Transformance Journal Volume: Volume 6 Issue 2

By Gil Tunnell, PhD

This issue of Transformance is a Special Edition devoted entirely to Senior Faculty member Karen Pando-Mars’ project on working with different attachment styles.

Karen’s work is groundbreaking and a brilliant contribution to the AEDP literature.   It is with much excitement that I introduce her article.

Described initially by John Bowlby and then documented and expanded in Mary Main’s research with 18-month-old toddlers in the “Strange Situation,” there are four distinct attachment styles:  Secure, Insecure/Avoidant, Insecure/Ambivalent and Disorganized.

AEDP teaches us how to activate the transformance pathway from the get-go, in the very first session, to begin the process of healing.  However, even with their transformance-focused AEDP therapists, many patients do not begin treatment having Secure attachment, which would allow therapy to proceed more smoothly with less defense work at the “top of the triangle.”  When that is not the case, the therapist must deal with Insecure or Disorganized attachment styles, and “top of the triangle” work plays a more central role in the treatment.

For several years, Pando-Mars has been studying diligently what she does clinically that is different for patients with each attachment style.  She has refined what she has learned, and this article is the result.  As she says, it is a work in progress.

Pando-Mars first elaborates on Fosha’s original description of the four attachment styles (The transforming power of affect, 2000), providing rich theoretical descriptions of their differences.  She then describes how she works with each style specifically.  Case vignettes demonstrate what the sessions look like in real time.  Finally, she has developed three highly detailed—but at the same time very succinct—Grids as quick guides to how Insecure and Disorganized patients appear when they begin AEDP in “self-at-worst” mode, what each style distinctively needs from their AEDP therapist, and interventions to help clients grow into a more Secure attachment, i.e., functioning as “self-at-best” more of the time.

In her introduction to this special issue of Transformance, Diana Fosha places Pando-Mars’ work in the more meta-context “of what has come before it and the new era I think it is ushering in,”  by which she means, an innovative, AEDP-specific way of working with psychopathology.

Although Karen Pando-Mars’ article is longer than usual, please take your time to savor it.  “Tailoring AEDP Interventions to Attachment Style” is a valuable and significant contribution to AEDP.

By Diana Fosha

You are about to embark on the wonderful new work from Karen Pando-Mars on tailoring AEDP interventions to specific attachment styles. This is a momentous achievement in and of itself, as you will see.  However, to my mind, it also ushers in a new phase in the development of AEDP.  I say this because I want to put Karen Pando-Mars’ work on tailoring AEDP interventions to each attachment style in the context of what has come before it and the new era I think it is ushering in.  This article, to which an entire issue of Transformance is dedicated, is the product of five years of work.   In my view, the article by Karen Pando-Mars is groundbreaking not only in the content of her work, which is awesome, but that it also jumpstarts AEDP’s own theory and practice of how to work with psychopathology.

And, as such, I thought it important to place it in context.

We are in a phase of flourishing and expansion in AEDP.  In recent years, we have had a significant addition to the theory of AEDP in Eileen Russell’s (2015) profound contribution to our understanding of resilience and its role in transformational work with our patients.  Her book introduced several major constructs such as the yellow light signal affects, the transitional self, and the therapist as transformational other.   Another major development is the application of AEDP to treating couples:  David Mars’ systematic AEDP for Couples method (2011, 2015, 2016), and the work of Gil Tunnell (2006, 2012, 2015) and David Greenan (2015) in integrating AEDP with traditional systemic/structural couple therapy (Nichols & Minuchin, 1999).

AEDP is also expanding by leaps and bounds in its application to supervision in the soon-to-be released book on the topic, coauthored by Natasha Prenn and myself (Prenn & Fosha, in press).  And finally, we now have the beginning of research publications documenting the efficacy of change mechanisms in AEDP (Iwakabe & Conceicao, 2016) and of AEDP training (Faerstein & Levenson, 2015), with these two studies being only the beginning.  Stay tuned.

With Karen’s new work, the focus on categories of maladaptive patterns and how specifically to transform them becomes fair game for AEDP’s contribution and innovation in psychotherapy.  Let me be specific about how Karen’s work opens and walks through a door that has been previously bypassed or, to use a different metaphor, takes and walks on the road not previously taken, actually actively eschewed, by AEDP, i.e., the focus on psychopathology.   Let me articulate below the nature of the road privileged by AEDP, a road that had to be trailblazed, as it really didn’t quite exist prior to our establishing it.  Because we trailblazed it, we have favored it and privileged it.

AEDP has made its contribution and theoretical mark by outlining a new path to transformational work to undo emotional suffering, with a special focus on healing attachment trauma. The path that AEDP trailblazed—captured in phrases like “healing from the get-go,” “leading with the corrective emotional experience,”  “making the non-specific factors of treatment specific,” and “being a transformance detective”—is rooted in its central concept of transformance. Wired within us, we have the drive to heal, grow, learn, self-repair and resume impeded growth. This force exists within us as a capacity and a motivational drive, one which can become more tangible and reawakened under conditions of safety. We understand that healing is not just the result of healing trauma, but that healing exists side by side with trauma.  However, for it to come to the fore, conditions of safety must prevail.

In AEDP, we understand transformance/healing and psychopathology/resistance to exist side by side.  The nature of the affective/relational environment that exists in a given situation contributes powerfully to which one of them emerges, and the patient’s experience of either safety or stress/threat respectively brings one out. More to the point, no matter what history of trauma, chronicity of pathology, compromised functioning, what have you—no matter what—the capacity for health, healing,  secure attachment, connection and emotional experience is there. It exists intact, side by side with the maladaptive patterns resulting from the unbearable suffering; and it is ready to manifest itself in conditions of safety and nurturance. This capacity,  although usually camouflaged by pathology and engrained patterns of maladaptation, nevertheless makes itself felt through glimmers of positive affect, vitality and energy, what we refer to as in AEDP as the positive somatic affective markers or the vitality affects. These glimmers (which we track moment-to-moment at all times) are a way to access the transformance drive, i.e., healing, from the get-go, from the first moments of the first session and then throughout the entire treatment in each and every session.

As a consequence of its healing-from-the-get-go orientation, AEDP pioneered techniques for detecting transformance, melting or bypassing defenses, accessing emotional experience and working with it through dyadic affect regulation, processing emotions to completion or to an affective shift from positive to negative, metaprocessing transformational experiences and, of course, work with core state.  From our healing orientation, AEDP also introduced to the world of psychotherapy an attachment-based stance that is affirmative and emotionally engaged, a stance that seeks to co-construct safety, as a positive, reparative relational bond is forged.  This affirming and nurturing mindset, and the relational work that leads to the establishment of a therapeutic relationship characterized by secure attachment, allows the work to proceed under the aegis of transformance, and allows the therapist to form an alliance with the patient’s self-at-best, so that, together, they can work with the patient’s  self-at-worst.

Thus, in the realm of attachment, contrary to patterns of insecure or disorganized attachment shaped by histories of trauma and attachment trauma, AEDP’s contribution to date has been to show the capacity to form secure attachments from the get-go, if only in glimmers and for moments, and to enlarge that capacity by making the implicit explicit, the explicit experiential, and the experiential relational. By working with receptive affective experiences of feeling seen, feeling felt, feeling cared for, feeling loved, we have again been pioneers in showing how to wire in such new corrective experiences through work aimed at increasing receptivity and growing the capacity to process and take in receptive affective experiences.

Most recently, my work on recognition and on transformation from the outside in (Fosha, 2009, 2013) has shown how serendipitous experiences of recognition, i.e., experiences marked by the click of recognition, have the capacity to access not only transformance glimmers, but at times, with incredibly rapid speed, to grant access to the full felt sense experience of the neurobiological core self.  In other words, when these serendipitous clicks of recognition occur, it is possible to sometimes witness the patient’s dropping down from State 1 not only into affect and State 2 work, but also unexpectedly dropping down from State 1 to State 4 in one fell swoop, with experiences of core truth and “this is me.”

All of these transformance-based metatherapeutics are supported by the emergent science of neuroplasticity and the seamless integration of developmental research, especially developmental research into caregiver/infant moment-to-moment interaction, attachment theory and research, emotion theory, affective neuroscience, interpersonal neurobiology, the polyvagal theory of the autonomic nervous system, other trauma based treatments, and transformational studies.

Furthermore, our metatherapeutics have produced a rich methodology and technical armamentarium of AEDP-specific interventions we teach in our two-year-long sequence of AEDP Essential Skills courses and in supervision sessions. While AEDP therapists learn interventions on how to work with dysregulation, dissociation, and pathogenic affects, so as to transform them to access adaptive primary core affective states where the transformational work can take place and develop, the theory of how AEDP works with different types of psychopathology has not been a focus of innovation, and much less of theoretical work in AEDP.[1]  It is the old road of psychopathology that AEDP has eschewed for so long, yet we now are ready to tackle it, confident that we can do so in our own distinctive AEDP way and make traveling on it a very different experience.

Until now, whenever I was asked the specific psychopathology question, i.e., “So what is the AEDP approach to working with avoidant attachment or eating disorders or …. (fill in the blank),” my rather proud answer would be, “There is no AEDP approach to working with (fill in the blank) per se.”  Then I would elaborate that the AEDP path is always fundamentally the same, regardless of the psychopathology we encounter.  Since all disorders are in the realm of psychopathology and self-at-worst functioning, the AEDP approach for working with them is to see how much they can be put to the side and how much glimmers of transformance, evidence of resilience, and manifestations of self-at-best can come to the fore. Once we do that, we can form a relationship with the patient’s self-at-best, and then with the accompaniment of self-at-best, we work with the stuff under the aegis of self-at-worst to transform it. Even in State 2 work, our focus has been toward the universals.  We have emphasized interventions designed—as rapidly as possible and as effectively as possible—to access the adaptive neurobiologically wired-in pathways to healing represented by the emotions, sensations, self-states and coordinated relational experiences.

In essence, as Jerry Lamagna wrote (personal communication, October 23, 2016):

[It is important to not let]  diagnosis or life history limit our view of our patients and what they are and are not capable of feeling, being, etc. It is a truly wise, open stance to being with another person. …… [as Buddhists also teach us],  thankfully everything that is and can be is pre-baked into the therapeutic cake waiting for the right conditions to bring them forward. This is so simple that it is hiding in plain sight: Safety, connection, presence, receptivity.  If those conditions can be activated in therapist and patient — the process largely takes care of itself.

Which takes us to what happens when those conditions cannot be activated, or cannot be sufficiently activated? What happens when the transformance path is blocked or so full of ruts and ditches as to not be travel-able?

Enter now the work of Karen Pando-Mars on tailoring AEDP interventions to the secure, insecure and disorganized attachment styles. It spearheads differentiated AEDP work within the realm of self-at-worst and the patterning that emerges as particular attachment-style states of mind, as a result of attachment trauma. It goes down the old road of psychopathology but does so in a distinctly AEDP way. You will discover its riches—theoretical, clinical and technical—for yourself in the pages to come.  It shows us that indeed AEDP does have its own unique contribution to make, not only on how to bypass pathology and access adaptive wired in aspects of ourselves from the get-go and throughout, but also to how to work in the realm of psychopathology and the realm of self-at-worst in a differentiated and specifically AEDP fashion.

Karen’s work bears the hallmarks of quintessential AEDP:  (a) a healing/health/resilience orientation, (b) an attachment-based therapeutic stance, and (c) an understanding of defenses and the maladaptive patterns they spring from.  In her article, Karen elaborates on AEDP’s premise that the defenses and maladaptive behaviors are the patient’s best efforts at self-protection, given the difficult circumstances in which they arose.  Finally, the other quintessential AEDP feature that characterizes Karen’s work is that it is informed by the seamless integration of attachment theory, interpersonal neurobiology, and research from other fields relevant to AEDP.  These bodies of literature are reflected in the specificity of the three grids Karen introduces to organize and structure her work.

Gil Tunnell and I are very proud to have this work appear in Transformance: The AEDP Journal.  Rather than dividing it in parts and publishing it serially it in two or three issues, we decided to preserve its integrity and offer it to you in a Special Edition.

I think you will find it illuminating and very useful.  Laminated versions of the three grids will probably be a very useful accompaniment to AEDP therapists and other clinicians as well!

Personally, I look forward to future work that expands and develops AEDP’s healing-based orientation, and that elaborates on specific interventions that foster transformational work.  I also look forward to further development of AEDP-specific approaches to different aspects of self-at-worst functioning  (e.g., defense work, dealing with pathogenic affects) and different categories of psychopathology (e.g., addictions, eating disorders). In this way, we can enhance and expand the contribution that we can make to the field from the special vantage of our attachment-based, healing-oriented transformational methodology.

References

Faerstein, I., & Levenson, H. (2016). Validation of a fidelity scale for accelerated experiential dynamic psychotherapy.  Journal of Psychotherapy Integration, 26(2), 172-185.

Fosha, D. (2009). Emotion and recognition at work: Energy, vitality, pleasure, truth, desire & the emergent phenomenology of transformational experience. In D. Fosha, D. J. Siegel & M. F. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development, clinical practice (pp. 172-203). New York: Norton.

Fosha, D. (2013). A heaven in a wild flower: Self, dissociation, and treatment in the context of the neurobiological core self. Psychoanalytic Inquiry, 33, 496-523.

Greenan, D. (2015). Resiliency-focused couple therapy.  Transformance: The AEDP Journal, 5 (1).

Iwakabe, S., & Conceicao, N. (2016).  Metatherapeutic processing as a change-based therapeutic immediacy task:  Building an initial process model using a task-analytic research strategy.  Journal of Psychotherapy Integration, 26 (3), 230-247.

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

Mars, D. (2011).  AEDP for couples: From stuckness and reactivity to the felt experience of love.  Transformance: The AEDP Journal, 2 (1).

Mars, D. (2015).  AEDP for couples: Transforming potential divorce into falling freshly in love in the thirtieth year of Marriage.  Transformance: The AEDP Journal, 5 (1).

Mars, D. (2016). The community healing workshop: A final treatment phase of AEDP for couples.  Transformance: The AEDP Journal, 6 (1).

Prenn, N., & Fosha, D. (in press). Essentials of AEDP supervision.  Washington, DC: American Psychological Association.

Russell, E. (2015). Restoring resilience:  Discovering your clients’ capacity for healing.   New York: W. W. Norton.

Nichols, M. P., & Minuchin, S. (1999).  Short-term structural family therapy with couples.  In J. M. Donovan (Ed.), Short-term couple therapy  (pp. 124-143). New York: Guilford Press.

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

Tunnell, G. (2012).  Gay male couple therapy: An attachment model.  In J. J. Bigner & J. L. Wetchler (Eds.), Handbook of LGBT-affirmative couple and family therapy. London:  Routledge (pp. 25-42).

Tunnell,  G.  (2015). Facilitating transformance for couples: A comparison between structural family therapy and AEDP.  Transformance: The AEDP Journal, 5 (1).

Notes

[1] The exception is the powerful contribution of Jerry Lamagna and Kari Gleiser in 2007, introducing attachment-informed intra-relational AEDP. While the intrarelational work, i.e., AEDP parts work, is an important aspect of AEDP State Two interventions, it is a fortiori relevant and even necessary to patients on the  dissociative disorder spectrum.

[pdf-lite]

By Karen Pando-Mars

Abstract.  Accelerated Experiential Dynamic Psychotherapy (AEDP) is an attachment-based, experiential and transformational treatment model whose theory, procedures and maps are ideally suited to address and treat relational trauma, which often underlies the motivation of patients to seek psychotherapy. AEDP’s therapeutic stance is one that employs corrective emotional and relational experiences to help patients know they exist in the heart and mind of another. Yet, to enter this kind of explicit relationship can be daunting for patients with insecure attachment styles, whose adaptive strategies become defensive shields to protect them from further relational wounding. This can be challenging for the therapist and patient alike. This paper is part of a larger project on how to differentially apply AEDP’s comprehensive model to treat attachment wounding, given the distinct formations of each attachment style. The paper starts with a brief summary of attachment theory and styles, and how AEDP applies and adapts the theory to therapeutic work. The grids I developed are then introduced to help match defenses and interventions to attachment style, to help orient and guide the therapist. The first grid shows detailed configurations of defense and affect regulation strategies for each attachment style. The second grid identifies the configuration of secure attachment as applied to the psychotherapy relationship. The third grid identifies specific interventions and targets specific goals to mobilize optimal transformations for each style. Here, transcripts illustrate how these AEDP interventions can be optimally attuned to patient attachment style.

The first time I introduced attachment styles and working with attachment in an AEDP Essential Skills course, the question came, “But what do you do with the patients who have these different attachment styles?” That question and others like it launched me to undertake this project of tailoring treatment to meet the distinct presentations of each attachment style. Excited to inquire phenomenologically, I set out to explore what I was doing in the process of treatment with my patients. This paper is the net result of studying each attachment style’s specific and contrasting elements.  It remains a work in progress.

AEDP’s comprehensive theory is a profound match for the healing of the relational trauma that underlies insecure attachment. The AEDP therapist is theoretically poised and methodically trained to build a secure attachment in the therapeutic relationship, which provides an essential base for treatment (Bowlby, 1988; Fosha, 2000). Sometimes, however, a patient’s capacity for security does not easily come online and we find ourselves in the domain of insecure attachment patterns. This paper is designed to address these challenges by bringing greater precision to the understanding of the whole composition of each attachment style. In this paper I will first provide a brief summary of attachment theory and styles, and how AEDP adapts attachment theory and interpersonal neurobiology to psychotherapy practice. I will then discuss the challenges for therapists when insecure attachment shows up in the therapy room, and present the grids to help understand what’s happening and provide a compare/contrast among attachment styles. Lastly, I will explicate interventions tailored to each attachment style, with transcripts of videotape illustrations.[1] My overall intention is to show that when the clinician addresses the particular needs of patients that are paramount to each attachment strategy, treatment can mobilize the specific transformations needed to bring about their “earned secure attachment” [2] (Siegel, 1999).

BOWLBY AND ATTACHMENT THEORY

Attachment theory has its roots in animal studies, i.e., ethology. When John Bowlby was seeking to understand the profound impact of maternal loss and deprivation on young children, he was introduced to and inspired by Konrad Lorentz’s work on how ducks imprint (Bowlby, 1988; Parkes et al., 1991). His studies led him to see how the bond of attachment serves humans across their lifetime. He is known for saying, “Attachment operates from the cradle to the grave,” meaning that human beings need relationships with others throughout our whole lives. We are social creatures and our nervous systems are designed to see and be seen, to care and be cared for, and to participate and belong to family and social groups with others (Adler, 2002; Cozolino, 2006).

Bowlby identified three behavioral systems of attachment:  the attachment system, the caregiving system and the exploratory system. Young beings engage the attachment behavioral system when they are in pain, fatigued or frightened or if the mother appears to be inaccessible. This proximity brings protection and thus provides a “secure haven.”  The caregiving behavioral system (parenting) refers to that aspect of the attachment relationship in which the mother responds to the child’s needs, providing comfort in times of distress and reassurance in times of fear. With these in place, a child has a “secure base” from which they can explore the world, developing “the exploratory behavioral system” (Bowlby, 1982).

Bowlby also developed the construct of the internal working model, the way the relationship between child and caregiver is internally represented (Bowlby, 1969, 1973). In the achievement of a secure attachment bond, when one’s caregivers are sensitive and responsive, the “Other,” i.e., the caregiver, is represented as responsible and reliable, and the “Self” feels protected, worthy and secure (Ainsworth, 1978). Someone with a secure attachment has an internal template for relationship that represents others as capable and willing to respond, and one’s own self as worthy of response.   This brings about trusting and seeking proximity and help in times of need to be a natural experience.  Bowlby (1988) has further postulated that psychotherapists can build both a safe haven and a safe base with patients, which allows them to feel safe in the relationship and to explore the necessary memories and experiences that need attention and healing in psychotherapy.

When she joined Bowlby at the Tavistock Clinic, Mary Ainsworth developed the  “The Strange Situation” as a prototype for attachment research,[3] which led to the classification of attachment styles.   Subsequently, her student Mary Main gathered data about those with inconsistent responses that did not fit into the existing classifications. Main and her colleagues identified this category that arises specifically in response to trauma as reflecting “disorganized attachment” and characterized its dilemma as being “fear without solution” (Main & Solomon, 1990). Main also developed the Adult Attachment Inventory (Main, 2000), and studied how the attachment styles and representations maintain across time and how the attachment style of each parent impacts the attachment style of the child in interaction with that parent (Main, Hesse, & Kaplan, 2005).

Role of Mentalization

Peter Fonagy has written extensively about the biological need to be understood and how we internalize others to build a sense of self.   He has focused on the development of a reflective state of mind and identified this as mentalization: when a person has the capacity to think about their feelings and feel about their thoughts (Fonagy & Target, 1997). In describing how the reflective state of mind develops, Fonagy describes that when the internal world and the external world are equated, this is psychic equivalence: “how I think of myself matches what comes to me from outside of myself.”   When the internal and external world decouple, this is the pretend mode: how I think about myself has no relationship to what presents in the outside world.  Mentalization is the integration between these two modes.

“In normal development, the child integrates these two modes to arrive at the stage of mentalization—or reflective mode—in which states can be experienced as representations.  Inner and outer reality can be seen as linked, yet they are accepted as differing in important ways and no longer have to be either equated or dissociated from each other”  (Baron-Cohen, 1995; Gopnik, 1993; from Fonagy, 2005, p.57).  In other words, with a developed reflective function, which is achieved in secure attachment, there is flexibility between how a person relates their internal world with external reality.

Fonagy also has identified the alien self, a representation of unresolved trauma, akin to an introject. The child internalizes the mind of another, which can be very disturbing when it erupts later in life. When this happens, the person’s felt experience is that this is “not me.” This becomes relevant to know with traumatized patients who have not received adequate mirroring and care, and subsequently lack a developed reflective capacity.  Fonagy says: “Attachment theory shows us how a person’s sense of self emerges through their early bonds with caregivers, but that this is not an end in and of itself, but is part of how we develop a representational system that has evolved to aid human survival. That with secure attachment, we are able to know our own selves and are able to know and understand another” (Fonagy, 2005, p. 2).   When a parent can hear and perceive the distress in their child’s cry and reliably respond with the specific help that is needed for that child in that moment, most often the child settles and receives the comfort that is offered. When this expression of their internal state is met by their parent’s response, the child can form a representation that their needs can be soothed by another. They are, in fact, soothable.

Interpersonal Neurobiology of Attachment

Allan Schore has contributed immensely to our understanding of affect regulation and right brain development, and how caregivers’ behavior with their children shapes how the children’s brains will mature to appraise, as well as respond to human communications. He also speaks about state-sharing in psychotherapy which addresses how our right-brain to right-brain communications with our patients are essential to promote growth and development. He states, “At the most essential level, the intersubjective work of psychotherapy is not defined by what the therapist does for the patient or says to the patient (left brain focus). The key mechanism is how to be with the patient, especially during affectively stressful moments (right brain focus)” (Schore, 2012, p. 44). This right-brain-to-right-brain accompaniment is an essential ingredient to providing corrective emotional and relational experiences by offering the deep “being with” that was absent at crucial times in a patient’s life.

Dan Siegel (2007, 2010) has integrated enormous amounts of interpersonal neurobiology as it applies to the practice of psychotherapy.  His contributions articulate the development of the reflective mind and how mindfulness practice contributes to earned security.   While Fonagy’s work makes clear how being understood leads to the development of a reflective mind, Siegel studies the neuroscience of the brain’s resonance circuits and explicates how the therapist’s mindful presence and responsiveness can help clients develop the specific parts of the brain that yield this capacity for reflective function (Siegel, 2009).

Fonagy established that it takes only one relationship with one understanding other for the impact of trauma to be transformed (Fonagy, 1995, from Fosha, 2000). Siegel’s recent work discusses the mind as an organizing process that regulates the flow of energy and information and expounds upon what happens in trauma and in health. In a state of trauma, there are many crossed wires, bundled circuits, where associative links trigger nervous system activation. Siegel emphasizes that when a person can identify their source of upset and can access their pre-frontal cortex to make understanding, they are creating linkages between different parts of the brain, which eases their disturbance (Siegel, 2007). This is ever so relevant to the healing of early attachment trauma and disorganization.

In gathering the essence of these contributors, it seems clear that what we psychotherapists have available to guide our interventions is paying close attention to our interactions with our patients and how they unfold. I want to remember that my patient was once a child who grew in the light and shadows of how his or her caregivers treated him or her. The way the caregiver attended the child’s nervous system arousal and recognized and responded to their emotion, formed the basis for how our patients now regulate their affect. When a child’s cues are heard and met with sensitive care, the child develops basic trust they can be met reliably and be understood. This helps the child to feel worthy and establishes a secure internal working model of self and other. Being seen, felt and understood forms the substructures of self- reflective capacity which matures into a deeper understanding of self and other that continues to evolve throughout the stages and seasons of life. However, when patients come into our psychotherapy offices for whom these early attachment needs have not been sufficiently met, our work begins, with all of this background in mind and heart.

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