Rrr…ahhh…

Th: Do you feel your legs?

I continue to suggest physical grounding to prevent moving too quickly into an anger portrayal; he has shut down in the past when we haven’t titrated movement gently enough.

Pt: Yeah…(swinging torso and hands around)  [green-signal]

Th: Mmm… And let the feeling through…through your body…you know?

I’m feeling energized by his expression, thus we collude in skipping over a formal grounding sequence.

Pt: (anger quiets, backs off) I don’t know…I’m resisting and it’s not really what I’m feeling…[red-signal; his affect drains quickly from a few seconds ago]

Th: What is happening inside?

Pt: I’m not angry any more…Which part? [red-signal affect: confusion or dissociation arising]

Th: When we just did what we did—physically.

Pt: It feels good to move and all that…and I don’t mind doing it…but it doesn’t feel right…[yellow-signal; dares to be authentically vulnerable in State One]

The above sentence spoken by James indicates self-state recognition and trust; he is sharing a disruption with me. With AEDP as our paradigm, the apparent disruption is easily remedied. When he seems to be shutting down, we come back to the inhibiting event in a relational context, and we metaprocess the disruption (Fosha, 2000, p. 238).

Th: Ok…let’s stay with that part…the part when you were down on the chair. Do you remember? (Still both standing)

I return to the experiential moment when clear affect was present as categorical anger with an energetic charge. I offer repair by explicitly sharing with him what I saw, and next I will indicate that perhaps my behavior stops his flow. Our active AEDP stance, after the energetic disruption, continuously allows our safe attachment to wind in and out of interventions of moment-to-moment tracking, attunement, ruptures, dysregulation, repairs and ultimately core-state transformation (Prenn, 2011).

Pt: It was mostly when I did this (fists clenched)…

Th: (my fists clenched) When it first felt right… [Mirroring]

Pt: It was a moment of

Th: Yeah…what’s it like to share that with me and for me to get it…that this isn’t right? [metaprocessing; In retrospect I wish I had not interrupted here as he seems to be moving into State Two. We manage to get back on track as follows…]

Pt: Well, I’m not saying it isn’t right…I’m just saying I’m not…

Th: That’s right that you’re telling me that… That you’re able to be with that and be with me at the same time…like remember? [rupture-repair;   mirroring his bravery and making our attachment explicit]

Pt: Yes…

Th: That’s part of your central terror…of that little Jimmy…To say ‘No mom…this isn’t right…this is right’. [left-brain platform; refer to former AEDP-IR work we frequent with “Little Jimmy” (Gleiser & Lamagna, 2007). I offer more repair with James by explicitly championing him, versus faulting him when my instruction “doesn’t feel right” to him]

Pt: (both still standing) Sometimes I wonder what would have happened if I didn’t live in that same house…If I’d moved…maybe I just would’ve been freed up and never needed to come do this.. I don’t know…I don’t know…whatever… [state-change: emerging affect; James retreats to protect the vulnerability of deepening, when he ends his phrase with “whatever.”]

Th: Can you feel your feet right now? [dyadic tracking; I slow him down towards a more holistic grounding rather than the potential portrayal, which was not useful to him, apparently]

Pt: Yup…

Th: And breathe…

Pt: Not the way you’re describing it…[bravely, little Jimmie speaks up!]

Th: What way? [I sense receptivity arising]

Pt: I just feel like— I feel the rug…

Th: Yeah?

Pt: Between my toes cause I wanted to stretch them…[state-change, use of his tactile ‘channel of experience ‘ (Mars & Pando-Mars, 2012, 2013)]

Th: (softly) What does that feel like— all the stuff you just mentioned?

Pt: Really good…the rug is cool as I move my position…it feels very, very good…

Th: Yeah…can you peak at me and tell me about that? (pausing and waiting)… Yeah… [maintaining connection through eye contact]

When we acknowledge the rupture together, a state-change evolves, and he describes the pleasure of his feet and toes on the rug. The rupture and repair cycle includes re-initiating eye contact, and his comfort and safety strengthens. In the following segment, James deepens into core affect, then “tremulousness,” cascading into transformational core-states (Fosha & Russell, 2008).

Pt: Sure…yeah, no… [He says both “yes” and “no”, which implies disorganization. Yet he also trusts me enough to stay with the experience.]

Pt: (continues) It feels great…soft, cool, not exactly ticklish but almost ticklish…pleasant…soft, cool feeling.

Th: (smiling) MMMM.

Pt: And I still feel like I’m lost in this process but keep going cause I’m going along with it…[he initiates metaprocessing]

Confusion is beginning to overwhelm him, and he is seeking security from sharing that with me. I’m sensing another moment of dysregulation and suggest we sit down together as a means to re-regulate, to offer repair.

Th: How about if we sit back down and regroup? See what’s here between us right now…[explicit metaprocess; initiate down-regulation of energy]

Pt: I was gonna say ‘sitting down’ but I didn’t know…I don’t know that it’s the right thing…it’s just something else that we’re doing. [tracks his own anxiety]

Th: Well, do you know what happened that made you decide not to say, “let’s sit down…let’s sit back down”? [metaprocess for safety and dyadic-regulation]

Pt: Um…because I didn’t…I mean it isn’t like a huge life thing right now…I’m not understanding…not having a sense of…when we first got up…from this  (fists clenched)…to this (pounding fists) and the noise in getting up…that’s when I didn’t connect as much anymore.

He is able to moment-to-moment track-backwards, so even through defensive confusion he’s also emotionally reaching towards me with trust. Next we see subtle state shifts as he moves up and down “the triangle of experience” (Malan, 1997).

Th: Like you were attuned to your connection and disconnection. And then what felt good with your feet on the rug. [left-brain platform]

Pt: No, that’s good (nodding, eyebrows raised)…that’s good and newish[tremulous State Three (Fosha, 2009 p.188)]

Th: Newish…well, it’s newish for us, too. Cause I can be pretty stubborn, right? [naming the rupture again, then mini-repair in a playful way]

Pt: Like I said, I’m better and better at it…saying where I’m at. So…that was good too. [pride emerges; State Three]

Th: Yeah…

Pt: I’m still a little confused right now…but that’s still ok too. [tremulousness]

Th: Well let’s just make room for it, ok? Is that all right with you? (James nodding) Be with the confusion with me and breathe into the chair. [regulating and metaprocessing to help ground his energy]

Pt: I still don’t understand it, but that makes sense…[trust: Green Signal]

Th: Yeah…mmm…

Pt: Yeah (smiling). I get up in here a lot (finger circles around temple)…and totally forget about all this…(gesturing down toward his body) [recognition; shares somatic sensibilities; seems lighter]

Th: That’s very important… Right. Yeah…yeah…exactly…

Pt: I think that’s why I have a really high pain tolerance, or I never remember to pee…[Click of recognition: State Three]

Th: Right…yeah (nodding, smiling)

Pt: Which is good, but not good. [tremulousness] Even now…

Th: Even now…Yeah, what happens when you say that?

Pt: It’s sad. [core affect]

Th: Yeah…yeah…

Pt: Years ago, riding with Eric (ex-boyfriend) and we saw this guy in a parking lot…with a paper-bag… and I presume some sort of liquor…and he was just dancing in that parking lot…alone, homeless probably…but dancing[emerging new narrative]

Th: Yeah…

Pt: And I remember thinking to myself…he’s gonna feel like shit tomorrow…but in that moment, he is absolutely happy (sadness rises, chin quivers). [emerging ‘truth-state’]

Th: Right…and that brings you to tears again.

Pt: Yeah…

Th: If we can make room…make room for all of it, ok?

Pt: (nodding) Yeah…and then whoever is in that ambulance…(pause as ambulance siren enters and leaves)

Th: Right…the “patient in the ambulance part of me”..the “drunken dancing part of me.”. Right?

Pt: (nodding) You’re saying: “I love all of those parts”?

Th: Yeah…yeah…mmm…what happens when we acknowledge that? [spiral; dyadic attunement with tracking]

Pt: It feels really good…it feels like a real God connection…it feels like a little touch of a moment (raises hand slightly, pointing upward with index finger) of the bigger thing. [core state; transformance in action]

Th: Yes…yeah…I feel it streaming through my body, J. (hands sweep from head to feet. And I especially feel it in my feet. [self-disclosure]

Pt: (head tilts forward) I feel my feet…I was feeling my feet the whole time there. [pride emerges; energetic integration]

Th: Yeah…I bet you were…cause you’re connected.

Pt: I haven’t focused on my feet, but I didn’t suddenly feel my feet. I just was feeling my feet this whole stretch. But before this I didn’t.

Th: While you’re feeling your feet, tell me about the God aspect…the drunk dancer…the patient in the ambulance…loving all those parts of you. [coaxing him to stay with core-state healing spiral]

Pt: Because it’s real…It’s truth…[core state; the moment of “being” himself]

Th: Yeah…truth…Wow…that touches me…(hands rise up, body leans back and then forward again, smiling). [emotional solidarity through self- disclosure (Fosha, 2000, p. 230-231)]

Pt: It’s a little giddy almost…I start to giggle a little here.

Th: Well, you love those renegade-parts of yourself…that’s what you came in saying today (smiling), you know? That there’s a peacefulness. (hand circles in front of torso) [left-brain consolidation]

Pt: Oh, yeah that is what I started saying is that I have the crazy parts, then I have these calm parts and I know it’s all part of the (hands make swirling gesture)…journey that I’m going through…being real…being me…being the real me. [core state James]

Skip ahead 3 minutes; James references Danny Thomas, sharing with me that he is one of his idols:

Th: What happens when you talk about channeling Danny Thomas here?

Pt: Oh…that… I could just start crying…[core affect; spirals deeper]

Th: What is it that he does for you?

Pt: It’s the fact that he took the time and the energy to help these kids…

Th: Yeah…yeah…that’s a big part of you…that’s that real core…you were saying the core of me wants to help…that’s core James.

Pt: That is me. And I don’t mean this in a martyr-istic way at all; what I need is to be able to help. [genuine pride versus his dad’s hubristic pride]

Th: Right…you need it…in your bones.

Pt: That’s my…Energy[core state]

Th: That’s your energy…that’s life essence…..I know you, James…that’s why I feel like I won the lottery knowing you (lean forward, both laugh)…and working with you…[‘gluing the glimmers’[2], privileging our connection] 

Pt: I don’t understand why this makes me wanna cry (tears; voice softer)  [In this segment, James is moved by his emerging capacity to re-find feelings of love.]

Th: Stay with it…ok? Can we stay with the part that makes you cry?

Pt: (nodding) You should have been a lawyer. [playful connection; attunement-dance]

Th: I say that often! (both laugh)

Pt: Well yeah…thank you…that is correct…you are correct…

Th: Yeah…mmm…(exhale)…It’s so moving…it is so moving to me, James.

Pt: (nodding) Yeah…I miss it…I miss being loved (mouth squeezes as tears arise)…I miss being loved…[mourning of self; core affect]

Th: (gently coaxing) Yeah…stay there…(stay with him)

Pt: (tears) I felt love from my mom…felt love from Howard….With my dad, I only ever really got intellectual love.

Th: Tell me about how much you love your dad and miss your dad.  [In this statement, I override his young self’s need for defense against being able to love his dad, which he calls “intellectual love.”]

Pt: I miss what we barely ever had…(sobs emerge)

Th: MMM, (pause) Right…you miss what you didn’t get to have…

Pt: At the end of his life…Dinged…just nicked…I mean we could see each other…or we could feel each other’s gravitational force…[State Three metaphor, core affect, yearning]

Th: Tell me what the force feels like…

Pt: That we were able to say I love you…to each other…back and forth(more welling up with tears[State Four: love.  We continue with full cascade of core states for another 10 minutes until session is finished.]

Case Two

The second case excerpts a session after 10 months of working with a straight, white married female, age 44, who is the mother of a second-grade daughter. Laura came to therapy as an educated consumer; she is a practicing psychiatrist and currently training in AEDP. She has been in several non-AEDP psychotherapies in the past with little feeling of success.

Initially in our work, Laura asked for “body-therapy”, then completely abandoned movement by our third session. The week before this session, in relation to difficulty relaxing and being sexual unresponsive in her marriage, she asked that we re-introduce body movement to 1) regulate her anxiety to meet her deep desire to heal, and 2) to reconnect with a sexual self that she felt was robbed by her parents in puberty and adolescence. We had begun the movement the previous week and established an explicit need to repair the following rupture: A month earlier she insisted I see her husband for a session when he refused to see any other therapist. When I suggested he see someone else, she emailed the day of her session saying he was “coming in my place; I’m traveling for work and he wants to meet you.” I saw him that day, framed as a way for us to meet, gain trust to support Laura’s therapy, and to give him a well-matched referral for himself.

This transcript is the second of two repair sessions. In the first, she shared her need to withdraw in relation to me. Over the course of the full session we were able to uncover her truth: Some of her sexual withdrawal with her husband and current patterns of shame in relation to our work involved me meeting with her husband, John. There was dissociation and a memory lapse around “sharing” me with John, which had initially been set up as her own session.

This transcript begins as we stand four feet apart, me facing slightly to the side. I titrate our physical distance and orientation based on energetic and verbal dyadic-attunement (Siegel, 2007).  Beginning with a grounding sequence can be useful as an antidote to shame or dissociation, both common states for Laura. Grounding together in this session also crystallizes our mutual, emergent understanding of an absence of energetic sensation in her gut down through her hips, pelvis, and legs, into her feet. She describes her legs as feeling “floaty” or “rubbery,” along with a muted sex drive. She is dropping her energy down through her pelvis and legs towards the ground that holds her (Lowen,1977). Together we bend forwards, relaxing our heads and necks, fingers and hands dangling, tailbone up towards the ceiling like ‘rag-doll’ in yoga.

Th: Would you be willing to put your heels out a little?

Pt: (readjusts position, looks down towards feet)…

Th: (pause) Imagine sending your energy down through your legs towards the floor…on the out-breath…bend your knees slightly (demonstrating) so you start to feel your legs on the in-breath as you straighten them…Synchronize your breathing with bending and straightening your knees. (gentle voice)

Pt: (breathing is rhythmic and slow; she looks down)

Th: Wiggle your toes a little…yeah…(pause)    Can you feel your legs and feet?

Pt: Uh…yeah…they’re somewhat connected…yeah..I’m like halfway there…it’s still a little floaty but…(shoulders round forward, gazing down at feet)…. [ground to reduce “floatiness”]

Th: (gently) Do you like my directions? [metaprocess; enhance safety]

Pt: Yes…(slowly stands up to answer, arms float up from sides)

Th: (pause) Haaaa…hmmm (I demonstrate a “dive” position)…So put your knees forward and straighten your back behind you. Turn your head towards the hip that is on the same side as your head, and then very slowly the other way…so you’re wagging your tail and using your wide-open eyes to look behind you as you move.  Synchronize your breathing with the wags…haaaa(We slow our breathing down together; slow eye-movement used to loosen ocular blocks.) [dyadic-attunement in motion]

Th: How’s the floaty feeling? [Checking in, tracking]

Pt: It’s a little bit less floaty.

Th: (both of us stand upright now) Here, I want you to try one more thing, ok?  (pause) And just…bend your knees and breathe out (I exhale, while my soft fist drops towards the floor from above my head).  Very slowly alternate arms– letting their weight drop them down on the out-breath.

I choose this motion to encourage an experience of energetic discharge of the tension and anxiety in her head and upper body, to experience weight and soma in her legs and feet.

Pt: (repeats movements, exhales audibly while alternately each fist drops).

Th: Can you feel your feet each time? Follow with your eyes so they end up looking down to where your hand drops.

Pt: Ok…(deep exhale, arm slices down through air, movement repeated)

I non-verbally guide us to stand up and move back to our seats to meta-process and remain connected.

Pt: All right…(smiling, crosses and tucks legs on chair, clasps hands on lap)

Th: (gently) How’s it going, in terms of just our presence and contact? [energetic check-in and metaprocessing]

Pt: It’s going pretty…like better than average but…but still like, not fully comfortable…

Th: (check in after last session’s rupture/repair)  So, last time what happened? I mean you wrote me that really sweet text after the session…

(I do not read it to her although I share it here to illustrate our process): “That was transformational! Judy, that was quite a session. I feel a bit internally reorganized like we moved some organs around in there, made some room for some new stuff.” [“newness;” tremulousness; gratitude]

Pt: I wrote to you? (head tilts) [dissociated memory lapse; red-signal]

Th: (laughs) It was something like…thanks for the great session…it was sort of a thank you…

Pt: Did I ask you anything in there?

Th: I don’t know…I’m just asking you because I like to bring it back between us. [making the implicit explicit]

I acknowledge her enthusiasm and outreach to me between sessions to help her to become present through our shared relational experience. I intuit our need to continue the repair we began last week.

Pt: (nodding) Yeah…

Th: Yeah…Is there anything from our experience last week that you can bring in? (pause) We did a lot of talking and finally got to trace back a lot…We used the word “repair” a few times…

Pt: Oh right (eyes wide, energy rises)…that’s right, ok…We were talking about our relationship [green signal]…I guess…maybe I’m doing too many things and I’m just not remembering each one very well…in my life right now…[begins to regulate]

Th: More what matters here is… How’s it going now between you and I?

Pt: (laughs, chin lowers) Yeah…it’s better than it was a week ago…Just basic trust stuff… So I thought more about it and found the email I wrote you saying John was coming instead of me. I’d completely forgotten that. [green signal]

Her dissociation is waning, her memory is now accurate and she trusts telling me so. She’s moving to a point of stability from which to deepen.

Th: I’m taking this in Laura. “Trust” is your word here and it’s, you know, of course, one of my favorite words too.. [playful self-disclosure]

Pt: And you said in an email recently— That it’s real…You were like, “It’s a real thing, Laura”[deepens to State Two]

Th: Oh…(softly)

Pt: You were more normalizing. Yeah.. You said this ebbs and flows and it’s real and it’s worth our like…time and attention…(palms open and close). As opposed to just like…yeah, we have to like build our trust back up again…[State Two trust]

Th: (softly and gently) Right, right, right[cooing her…Solidifying repair we began last week]

Pt: Like it’s a real thing…[recognition and safety]

Th: (gentle voice) As opposed to trust being an aside…It’s very central…I can feel it right now in the room… [self-disclosure]

Pt: I just remembered…I just know that last session it was uncomfortable in my body (hands raise up, elbows bent) [She initiates metaprocessing.]

Th: We did some kicking. In the semi-beginning…like that…(I point to the couch).

I’m referring to her being prone last week while kicking the couch; I immediately saw it dysregulated her. Thus I led her to sit, with us facing one another.

Th: Oh yeah…that’s right…it was kind of shameful to have you see me (head turns to side)

Th: Ohhhh….

Pt: In a…in a prone position…Like, in a more exposed way…it was yayeee (head jiggles, makes goofy noise)…[red signal]

Th: To see you lying down? So let’s not pass this by that quickly, okay. I wondered about that…I remember asking, “Where do you want me to sit?”…Is there anything about that part of last week’s session right now? [initiating more repair]

Based on her request last session to re-start movement in therapy as related to her lack of sexual energy, I had suggested she lie on the couch and slowly drop one leg at a time, kicking from her hips to activate and/or integrate her pelvic energy. Her response, which she again brings to my attention here, suggests that the movement was a dys-regulating rupture.

Pt: At some point in the process early on…we did the first really deep and vulnerable thing…Maybe it was when we were talking about being four years old or something…Since that point, I think, I am more embarrassed and shame-prone around you in our session because …I know that we could go to those places…

Th: Well this is really important. I remember at the time… you were saying, “This is a hot potato”…We established that—together, that it could re-surface in some form. I appreciate you sharing it….[making explicit our “we-ness” (Prenn, 2011)]

Pt: (eyes wide, nods) Cool..yeah…so like looking at you…looking at people is hard for me…just like looking at people in their faces is like …[green signal; deepens to State Two]

Th: Well once in awhile…I’ll remind you…”Can you peek?” And it opens up a whole new experience for you–the stuff that you don’t get to talk about in life…[platforming]

Pt: That’s true, it does…yeah…so like…so, I’m basically like…opening myself up to you…on a pretty regular basis…[State Two] And there’s kind of steady level of like…embarrassment and kind of shame hanging out.  [Her shame transforms to an adaptive state.]

Th: Stay as present as you can…we’ll work with whatever happens… I know…You said last week, “I don’t know what to say when you ask ‘What’s it like?’” [more repair]

Pt: (laughs, head tosses back[green signal; relaxing] Yeah, but I’m trying to do the right thing (fingertips lightly and quickly tapping)…I’m trying to be a good therapy-student. [playful State Two]

Th: Well you’re trying to do both, and you definitely get an A+ as a therapy-student in here… (gentle voice) And, you’re also being real, Laura. [affirming her strength]

Pt: (tosses head back and laughs) That’s good…(tilts head). (green signal!)

Th: And when you let yourself believe me for those moments…for those split…seconds…like little sparks…Could we stay with that for a second? [more affirming; slowing her down]

Pt: Yeah, there’s like light coming in but there’s a little thing in there and it doesn’t want to come out…it’s not gonna like run out and be exposed and do a little dance…it’s gonna stay in there and just kind of ….(voice trails off)

Both possibility and shame are present in her experience now. She is telling me she feels safe to explore this small, young part.

Th: Mmmm. I really don’t want to abandon your little thing, and you…

Pt: Yeah…but it’s not comfortable under there though so…it’s like an overarching wet blanket over the whole scene. [referring to last week’s metaphor of shame being like a “wet blanket”]

Th: And now?

Pt: (inhales) Um… Yeahhhmmm…I don’t know…now I’m just kind of more generally anxious (hands make swirling gestures above lap; remote look) or something. [red-signal withdrawal; incipient dissociation]

Th: So what if we stand up again…do a little more grounding right now…a little more energy stuff?

Laura describes the ‘shut-down’ as it is happening; she’s now dissociating with shame/embarrassment. I decide to quickly switch energetic tracks, leading her in a brief yet powerful movement sequence so we can remain on course and reverse the energetic collapse. She easily accepts my attuned invitation.

Pt: Ok. (fingers form prayer mudra in front of mouth)…

Th: (gently) Are you willing? (Laura nods as we both rise to standing.) Let’s try it… [asking permission/inviting]

Pt: Ok…(standing about three feet apart, facing in the same direction)

Th: Alright, feel your feet, and send the energy down…

The constancy of my voice and tandem activity soothes her. With an energetic discharge, my intention is to reverse her shame-based confusion and micro-paralysis. I guide her to stand and move into an embodied state. I model, and together we bend our knees with an audible exhale on each swift down-stroke, alternating arms with soft fists lifted behind our heads and falling fast towards the ground in front of our legs. Our energetic action lasts 45 seconds; I gesture us to sit and metaprocess the experience.

Th: (both seated now) Do you mind pressing your feet on the wooden massage roller to feel them as we keep talking?

I am guiding her to stay grounded by engaging her feet while seated, hoping a regulated energy state will solidify.

Pt: (noticeably brighter, more present and relaxed) It’s easier to look at you now…I feel like I’m a little bit more on equal footing…than like being down or like…powerless or something…When it’s hard to look at you…I am a little bit down and you’re like a little bit up (one hand high above head; vital, relaxed affect). [immediate regulation occurring]

A new relational reality is emerging (Fosha, 2009, pp. 3-4), which she marks by a state of “equality” and symmetry between us. The movement was pivotal in transforming her shame from paralyzing and maladaptive, into moments of vulnerable adaptive shame, which can now be unfolded for healing.

Th: (gentle soft voice) And….When we are on the same level, what is that experience like…if you just stay with it (mirror spherical hand motion)…if we can stay with it together for 20 seconds? [asking permission]

Pt: Yeah…And it’s kind of… (gazing upward, hands clasped) Also…where do we go from here…if we’re on the same footing then like there’s no more work to do. (tears well up) [tremulous state change; enters State Three, then backs up quickly fearing vulnerability, overwhelmed by a sense of loss]

Th: What a brilliant question…it’s so great that this is what’s coming up and then you’re sharing it…(exhales).. [affirmation]

Pt: (head bows forward briefly) OK…(tearfully)

Th: (soothingly) Yeah…don’t worry Laura, I am not gonna abandon you[making the implicit explicit]

Pt: (slaps knees, smiles) That’s so good! [state change]

Th: Yeah..Is it touching when I say that?

Pt: It’s like “Really!?” or  “Let’s play, I’m so excited”… rather than like (voice contained) ‘Oh…thank you Judy’…It’s like a little, little kid who’s running around. And there wouldn’t be like any “positions” that we have to deal with…[core state vitality; emergent click]

Th: (smiling) Yes, Let’s play! [joining her core experience of relief/joy]

Laura spontaneously moves into AEDP-IR parts work (Gleiser & Lamagna, 2007). Her 4-yr old part is transformed from the near mute, shame-ridden 4-yr old we’ve met prior to this. She moves down to invite a relational uplift between us. Her metaphor of being “little kids” together is unburdened by roles and positions in contrast to her shut down state before the interlude of swift movements. Now she is energetically and socially unconstrained.

Th: Like when you playfully braved helping me park this morning…right? [platforming and metaprocessing]

Pt: (chin rises, laughs) [recognition]

We metaprocess her shame about stepping out of role by spontaneously directing me in parallel parking right before we met: (“Maybe you wanted 3 more fucking minutes to yourself before you started working…”). She now feels accompanied versus separated, and tells me that each night when she’s finally able to let down, she chews on shame related to events during her day, such as taking the risk to help me park my car. We succeed at undoing her deep sense of aloneness (Fosha, 2000), leading to an emergence of core-state pride at her relational warmth and effectiveness.

Summary and Conclusions

In AEDP, the body unequivocally holds energy and trauma, somatic memories and accessible affect. These cases show the body’s capacity, in conjunction with rupture-repair and guided AEDP protocol, to inspire affective change processes and deepen into transformative experiences (Fosha, 2009). The movements are structured and led by me, and tend to be subtler and softer than classical bioenergetics. They allow palpable shifts in these two patients for deep healing states, as the energy safely unfolds. My careful guidance includes when to introduce and/or end movement, what movement to suggest, how to carefully attune to the patient before, during and after the movement phase, and when to sit down to metaprocess– with AEDP as the overarching healing paradigm. Neither case demonstrates classic bioenergetics and exemplifies my theory: Movement-inclusive AEDP is a means of using elements of body-oriented psychotherapy under the auspices of attachment-in-action. I purposely did not include cases where a strict Bioenergetic Analysis paradigm was maintained; I now use movement, energetic technique and theory only inside the parameters of AEDP.

The patient in the first vignette, James, is less comfortable working directly with his body. “Resistance” (his term) came up repeatedly in our prior treatment years ago, when he sought out bioenergetics. This time around, with a movement-inclusive AEDP paradigm, James is boiling over with dischargeable energy as the session begins. When I suggest he stand with clenched-fists and move towards an anger portrayal, he complies and our attempt to engage the anger is too avid. We remain loyal to moment-to-moment state tracking without judgment, and follow his energy and micro-state changes. He experiences an energetic core affect of sensory delight, exclaiming a state-change. Returning to sit together allows him a different sort of shared energy than the rigorous movement. We metaprocess the dysregulation, and he spirals into a “safety and repair” sequence. We are able to deepen into State Three, maintain it, and move into a cascade of transformational core state (Russell & Fosha, 2008). The movement sparked an energy shift with charge and discharge (Lowen,1957) reigned into both inter and intra-psychic AEDP healing phenomenon.

In the second vignette, we explore adaptive shame through rupture/repair, which began the prior week. Structured “grounding” to begin the session begets an intra-psychic, intra-body, and inter-personal connection, helping her avoid dissociation for most of the session. We work in deepened states and revisit the prior weeks’ experiences to continue repair of feelings of overexposure, while Laura manages to stay emotionally present and connected. We transform her shame into workable vulnerability, spontaneously leading to an intra-psychic AEDP-IR moment (Gleiser & Lamagna, 2007) with the “little thing’s” appearance. Despite this part’s strong pull to hide, she dares expose it to us, when suddenly an energetic collapse begins. I respond swiftly, by leading her in a second burst of movement chosen intuitively to jump-start regulation and bypass maladaptive shame. Her energetic self-state revives through tandem movement and metaprocessing, and successfully deactivates her shame. She experiences joy and playfulness, a healing core state. We share a felt experience of true play, and explicitly explore the trust and equality we’ve developed which organically surfaced. Despite her complex trauma history, sexual anxiety, and inhibiting energy blocks, through a course of steady dyadic-attunement including movement, we deepen into healing processes. Our work in this vignette leads to a transformance phenomenon, and she reports that she sustains this ‘true-self’ in her family and marital life. (Russell & Fosha, 2008; Winnicott,1960).

[1] Identifying information is disguised to protect confidentiality for both patients.

[2] “Gluing the glimmers” is a concept introduced by SueAnne Pilierio.


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The Judicious Use of Touch in an AEDP Treatment: Responding to Developmental Need and Transformance Drive

By Hilary Jacobs Hendel, LCSW

Abstract.  The use of touch in talk therapy has long been considered controversial and even taboo. However, touch when used thoughtfully and judiciously has the potential to facilitate healing. When confronted with the developmental and core need for touch, psychotherapists should have the ability to think through when it could be helpful and when it could be harmful. This paper considers the use of touch in a clinical case and the way it is negotiated by the patient-therapist dyad.

This paper discusses an AEDP treatment where touch was incorporated into the work. I discuss viewpoints from the literature; some considerations regarding the use of touch that are born from the sum total of my education and training both as a psychoanalyst and an AEDP psychotherapist; and my specific rationale for incorporating touch into this particular treatment. A verbatim transcript from a mid-treatment session illustrates clinical work with touch. At the end, I present some general guidelines for the judicious use of touch.


Touch in psychotherapy is a controversial topic. Freud used touch in his early work but later denounced it citing the dangers of touch where intense transference exists. Since then, psychoanalysts, lawyers, risk managers, and ethicists have advised psychotherapists to rule out touch as part of talk therapy with the main reason being that touch is a “slippery slope.” The slippery slope argument that has dominated current practice results from the lack of theoretical distinction in the psychoanalytic literature between nurturing touch and sexual touch. But, it is precisely that distinction which matters in a thoughtful discussion on the use of touch by a psychotherapist.In the early to mid 20th century, Object Relations theorists such as Rank, Klein, Fairburn and Winnicott, shifted the focus to pre-oedipal development and opened a door to differentiating between sexual touch and early developmental needs for soothing touch. Harlow and his famous research using wire and cloth monkey mother surrogates (Harlow, 1971), followed by a long line of infant-child and attachment research furthered our understanding of attachment and the need for physical touch to provide comfort and affect regulation in infants and babies. Attachment research, not to mention intuition, validates that touch is paramount to healthy development especially in infancy and childhood.  Currently, body psychotherapies like the Alexander Technique unabashedly use touch. As Zur (2011) note, other body psychotherapies such as Reichian (Reich, 1972) and Bioenergetics (Lowen, 1958, 1976) use touch as their primary tool in psychotherapy, see its value, and endorse it as a therapeutic tool whole-heatedly.   Additionally, experiential psychotherapists routinely touch patients as when they are tapping on a patient’s knees during EMDR processing, pressing on a patient’s stomach to “take over” physical tension as practiced in Hakomi (Kurtz, 1990), or having the patient push against the therapist’s hands to experience the physicality of setting boundaries as in Somatic Experiencing (Ogden et al., 2006). Furthermore, some talk psychotherapists will touch their patients when the patient initiates so as not to insult or embarrass them. Examples of this type of casual touch include a spontaneous hug, a handshake, a kiss on the cheek, or a “high five” as a show of support. Most psychoanalysts are highly opposed to any form of touch in therapy (Menninger, 1958; Wolberg, 1967; Smith et al., 1988). However, many other orientations support the clinically appropriate use of touch (Williams, 1997; Young, 2005; Zur, 2007a, 2007b). The literature is replete with pros, cons, guidelines and advisements on touch. Zur and Nordmarken (2011) have written an exhaustive paper on the clinical, ethical and legal considerations of touch in psychotherapy.

Touch, like all psychotherapeutic interventions, has the capacity both for harm and for healing. Rothschild (2000) believes that, in some cases, judicious touch is useful as long as client and therapist agree.  It is crucial to think before acting; to understand the counter-transference and transference implications; to collaborate with our patients about potential benefit and harm, all of which will result in making wise clinical choices. Surveys of clients who have experienced touch in psychotherapy indicate that touch reinforced their sense of the therapist’s caring and involvement. The findings also “support the judicious use of touch with clients who manifest a need to be touched, or who ask for comforting or supportive contact” (Horton et al., 1995, p.455).

Years ago, during my analytic training, before I ever thought about actually using touch with a patient, I remember reviewing the NASW’s and APA’s guidelines on touch—mostly out of curiosity. I was surprised at the time, since the taboo felt so strong in my mind, that neither of them expressly prohibits touch. They do expressly prohibit sexual boundary crossings and imply the essential message for all caregivers and health professionals:  Above all, do no harm!

Being held is a profound developmental need. If a patient has been deprived of this basic need, it makes intuitive sense that a therapist’s skillful use of touch could foster healing. There is also an argument that not using touch when needed might hamper healing or even cause harm.  For patients who were denied adequate physical affection or were outright neglected, not tending to these developmental and basic needs for physical comfort and soothing, when needed and/or requested, could be construed as an enactment of the original trauma. Instead of a blanket rule against touch, I think a better way to think about touch is whether it could move someone toward transformance[1] (Fosha, 2007) and healing, versus re-traumatization. I consider touch the way Ron Kurtz (1990) of Hakomi Therapy does, that it is a form of nourishment.  He believes, and my observations concur, that if a therapist provides the right nourishment that the patient truly needs, the patient will accept only what is needed and when replete with nourishment will move from dependency to exploration of the world at large. In other words, supplying what is truly needed will lead natural development to continue.

Case Presentation

My patient is a 29 year-old single, college educated, bi-sexual, woman of Russian Jewish descent who grew up in the southwestern part of the United States. Sara, as I will call her, was raised in an intact family by a verbally abusive mother, who relentlessly screamed at her for doing anything other than validating her mother’s own wants and needs. Ever since she can remember, Sara was yelled at for using the “wrong” tone, for saying the “wrong” things, even for having a flu or throwing up when she was sick. Sara never knew what would set her mother off and therefore had to constantly monitor her mother as well as her own verbal and non-verbal communications. She has a loving father who allowed the abuse to occur because of his own fears of the ramifications of intervening. The father, as well as Sara, suffers from Obsessive Compulsive Disorder (OCD). The father’s OCD led him to criticize Sara for being dirty and thereby left her with a belief that she is disgusting. Between her mother’s mental illness and her father’s aversion to natural body secretions and odors, I wonder if Sara was adequately held.

Some of her problems at the start of treatment include: OCD since age 6, fear of emotions, fear of assertion, intense focus on pleasing others to avoid anger at all costs, and difficulty knowing her own needs and wants. All of these problems make it hard for Sara to be in relationships and, consequently, leave her feeling isolated, alone, depressed, and anxious. She is extremely hard on herself and, when I first met her, engaged in self-harming behaviors such as cutting and head-banging. These behaviors seemed to act as self-punishment for her perceived badness, but also may be maladaptive attempts to regulate skin pain (pathogenic affect) caused by early neglect.

In our earlier work, Sara was terrified that she would anger me. Triggered by any sign she interpreted as my displeasure, I witnessed her plunge into frozen uncommunicative states.  I was unable to do much for her in those moments except to reassure her that I was not angry (and I was not!) and remind her I was here. Inquiring after these episodes passed what I could do next time to be of more help, she would instruct me to just stay quiet and let her be still until she naturally calmed down on her own. Over time we experimented with other ways to help her “come back” such as grounding her feet on the floor, breathing, talking about light-hearted things like her favorite television shows, sharing with her what I thought she was experiencing in the moment, and finally extending a hand for her to hold on to if she wanted. All of these interventions helped yet it took her a while to recover. My thought was that the threat of my anger connected to the pre-verbal memory of her mother’s frequent emotional abandonments and the accompanying emotions of terror, rage, despair and massive amounts of anxiety.

The treatment has focused on helping her regulate anxiety, differentiate me from her mother, build her tolerance to the full spectrum of affects and their accompanying experiences including body sensations and impulses, and recognize and process core emotions to completion (Fosha, 2000). Additionally, I am helping her become familiar with and gain separation from younger selves or “parts” (Schwartz, 1995), also referred to in the literature as self-states[2], so she can listen to their needs and respond. In fact, a main theme in our work is managing the intense longings of these younger self-states, which I will refer to as “parts” or “selves.”  Facilitating a dialogue between parts of the self makes it possible to manage internal conflicts and transform maladaptive coping strategies, such as self-harm, into adaptive ways of dealing with conflict (Lamagna & Gleiser, 2007). As internal parts come to understand and accept each other, self-compassion, not to mention self-awareness, grows exponentially.

By her own report, throughout her life she has sought out mother figures in the hopes of receiving some of the mothering that these younger selves need. I am the most recent of these maternal figures and the maternal transference she has towards me is strong. These strivings are adaptive and resilient in the sense that she is looking for something she truly needs. They are maladaptive in the sense that she can’t ultimately obtain what these child parts need from others as the demands are too high and healthy adults in relationships have limits.  Only her present-day Self (Schwartz, 1995) is uniquely positioned to care for her younger selves. I explained this concept to her early in the treatment, i.e., in service to her being able to sustain an adult loving relationship, ultimately it is in her best interest to be her own good mother.

When we first began working, younger parts didn’t want comfort from within. They wanted it from me. This is something we still work actively together on shifting. As the treatment has progressed, internal parts are relating more and more to each other. As a result, her self-compassion is growing. In essence, we are slowly transferring the job of caretaker and soother of her younger selves from me to her.

Sara and I have always worked collaboratively. She is honest, hardworking, communicative (except in certain distressed states after which she can reflect on experience quite well), and we have a great appreciation for each other and the important work we are doing together. From the beginning, her longings for and access to me were major themes. Teaching and modeling boundaries is extremely important in our work, as her mother disrespected hers with verbal assaults and, as a result, setting boundaries was not modeled properly. Contact between sessions was discussed and at times I set limits. Having extensively discussed the importance of boundaries in good/safe relationships, I knew Sara had a sense of me as a well-boundaried therapist. She was aware that where boundaries were concerned, I considered and modeled taking care of myself as part of the equation. Consideration and establishment of boundaries is especially important when a treatment includes the use of touch so the patient feels safe accepting what she needs without fear of other boundaries being transgressed by the therapist.

Prior to first holding her, I had thoroughly examined my own thoughts and feelings about touching Sara. I thought through, both on my own and in supervision, my motives and goals for acting. I had thought through her possible responses. We had a history of being able to successfully process ruptures and metaprocess[3] (Fosha, 2000; Prenn, 2009) our interactions together. We discussed my touching her before we acted and subsequently metaprocessed the experiences.  We also discussed how others might judge my holding her (which was an issue she raised) and how she would feel and deal with those imagined judgments. Other issues we processed included her fears of becoming dependent on me, her fears of my feeling manipulated, and secondary sexual gratification she might obtain. These preliminary discussions were the foundation on which I allowed our work to expand into the realm of touch.

My decision to sooth Sara through holding her in my arms came after months of working together.  Early in our work, Sara would be triggered into a very dysregulated freeze-like state whereby, among other signs and symptoms characterizing her distress, her skin would hurt, “It feels like I have no skin.” Inquiring into the sensation to see what it needed, the need to be held was the answer it gave. Sara’s body told the story of a developmental deficit which needed transforming. Being adequately held and soothed is a crucial state of development. Lipton and Fosha (2011) write, “Beginning at birth, right-brain-to-right-brain, contingent processes such as holding, touch, gaze sharing, face to face contact, entrained vocal rhythms, and spontaneous moments of play and delight are crucial for (i) the regulation of the autonomic nervous system, (ii) optimal brain development, (iii) the emergence of stress- and affect-regulation, and (iv) the creation of secure attachment” ( p. 5).  When a baby or child is not adequately held and soothed, the child cannot bear the distress and the mind adapts the best way it can to survive.

The need for touch and holding, from an AEDP perspective, is considered an attachment striving, a core need, and an inter-subjective experience of pleasure (Fosha, 2008; Russell, 2014).   But, being adequately held is also a developmental need that when left untended makes it hard for a growing child to feel confident enough to explore the world. Margaret Mahler wrote about a similar phenomenon when she described the rapprochement phase of development:

Previously fearless in action, the toddler may now become tentative, wanting his mother to be in sight so that, through action and eye contact, he can regulate this new experience of apartness. The risk is that the mother will misread this actually progressive need and respond with impatience or unavailability, precipitating an anxious fear of abandonment in the toddler, who does not yet possess the psychic capacities to function as an independent agent (as cited in Mitchell & Black, 1995, p. 47). Disruptions in the fundamental process of separation–individuation can result in a disturbance in the ability to maintain a reliable sense of individual identity in adulthood leading to chronic depression. So it is with a baby who innately turns to her mother for physical soothing and finds her unavailable. Overwhelming levels of affect and unbearable aloneness, stemming from this neglect, lead to the formation of pathogenic affect (Fosha, 2000).

Hugging and holding satisfy a developmental need. Sara reported she had a felt sense of that dysregulated part of her as very young. I imagined a distressed baby in need of soothing that neither words nor fantasy could calm. She could not self-soothe either. I wanted to experiment with holding to see if it might help to regulate this un-symbolizable affective experience wreaking havoc on her nervous system. And it did. Touch can intervene at the physiological level in the regulation of affective states and directly address dissociation and dysregulation (Shore, 2003). Sara’s newfound ability to recognize her need to be held and ask for it represents a moment of “transformance” (Fosha, 2007). Meeting that specific need is transformational and leads to healing.

A final word about sex as it pertains to this treatment. Sara felt guilty should she derive any sexual pleasure from being hugged. She is not to blame for having feelings. “Feelings just are,” I remind her frequently, “they are normal and natural.” Judging and acting on feelings and impulses is not helpful but noticing them and listening to them is. So it is with sexual feelings. Discussing her concerns and making my thinking explicit has allowed us to move forward in helping younger parts express their true needs for holding without too much conflict and shame from developmentally older parts that simultaneously experience different wants and needs than infant and child parts. When shame or conflict arise in the moment, we return to State One “Defense Work” (Fosha, 2000) until safety is restored.

I have used various forms of touch in my work with Sara, although the vast majority of our sessions are just talk. We hold hands; we explore fantasies together that include me holding her; and then there are times when I physically soothe her. The purpose of each form of touch is briefly reviewed as follows.

First, I offer my hand to hold during moments of both emotional processing and dysregulation, in order to help undo “unbearable aloneness” when words and my presence alone is not enough.  Second, when child parts are distressed and want to be held, I invite us to first cultivate a fantasy, or portrayal, in lieu of actual holding. I do this to help her increase her self-soothing capacity. When we use fantasy, she is in charge, but I do guide her. I encourage her present-day self to relate to her younger parts if they are willing (Schwartz, 1995; Lamagna & Gleiser, 2008). When those parts want “only me” to comfort them, I encourage and invite the fantasy to become vivid imagining exactly what she needs from me and how she is experiencing it. I ask her to sense me holding her and how it feels on her skin and anywhere else she can notice. When I am comforting (in fantasy) the child parts, I typically invite the present day Sara into the scene in any way both she and her younger parts will be comfortable. Sometimes Sara sees herself standing on the periphery of the room in the scene or sometimes we are “group hugging.” This is integration in process!  While technically not touch, these vivid portrayals are an extremely intimate experience and could be triggering in the same way that actual touch could be, so I consider it a form of touch.

Third, when I actually hold Sara, I typically join her on my sofa. She leans in to me and my arms envelop her.  Sometimes I stroke her hair. When her skin burns raw, where words and fantasies are of no use, the actual physical contact is needed to undo the aloneness. More specifically, it supplies the development need that was lacking at a critical stage and thereby transforms its pathogenicity. Holding brings immediate relief, typically followed by “mourning-the-self” affects and gratitude as seen in State Three phenomenology (Fosha, 2000). When I do hold her, I let her release the hold first so she takes as much “nourishment” as she needs, unless we are out of time. We almost always metaprocess the impact of our physical contact, as we do with other relational interventions.

The session below demonstrates touch using a fantasy portrayal followed at the end by physical soothing. During a moment when the longings of a young part arise with intensity, I guide her to tune into her body, to notice what she is experiencing, to bring attention to what she notices, and to hear what her body is telling her. Then when she recognizes a desire to be held, we honor it and work with it so see if she can sooth it internally with fantasy. It is only at the end of the session that I actually hug her to help her relax and regulate even more before she goes back out into the world.

This transcript is from a recent session of a 2x/week treatment currently approaching its 4th year. We begin 13 minutes into a session before she is going away on vacation for a week. Comings and goings, needless to say, are fraught and always triggering of fears and insecurities.

Pt: Whenever I go away, not only do I worry about you dying, but I also worry that I will die and you’re not going to know that I’m dead. I don’t know…I just want you to know that if I die, thank you for everything and I love you. And hopefully you’ll find out somehow. [abandonment anxiety coming up.]

Th: I hear that you want me to know that you love me and are grateful for me.

Pt: Yes. (nodding)

Th: And I think the chances are very, very good we will both be ok and we’ll see each other next week but– is there someone you can ask to let me know if anything happens to you?  Would that be a comfort to you? [honoring her experience; going beyond mirroring to problem solve]

Pt: Yes, I think I can tell Flo—she knows I see you [Sara hasnt told her parents she is in therapy for fear of repercussions and judgments.]

Th: So if you tune in and notice what’s coming up now…

Pt: (tension around her mouth which she squeezes tightly shut.)

[Squeezing her mouth closed is always a signal to me that shes having an emotion and working to hold it down.]

Pt: (silence)…A bit of sadness…like…just sort of maybe hearing you talk about comings and goings from zero to 3…(puts hands over her eyes)…yeah

[We had discussed earlier in this session how current comings and goings resonate with early abandonments like when connected mom would switch into angry mom and how terrifying that abandonment was.]

Th: That touches something…let’s stay with physical sensations? [Previously she has told me that when affect overwhelms her, it is helpful to stop everything we are doing and focus strictly on her body sensations. Helping her regulate affect is the purpose of my suggestion to stay with her body.]

Pt: (labored breathingsome tension in chestthen a relaxing upon recognition.)  It’s like a physical sensation of wanting to be held.

Th: Can you make some room for that…and maybe get a sense of how old that part is…or even get an image of that part?

Pt: (eyes closed) Like two years old maybe…(eyes more scrunched closed, labored breathing, increasing distress)

Th: See if you can separate from that part more and make it further away so its feelings don’t overwhelm you as much. [Im hoping my suggestion will help her regulate a bit, but it doesnt.]

Pt: (more distressed) It’s crushing me!!! [pathogenic affect]

Th: Where is the crushing feeling inside?

Pt: (points to chest)

Th: What does it need? What does it need to make the experience a little less intense so it stops crushing you? What is this crushing tell us? I’m right here. I’m not going anywhere. (lots of silence)…Scary, huh!

Pt: It’s telling me that I want…(squeezing lips to hold down the feeling)…it’s telling me that I want physical contact.

Th: Which part? How old? [I may be too cautious here but I always want to know the age of the part before I act on physically holding herif she said the part was 16 years old, we would have done something different.]

Pt: (nods yes) Two years I think but maybe the six-year-old too.

Th: Yeah…can you check in exactly how it needs the contact and imagine it just the way it needs it. Is that ok? [I move to do a fantasy portrayal.]

Pt: Yes.

Th: Let’s see if we can take care of that sweet, sweet little girl first and see if we can help her be less distressed.

Pt: It would help if I hugged the pillow.

Th: Great! Feel free. (She flops sideways on couch and grabs my pillow and hugs it, which is something shes done many times before.) Is that a bit better? (Her body relaxes a little.)

Pt: Yes.

Th: Can you get more of a sense of her and where she is?

Pt: Alone in the living room floor crying her eyes out and confused and alone?

Th: Where did everybody go?

Pt: (shaking her head back and forth)

Th: You don’t know? [Her childlike voice suggests that she seems to be in the part.]  What does she need?

Pt: She needs you!

Th: Can you bring me in to be with her? [suggesting we use fantasy]

Pt: (nodding head)

Th: Am I with her? What’s happening? [asking her to elaborate on the fantasy]

Pt: You pick her up and take her away to your house, you’re sitting together on your sofa and she’s on your lap.

Th: Can you describe more of what you see? [I want the portrayal to light up the neural network as much as possible thereby fostering integration.]

Pt: She’s on your lap, holding onto your torso and crying into your neck.

Th: Beautiful…can you tell her I’m with her for as long as she needs me and just the way that feels right to her?

Pt: (visibly relaxing)

Th: What do you notice now …just in your body…

Pt: The crushing is gone…

Th: And in its wake, what do you notice?

Pt: An emptiness…(still lying down and holding a pillow)

Th: What’s it like—that feeling…like how big is it, what shape is it, can you take lots of time to get to know it.

Pt: it’s like 8” oval down my chest…

Th: How is it to make contact with it while we’re together? Is it ok?

Pt: Uh huh

Th: Is there a color associated with it…like if we stand on the perimeter and look in together and I’m holding you securely so you can’t fall in…like we’re holding hands and I’m tethered to a big tree so we can’t fall in… Just anything you notice even a glimmer…

Pt: It’s just kind of black….

Th: Just kind of black.

Pt: uh huh.

Th: Can I get you curious about that blackness or is your instinct to stay far away from it or anything in between?  I think it’s meaningful. And I only want to look at this together, never alone.

Pt: I just want to pretend it’s not there.

Th: Is it something you know was there or is this a new discovery?

Pt: I felt it before (lying quietly then pops up a bit)…I’m sorry.

Th: For what?

Pt: I don’t know…I’m being pathetic.

Th: I don’t think you’re pathetic at all. We are touching on very deep and profound experiences that have huge meaning.

Pt: Ok.

Th: I think you’ve done amazing today!! [affirmation]  What’s your sense about how we have such a different take on the experience we’ve been sharing today? [metaprocessing. I seize the opportunity to have her practice being all right with two different subjectivities, something that her mother could not tolerate.]

Pt: (big smile–pops all the way upsitting up now looking happy and regulated) I’m not surprised (laughing) by now I know how we differ in that way.

Th: Is it possible that when you label something as pathetic, what you’re actually feeling is incredible vulnerability. We don’t have a lot of language in our culture praising vulnerability—just the opposite, in fact.

Pt: It feels like…to me pathetic means that I wasn’t able to overcome something. Like I wasn’t able to…like I gave in to the feeling or something…instead of like trying to cover it up and go on as if nothing was happening.

Th: You mean right here right now today?

Pt: Yeah. Like I should have umm you know…tried not to feel that way…

Th: Really?? Why is that?

Pt: I don’t know.

Th: That seems like it would be more of doing what you had to do throughout your life to survive in your family.

Pt: Yeah!

Th: is it your sense that that would be helpful?

Pt: (shakes head no)

Th: That’s why I am so proud of you for doing something so brave. It’s hard to touch on these very deep old, old, old experiences that basically don’t have language—they get stored viscerally just in these black spaces we all have. They feel like holes but they are markers for lonely, overwhelmed, in the darkness feelings. [I do some psycho-education here by bringing on the left-brain to organize right brain experience. Fosha (2008) refers to this as platforming. Saying we lets her know that this is a normal experience, mitigating shame and aloneness.]

Pt: Yes! [recognition] I feel lonely and overwhelmed like all the time.

Th: Yeah so maybe that’s this part when it comes to the front.

Pt: (nodding yes) Maybe…

Th: And maybe we could spend some time here getting to know this place and what it is telling us about what happened and maybe it would heal a bit and you wouldn’t have to keep feeling as overwhelmed and alone. That it’s just a feeling memory in a way…

Pt: Yeah…(looking down and shaking head yes)

Th: I guess I’m curious what it is like, if you just check me out for just a second…is that ok for you? [Mid sentence, I invite her to shift from a downward gaze to look at me, which she does.]

Pt: Yeah (smiles)

Th: What it is like…to touch on a feeling that is full of such aloneness but to do it when we are connected. How that changes the experience or what it is like…[metaprocessing and undoing aloneness]

Pt: (deep breath) It is good to have you share in it and know about it umm…it is hard because I know we are together but like sometimes I need…

Th: Feel free…

Pt: Sometimes I need the physical contact and it’s not… just being here together is being good but it is not the same and it doesn’t feel…(Really struggling)…like…[lots of affect and anxiety coming up. I notice her hands are rubbing together, deep sighing, mouth clenched, all of which signify that emotions are pushing up in response to her trying to express her needs.]

Th: It’s hard…it’s ok. I would imagine it would bring up lots of feelings maybe of sadness and maybe some anger. (she is nodding yes) And if we just make room? [gesturing with my hands the idea of making lots of room.} Just to label the feelings coming up—and we’re not going to be with them today, because we don’t have time. But just to label them and let them be. And if you still want a hug goodbye from me today, I would love to (shes nodding yes). And if you feel angry (nodding no with a smile) and don’t want a hug, that would be ok too.

Pt: (nods yes) No, I don’t feel angry. I just feel this intense longing. And I’m not angry because I know it’s important to try and take care of that without actually needing it but it’s so incredibly painful.

Th: So painful!  Just keep trying to keep that young part separate so she doesn’t overwhelm you again. If you can keep the young part separate… [gesturing separation with my hands]…like really keep her far away and then just talk to her or sit with her so she’s not alone.  And even if it’s not perfect, it may be better than nothing.

Pt: (nodding yes with big smile) Yeah.

Th: Play with that and let me know.

Pt: Ok.

Th: And I’m right here—take me with you to Paris. [I mean in fantasyentraining object constancy and undoing aloneness.]

Pt: And maybe I’ll send you a nice picture.

Th: I’d love that. We have a few minutes, do you want me to sit with you and have real physical contact before you go?

Pt: Yes

Th: [I sit next to her on couch, she leans into me and I put my arms around her.]

Pt: It feels so good…

Th: Everything’s going to be ok. I think you’ll have a great time…the beauty; the food…and then you’ll come back. And it is not like it was when you were a little girl. Now as a grown up you have all these skills and tools in your toolbox to reach out and cope with what comes. When you were little, you had none. That’s why it is important to stay in touch with little Sara in any way she’ll have you and any way you are willing…even if it is just being in the same room and sitting quietly with her so she knows she’s not alone any more.

Pt: Sounds good.

Th: I love how you are more and more getting to know and share exactly what you need. [affirming her, loving her up]

Pt: And sometimes the fantasies help and sometimes not.

Th: Yes and as we keep working together, it will get easier and easier to recognize little Sara and satisfy her needs just as we’ve been noticing all along.  And you’ll feel better and better just like you have been. And maybe even this latest shift that you shared today about the OCD part having two settings now instead of one is really a testament to the fruits of our labor. [She had shared that some days she doesnt have to do the entire washing ritual if she has to get out of the house for an important reasonthat she negotiates with the OCD that shell do the ritual the next dayand it listens!!]

Pt: It’s true. I’m being kinder and more compassionate to myself.

Th: Yes you are.

Pt: (hugging me tight) Thank you so much! You are so soft and warm.

Th: You’re so snuggly! A good snuggler!  [using evocative words of nurturing]

Pt: Thank you. When’s your birthday? [Feeling safe engenders curiosity.]

Th: September 18th. When is yours?

Pt: October 5th. I’ll be 30.

Th: Very respectable age. What makes you think of this now?

Pt: I have actually been wondering for a long time. Not that I couldn’t ask, it just felt particularly safe to ask now.

Th: Hmmm it feels very safe right here right now.

(Sara gets up, cheerfully exits to leave on her vacation)

In addition to the immediate relief and affect regulation that holding provides, there have been many overall shifts in her Self (Schwarz, 1995) and internal organization. Sara reports sensing a lifting of her depression that she attributes to the moment I held her for the first time when she was experiencing the painful skin sensation I referred to earlier.  She no longer self-harms, she no longer berates herself for small infractions like being late for a session. She rarely freezes in session and when she gets dysregulated she comes back quickly. Her capacity for self-compassion is growing almost from each week to the next. Sara feels like dating again and traveling and, in general, she is more adventurous. Her growing assertiveness is evident both in session with me and out of session with her friends and colleagues.

Several days after this session, I received an email from Sara who was on vacation. I have quoted it below because it was significant:

I’m having a very pleasant time here so far! The weather is great and I’m feeling pretty relaxed. Monday’s session was a huge help in making me feel safe and secure about being away – thank you so much! Below is a picture of ______ , which we visited today. I hope you’re having a great week. I miss you and can’t wait to see you on Tuesday!

I was moved by this communication. It beautifully illustrates how she is moving through the process of individuating and separating. This growth has allowed her to begin to explore the world safely and happily with the knowledge that she has a secure base to which she can reliably return (Bowlby,1988).

In conclusion, touch when used judiciously and mindfully is a healing and transformational experience. Sara reports that the holding has helped her feel worthwhile as a human being, and deserving of love, attention and connection. Her sense of being disgusting and bad is diminishing rapidly. Additionally, she is becoming more and more compassionate to herself. She is far less dysregulated, with a growing tolerance for core affective and core relational experiences that can be processed to completion thereby releasing adaptive action tendencies (Fosha, 2000). The request or need for holding has not increased; in fact, it has decreased. I anticipate that with these early needs nurtured, her desire to explore the world will grow, as will her capacity to navigate the trials and tribulations of adult relationships.


General Guidelines for Touch When Requested by the Patient

  1. Experiment with fantasy holding first—it is generally all that is needed and it facilitates self-soothing capacities in the patient.
  2. If therapist feels an impulse to hold patient or patient request it, think through why this is coming up now and about counter-transference. Think about motivations for wanting to touch patient. Think through transference implications and how various parts of the patient might react.
  3. If the therapist has a sense that the patient could benefit from actual touch, discuss first with the patient. If patient is interested, go to step 4. If not, drop it. Metaprocess the therapist’s inquiry and how the patient feels about it.
  4. Think through alone and together potential reactions to actual touch, using fantasy for a dress rehearsal.
  5. Have patient sign “Consent to Touch” form before using touch.
  6. In future sessions, when touch seems appropriate, remember to check with patient if they want to be touched in a particular moment.
  7. Metaprocess the experience afterwards.

Sample Consent to Touch Form*

(Name of therapist) may incorporate non-sexual touch as part of psychotherapy. Sexual touch of clients by therapists is unethical and illegal. (Name of therapist) will ask your permission before touching you, and you have the right to decline or refuse to be touched without any fear or concern about reprisal. Touch can be very beneficial but can also unexpectedly evoke emotions, thoughts, physical reactions or memories that may be upsetting, depressing, evoke anger, etc. Sharing and processing such feelings with the therapist, if they arise, may be a helpful part of therapy. You may request not to be touched at any time during therapy without needing to explain it, if you choose not to, and without fear of punishment.

Name ____________________________________

Date _____________________________________

* It’s best to consult with your malpractice insurance on any forms they might endorse.

[1] “Transformance” is Fosha’s term for the “overarching motivational force, operating both in development and therapy,that strives toward maximally adaptive organization, coherence, vitality, authenticity and connection.”

[2] The term “self-state” or “part” refers to discrete experiences of subjectivity created when the brain links somatic, affective, cognitive, and behavioral representations into a cohesive, functional whole (Siegel, 1999).

[3] Metaprocessing is an AEDP term and a cornerstone of AEDP theory. It refers to the process of reflecting on experiences of transformation. Metaprocessing the healing and transformational moments of a therapy session leads to ever-expanding spirals of deepening between patient and therapist and patient and self (Fosha,2000).


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