Originally published in Marion F. Solomon & Daniel J. Siegel, Eds., (2003). Healing Trauma: Attachment, Trauma, the Brain, and the Mind. Pp. 221-281. New York: Norton. Web version posted here with permission of the author. Note that this online version may have minor differences from the published version.
Mary Main ended her talk (2001) with a plea and a mandate: "Effective interventions effect change. Study and document that process." Precisely. In the unfolding conversation between clinicians and affective neuroscientists, the data of clinical change processes can spur the next wave of progress in neuroscience, namely the elucidation of the psychobiology of plasticity.
Emergent understandings based on advances in affective neuroscience (Damasio, 1994, 1999; LeDoux, 1996; Panksepp, 1998; Porges, 1997; Schore, 1994; Siegel, 1999), attachment theory and research (Ainsworth et al, 1978; Bowlby, 1973, 1980, 1982, 1991; Fonagy et al., 1995; Main, 1995), and developmental research into mother-infant interaction (Beebe & Lachmann, 1994; Emde, 1988; Jaffe, et al., 2001; Stern, 1985; Trevarthen, 2000; Tronick, 1989, 1998), are increasingly informing and transforming how we do clinical work (Beebe & Lachmann, in press; Fosha, 2000b, 2002a; Hughes, in preparation; Lachmann, 2001; Rothschild, 2000; Stern et al., 1998; van der Kolk, 2001). Clinicians need to make this truly a two-way conversation: by putting forth their privileged understanding of how change occurs, along with the phenomenological evidence of healing in psychotherapy on which their understanding is based, . the data documenting change in psychotherapy can then shape future questions in neuroscientific and developmental research. What clinical experience reveals about the mind can thus contribute to the further unlocking of the secrets of the brain and of the developmental processes by which it is molded; such scientific advances can, in turn, only further enhance the effectiveness of therapeutic intervention.
For instance, it appears that (a) the right brain and subcortical structures like the hippocampus and the amygdala are centrally involved in emotional processing, that (b) the pre-frontal orbital cortex plays a major role in affect regulation and secure attachment, and that (c) trauma and emotional neglect -which lead to disorganized attachment-- compromise the structure and function of right hemisphere, subcortical structures and the pre-frontal orbital cortex. But it also appears that therapeutic interventions that involve emotion, the body, somatosensory activation and bilateral information-processing mechanisms (see Fosha, 2000b, 2002a; Levine, 1997; Neborsky, 2003, 2003; Rothschild, 2000; Shapiro, 2003; Siegel, 2003) are effective in functionally reversing the effects of trauma. How does neuroscience explain such therapeutic results? What mechanisms operate in the brain when life-long patterns of behavior, emotion regulation and relatedness are rapidly transformed?
Questions such as these reveal a paradox between continuity and plasticity, between structure and state, between vulnerability and resilience, between intransigence and transformation.
CONTINUITY OF PSYCHIC ORGANIZATION OVER THE LIFESPAN AND ITS INTERGENERATIONAL TRANSMISSION.
On the side of continuity, we have powerful evidence that affect-regulating experiences with caregivers become immortalized in the psychic organization of the child (Cassidy, 1994; Fonagy, et al, 1991; Hesse & Main, 1999, 2000; Main, 1995) and shape the landscape of the brain, particularly the right brain (e.g., Schore, 1996; Siegel, 1999; Trevarthen & Aitken, 1994). For example, neglect and emotional deprivation in the first years of life lead to left hippocampal shrinkage, corpus callosum damage and dendritic burn-out (Schore, 2003; Siegel, 2003; Teicher, 2002). The characteristics of affect-regulating relationships, or lack thereof, are also immortalized through their transmission to future generations (Fonagy et al., 1995; Main, 1995). The intergenerational transmission of attachment states of mind is an extraordinarily robust finding, with wide-ranging implications. Witness the continuity of the Adult Attachment Interview (AAI) ratings over time (Hesse, et al (2003)), and its uncanny capacity to predict the attachment status of babies yet unborn (Fonagy et al., 1991). We have evidence of the stability of attachment classifications over time and their power to predict academic and social functioning, predisposition to pathology, and vulnerability for trauma (see Main, 1995; Sroufe, 2000). Such evidence strongly supports the psychoanalytic axiom that early experiences with caregivers determine lifelong patterns (Seligman, 1998), which makes the possibility of effecting change seem quite daunting (Fosha, 2000b, p. 55-56).
RESPONSIVENESS OF PSYCHIC ORGANIZATION TO CURRENT CONDITIONS.
And yet --on the plasticity side of the paradox-- we have equally powerful data that document the suppleness of the psyche and its attuned responsiveness to current conditions, especially those favoring self-righting tendencies (Eagle, 1995; Emde, 1981, 1988; Lamb, 1987). As Siegel notes, in children, security or insecurity of attachment is not a characteristic of the individual, but rather of a relationship: it is not uncommon for a child to be securely attached with one parent, and disorganized (or insecurely attached) with the other (Main, 1995). There is evidence that just one relationship with a caregiver (and that caregiver does not have to be the principal caregiver) who is capable of autobiographical reflection, i.e., a caregiver who possesses a high reflective self function, can enhance the resilience of an individual: through just one relationship with an understanding other, trauma can be transformed and its effects neutralized or counteracted (Fonagy, Leigh, Kennedy, et al., 1995). Moreover, there is growing evidence that changes in the child's attachment status occur reliably as attachment-focused interventions produce changes in the caregiver (Marvin et al., 2002; van den Boom, 1990). For example, changes in the attachment status of toddlers from disorganized to secure are being obtained by means of a 20-session group intervention protocol with their caregivers (Marvin et al., 2002). As parents move from defensive processes to increased empathy for their children, the children's attachment security increases.
Thus, on one side we have the continuity of psychic organization over time and the power of early experience to shape mind, brain, psyche, and behavior of both the individual and of future generations. On the other side, there is the equally compelling evidence of the psyche's exquisite responsiveness to current conditions, especially when these conditions favor the activation of the individual's self-righting, self-healing mechanisms. It is here, on the side of plasticity, that we find these change phenomena in search of a biology. And it is in this rich soil that the affective neuroscience of psychotherapeutic healing can take root and flourish.
The data I contribute have been obtained through the application of Accelerated Experiential-Dynamic Psychotherapy (AEDP), a therapy model informed by a change- and transformation-based metapsychology (Fosha, 2000b, 2002a, 2002b). AEDP seeks to activate healing by facilitating the individual's visceral experience of core affective phenomena within an emotionally engaged patient-therapist dyad: the provision and fostering of new emotional experiences is both AEDP's method and its aim. In Part 1 of this two-part paper I will present AEDP, and show how it is harmonious with the implications of recent advances in affective neuroscience and attachment studies. Throughout, the focus will be on the relationship between the dyadic regulation of affective states and the experience of intense emotion in therapy, in optimal development and in psychopathology. Part 2 of the paper is a case study I call "Fright without solution." The title comes from a paper by Hesse and Main (2000) on the role of fear in disorganized attachment. I present clinical work from two consecutive sessions which proved pivotal in fostering a major transformation in the patient. Detailed transcript material is provided and micro-analyzed to illustrate AEDP and the actual moment-to-moment tracking of affective experience involved in experiential clinical work.
The neurobiological processes involved in the processing of emotion and affect regulation in optimal emotional development and compromised in trauma involve the right brain: The right brain, the dominant hemisphere for emotion and affect regulation, is early maturing and dominant in the first three years of life, indicating the primacy of emotion and the essentially emotional nature of mental functioning in the first years of life. Right brain functioning, the quality of the right mind, so to speak, involves processes that are emotional, visual/imagistic, and somatosensory; the language in which emotional experience is encoded is non-linear and not linguistically-mediated, but, instead, body-focused, and experiential.
Crucial aspects of the development of the brain are shaped in early experiences (Damasio, 1994) between infant and caregiver (Schore, 1996). During the first two years of life, the brain is growing at the most rapid rate of the entire lifespan. Dyadic emotional processes between infants and caregivers involving attunement, empathy, affective resonance, gaze sharing, entrained vocal rhythms and mutually shared pleasure (Beebe & Lachmann, 1994; Jaffe et al., 2001; Panksepp, 2000; Stern, 1985; Trevarthen, 2000; Tronick, 1989, 1998), processes primarily mediated by the right brain, are associated with positive affective states (Schore, 1996; Siegel, 1999). The maintenance of positive affective states associated with dyadic experiences of affective resonance has been suggested to be crucial to optimal neurobiological development. "The baby's brain is not only affected by these interactions, its growth literally requires brain-brain interactions and occurs in the context of a positive relationship between mother and infant" (Schore, 1996, p. 62, emphasis added; see also Trevarthen & Aitken, 1994). The positive affects associated with these moment-to-moment, dyadic, right-brain to right-brain affective experiences are the stuff of secure attachment (Schore, 2000). And secure attachment is at the foundation of optimal mental health and resilience, and operates as a powerful protective factor against the development of trauma.
Disorganized attachment appears to strongly predispose the individual to the development of psychopathology and vulnerability to trauma. Both trauma and the chronic states of dyadic misattunement that become the constituents of disorganized attachment are highly stressful states that compromise development. Trauma is marked by the arousal of the "vehement emotions" (Janet, 1889, in van der Kolk, 2001, p. 3), which are so intense that they interfere with the appraisal and processing of emotional experience and thwart its integration into a coherent narrative. The high levels of arousal that define the vehement emotions interfere with the functioning of areas of the brain, such as the frontal lobe, the prefrontal cortex, and the hippocampus, which are involved in appraisal and executive processes, and lead instead to the automatic and fragmentary nature of sensory and emotional experience characteristic of post-traumatic stress disorder (van der Kolk, 2001).
The sequelae of emotional neglect and deprivation are as stark and damaging as those of overt trauma. Chronic involvement in such states leads to actual dendritic shrinking and atrophy of certain regions of the brain (Schore, 2001; Siegel, 1999; Teicher, 2002). In infancy, aversive dyadic interactions actually have been shown to lead to neuronal cell death in "affective centers" in the limbic system as a result of the high corticosteroid levels generated, as well as to lead to alterations in opiate, dopamine, noradrenaline, and serotonin receptors (Lyons-Ruth, 2001; Schore, 2003; Siegel, 1999; van der Kolk, 1996).
As a result of the high stress of both frank emotional trauma, and of chronic misattuned dyadic interactions resulting in disorders of attachment (see below), the individual is immersed in prolonged exposure to unmetabolized, intense, and intensely negative affects. It appears that right hemisphere, limbic structures and the links between the orbito-frontal cortex and the right hemisphere, brain structures involved in the processing of emotional experience, are adversely affected. The individual's capacity to process and regulate emotion, fundamental to human relatedness, is substantively affected. The sequelae of trauma and neglect become evident not only in the dramatic disturbances of PTSD, but also make themselves known and felt in the havoc wreaked on social relationships and the devastating ruin of a baseline of well-being.
The moment-to-moment dyadic regulation of affect through psychobiological state attunement is the mechanism through which attachments are formed (Fosha, 2001; Schore, 1996). The attachment paradigm (Bowlby, 1973, 1980, 1982), fundamental to understanding human emotional development, is thus intimately linked with emotion regulation and right brain development. Attachment status (secure, organized insecure, or disorganized) reflects the capacity of the dyad to regulate intense affective experience while simultaneously maintaining mutual connection. Optimally, the processing of emotional experience solidifies, rather than taxes and erodes, the attachment bond.
Evolutionarily, the function of attachment has been to protect the organism from danger. The attachment figure, an older, kinder, stronger, wiser other (Bowlby, 1982), functions as a safe base (Ainsworth et al., 1978), and is a presence that obviates fear and engenders a feeling of safety for the younger organism. The greater the feeling of safety, the wider the range of exploration and the more exuberant the exploratory drive (i.e., the higher the threshold before novelty turns into anxiety and fear). Thus, the fundamental tenet of attachment theory: security of attachment leads to an expanded range of exploration. Whereas fear constricts, safety expands the range of exploration. In the absence of dyadically constructed safety, the child has to contend with fear-potentiating aloneness. The child will devote energy to conservative, safety enhancing measures, i.e., defense mechanisms, to compensate for what's missing. The focus on maintaining safety and managing fear drains energy from learning and exploration, stunts growth and distorts personality development.
The qualities of effective caregiving have been elucidated by research into what promotes optimal development and secure attachment. The caregiver's affective competence (Fosha, 2000b), reflected in her own internal working models and reflective capacity (Fonagy et al. 1994, 1995; Fonagy & Target, 1998; Main, 1995), has been found to promote secure attachment. Conversely, the caregiver's compromised affective competence, i.e., her inability to flexibly attune to the child in the process of dyadic affect regulation, makes it necessary for the child to institute defense mechanisms to compensate for such caregiving lapses, leading to insecure attachment organizations, or disorganized attachment states of mind, when even defensive efforts fail.
1. The caregiver's affective competence. The caregiver qualities that have been empirically demonstrated to be crucial to the child's affective competence, i.e., to promote the development of secure attachment in the child, all involve the caregiver's emotions (Ainsworth et al., 1978; Bates, Maslin, & Frankel, 1985; Cassidy, 1994; Emde, 1983; Panksepp, 2000; Schore, 2000; Trevarthen, 2000). A quality I wish to highlight here is the capacity to go 'beyond mirroring' (Grossman in Fonagy et al., 1995): it involves actively helping the child with stressful and distressing situations, which are beyond their resources to manage. This emotional lending of a hand, mostly involving the management of the high-stress categorical emotions, is crucial to dyadic affect regulation. The caregiver's affective competence --informed by an internal working model where affect and relatedness, self and other, and feeling and dealing can all operate in harmony-- is at the foundation of the child's sense of security (Fosha, 2000b).
2. Existing in the heart and mind of the other: the caregiver's reflective self function. Being able to reflect on emotional experience, one's own and that of the other, is another aspect of affective competence. This has been called the capacity for reflective self function by Fonagy (Fonagy et al., 1995), and the capacity for maintaining a coherent and cohesive autobiographical narrative by Main (1995). Most remarkably, this autonoetic capacity (Siegel, 1999) has been shown to interrupt the intergenerational transmission of psychopathology (Hesse, et al (2003)), and to promote the child's resilience under stress (Fonagy et al., 1994).
The caregiver's capacity for reflective self-functioning allows the caregiver to attune to the child and his needs, without her response unduly reflecting the pulls of her own emotional experience. The result of receiving such caregiving is that the child has the experience of existing in the heart and mind of the other as himself, and not as an extension of the caregiver. Such experiences become internalized in the individual's own reflective self function which "... equips the individual with ballast, a self-righting capacity" (Fonagy et al., 1994, p. 250). The individual develops his own reflective self function which allows him to modulate emotions, coordinate self attunement and other responsiveness, and respond flexibly to new situations.
Thus, the roots of security and resilience are to be found in the sense of being understood by and having the sense of existing in the heart and mind of a loving, caring, attuned and self-possessed other, an other with a mind and heart of her own. In the face of the demonstrated potency of the reflective self function, we can assert, as Fonagy and his colleagues do, that "[t]he biological need to feel understood ... takes precedence over almost all other goals" (1995, pp. 268-69). In one bold move, empathy becomes a central tool for serving the most basic adaptational aims of the human being. And the right-brain to right-brain communication underlying empathy becomes crucial to both the developmental and therapeutic endeavors.
3. The institution of defense mechanisms to compensate for caregiving lapses: the resulting attachment classification. The quality of attachment reflects the capacity of the dyad to regulate the intense emotions associated with the vicissitudes of their relationship while maintaining connection. The caregiver assists the child in handling his overwhelming emotions; a large part of the caregiver's affective competence vis-a-vis her child's emotions depends on her ability to regulate her own emotions--triggered by the situation, and by his emotions--so that they enhance, rather than disrupt, her functioning. The caregiver's own secure internal working model allows her to feel and deal while maintaining connection (Fosha, 2000b), and helps her child do the same.
When the caregiver's emotional availability, responsiveness and reflective capacities are compromised, often as a result of her own trauma and loss, dyadic affective regulation cannot proceed optimally. The more the child's emotions trigger the caregiver's fear, shame, helplessness, or guilt, the more she will disengage emotionally. Desperate to maintain and restore the attachment bond, the child resorts to the defensive exclusion of whichever emotions produce aversive reactions in the caregiver, regardless of how vital they might be to him (Bowlby, 1980; Main, 1995).
The chronic reliance on defenses against emotional experience instituted to compensate for these lapses in the caregiver's affect-regulatory capacities produces adaptations which are categorized by the attachment classifications, that have been translated into affective functional strategies (Fosha, 2000b). Whereas secure attachment involves the capacity to feel and deal without the need to resort to defense mechanisms, the two types of organized insecure attachment are the result of defensive strategies: the strategy of dealing but not feeling in avoidant attachment, and the strategy of feeling (and reeling), but not dealing in resistant/ambivalent attachment. However, when even defensive efforts are overwhelmed by the disruptive emotions resulting from unreliable caregiving, we are in the realm of disorganized attachment (Main, 1995, 1999): the only way both self and relationship can be maintained is through momentary immobility: the individual can neither feel (dissociation) nor deal (paralysis).
What are the implications for a therapy, informed by this wealth of insight into the nature of processes underlying optimal development, attachment psychopathology, and trauma (see also Hesse, et al (2003)); Schore, 2003; Siegel, 2003; van der Kolk, 2003)? I discuss four of its features below. Note that the therapist's empathy and affective competence (Fosha, 2000b) are indispensable and underlie all four:
1. To access emotion and harness its profoundly adaptive and healing resources in therapy, it is important to be able to engage the relevant neurobiological processes. Emotional experience is not processed through language and logic; as the right hemisphere speaks a language of images, sensations, impressions, and urges toward action, therapeutic discourse must be conducted in a language that the right hemisphere speaks. Therapies dealing with disorders that are fundamentally emotional in nature need to be able to reliably access sensory, motoric, and somatic experiences to engage them in a dyadic process of affect regulation and eventual transformation. This requires a bottom-up processing approach of experiential therapies, rather than the top-down approach of most cognitive and insight-focused therapies (Greenberg, Rice & Elliott, 1993; van der Kolk, 2001). There is a premium on activating right-brain mediated emotional processes through techniques that focus on sensory, somatic, and motoric experience, and that involve reliving and picturing, rather than narrating, interpreting and analyzing.
2. By definition, dyadic affect regulation takes two to tango. Applying the central dictum of attachment theory, i.e., safety promotes an expanded range of exploration, therapist activities that promote the patient's sense of safety are essential. The therapist's emotional engagement, willingness to go "beyond mirroring" and actively share in the hard emotional work, and willingness to make use of her emotional experience are essential constituents of the therapeutic process. So is the striving to help the patient feel that he exists "in the heart and mind of the therapist.
3. Given the centrality of defense in the attachment-based understandings of psychopathology, a treatment model must also be adept at working with defenses and getting past them, so as to gain direct experiential access to feared-to-be-unbearable emotional experiences.
4. Once the patient feels safe, and the impact of defenses has been reversed, bottom-up processing will result in bringing the vehement emotions to the fore. A therapy must have techniques not only for accessing, but also for processing such intense, usually highly negative and toxic, emotions. Techniques need to help the individual metabolize these intense emotions so that their activation is not only not traumatic (i.e., the individual is not re-traumatized through the emotional exposure) but eventually therapeutic; when emotions are adequately processed, the adaptive benefits of emotional experience can be reached. Thus, emotions and the invaluable information they contain need no longer be excluded and can be integrated within the individual's autobiographical narrative, making it increasingly coherent and cohesive.
Accelerated experiential-dynamic psychotherapy (AEDP) puts into practice these fundamental elements. AEDP is characterized by an empathic, affirming and emotionally engaged stance and its experiential, dyadic, affect-centered techniques. The visceral experience of core affective phenomena within an emotionally engaged dyad is considered to be the key mutative agent (Fosha, 2000b, 2001, 2002a). AEDP is described at length in my book, The Transforming Power of Affect (Fosha, 2000b); here, I will focus on four of its distinguishing features, crucial in the context of this chapter:
(1) AEDP therapeutic stance and techniques aim to facilitate the patient's access to a deep, experiential, emotion-centered, body-focused, somato-sensory-motor experiencing. Once affective experience is thus viscerally accessed, regulated and worked through, AEDP aims to harness reflective processes in order to metabolize and integrate experience, alternating waves of visceral experience and reflection.
(2) The therapist's emotional engagement and use of her affect in the therapeutic process define AEDP's therapeutic stance. AEDP aims to (a) foster the establishment of an emotionally--engaged empathy-based patient-therapist bond within which affect regulation of previously disruptive emotional experiences can be processed and (b) bring about a deep, body-focused, affective-somato-sensory way of being both in the patient, as well as between patient and therapist. AEDP seeks to entrain dyadic affective processes involving attunement, empathy, and repair following miscoordination: face to face, eyes to eyes, affect to affect, these are essential to creating psychobiological state attunement and fostering a process of right brain to right brain communication within the patient-therapist dyad.
(3) Restructuring and bypassing defenses so as to get to core affect informs all AEDP therapeutic stance and techniques, an aspect of AEDP deeply informed by the experiential STDPs (Short-Term Dynamic Psychotherapy) tradition (Davanloo, 1990; McCullough Vaillant, 1997; Neborsky, 2003; Solomon et al., 2001). As both AEDP and attachment theory emphasize the centrality of defensive processes in the development of psychopathology, AEDP techniques for minimizing the impact of defenses are central in this endeavor.
(4) AEDP uses a diverse array of techniques derived from both the experiential STDPs (Davanloo, 1990; McCullough Vaillant, 1997; Solomon et al., 2001) and experiential therapies (Gendlin, 1996; Greenberg & Paivio, 1997; Greenberg, Rice & Elliott, 1993; Kurtz, 1990) to both access and work with the "vehement emotions" that are aroused in traumatic situations, and dyadically regulate them until their adaptive action tendencies (see below) can come to the fore.
Thus, AEDP has a two-factor theory of therapeutic change: it involves affect and relatedness. Empathy, attunement, and the establishment of security and safety are essential, but not sufficient. The bond that gets created as a result of dyadic processes, the adult therapeutic equivalent of secure attachment, serves as a matrix, a holding environment in which deep emotional processes, the kind mediated by limbic system and right brain, can be experientially accessed, processed and worked through, so that they can eventually be integrated within the individual's autobiographical narrative.
The visceral, embodied experiencing and full processing of affective phenomena activates adaptive affective change processes involving categorical emotion, relatedness, the body and the self (Fosha, 2002a). The benefits of these affective change processes (see below) can be reaped through their embeddedness in a relational matrix that makes use of the emotions of both partners.
AEDP's therapeutics are rooted in a change-based metapsychology rather than a psychopathology-based metapsychology. The patient's visceral experience of change is key: "There is a distinct physical sensation of change, which you recognize once you experienced it... When people have this even once, they no longer helplessly wonder for years whether they are changing or not. Now they can be their own judges of that" (Gendlin, 1981, p. 7).
Affective change processes are naturally occurring phenomena: they reflect how we are wired. Their transformational effects operate not only in therapy (Fosha, 2002a, 2002b), but in development (Beebe & Lachmann, 1994; Tronick, 1988), in romance (Person, 1988), in religious experiences (James, 1902), in life-changing conversions, (e.g., Martin Luther, Gandhi; see Cooper, 1992), in authentic contact and communication (Buber, 1965), and in transforming experiences at trauma conferences! Affective change processes are at work whenever profound changes happen rapidly and one's self is simultaneously deeply engaged, challenged and supported (Buber, 1965; Stern et al., 1998).
The dyadic regulation of affective states, the experience and expression of categorical emotion, the empathic reflection of self, somatic focusing, and focusing on the experience of transformation itself (and affirming the transformation of the self) are the five affective change processes that AEDP focuses on (Fosha, 2002a). These change processes operate moment-to-moment, have clear-cut affective markers and operate through transformations of state, i.e., in quantum leaps rather than in a slow, gradual and cumulative fashion, in which the new state is characterized by greater access to emotional resources.
Table 1. The Phenomenology of Affective Change Processes
|Affective Change Process||Core Affective Phenomena||Core State Phenomena||Adaptive Consequences|
|Experience and Expression of Categorical Emotion||Categorical emotions: anger, sadness, joy, fear, disgust||Adaptive action tendencies associated with each emotion, core state experiencing||Emotional resources associated with each adaptive action tendency; unlocking unconscious material; new cycle of transformation activated.|
|Dyadic Regulation of Affective States: Attunement, disruption, and repair, leading to reestablished coordination||Core relational experiences; affective resonance, "in sync" feelings in response to attunement, reparative tendencies in response to disconnection.||Feelings of intimacy and closeness; trust; core state experiencing||Secure attachment; resilience; capacity to move easily between self-attunement and other-receptivity; unlocking unconscious material; new cycle of transformation activated.|
|Empathic Reflection of the Self: Empathy, validation, "going beyond mirroring."||Receptive affective experience of feeling known, seen, and understood; having the sense of "existing in the heart and mind of the other."||"True self" experiences of feeling "alive", "real", 'like myself"; core state experiencing.||Secure attachment; resilience; reflective capacity; self-esteem; consolidation of the self; empathy and self-empathy; unlocking unconscious material; new cycle of transformation activated.|
|Somatic Focusing: Shifting from in-the-head thinking to in-the-body sensing and feeling.||The felt sense; embodied experiencing.||The body shift; bodily states of relaxation, openness, and being in touch; core state experiencing.||Activation of self-righting tendencies; ease, calm, flow, energy, vitality, joie de vivre; unlocking unconscious material; new cycle of transformation activated|
|Focus on the Experience of Transformation: The activation of the metatherapeutic processes; mastery; mourning the self; and affirming the self and its transformation.||Transformational affects: joy and pride; emotional pain; the healing affects of (a) feeling moved and emotional within oneself; (b) love, gratitude, and tenderness toward the other.||Adaptive action tendencies associated with each emotion; core state experiencing||Self-confidence and exploratory zest; clarity, perspective, acceptance; empathy and self-empathy; unlocking unconscious material; new cycle of transformation activated.|
The hallmark of each process is a characteristic core affective experience, associated with a transformation of state specific to its mode of action. The experience, expression and communication of these core affective phenomena, in the context of a secure, emotionally-facilitating dyadic relationship, culminate in the activation of yet another state, the core state, in which maximally effective, transformational therapeutic work takes place. The manifestations of both core affect and core state phenomena associated with each affective change process are summarized in Table 1.
Therapeutic work with the affective change processes is a three stage process (see Figure 1), involving three states (defense, core affect, and core state) and two state transformations (from defense to core affect, and from core affect to core state):
The full visceral experience of a specific core affective phenomenon constitutes the first state transformation. When interventions aimed at counteracting defenses, anxiety, helplessness and shame are effective, core affective experience is accessed. The state in which the individual experiences core affect is experientially and psychodynamically discontinuous with the defense-dominated state that precedes it: Characteristic processing is right-brain mediated, that is, it is largely sensorimotor, image-dominated, visceral, non-linear. There is also much greater access to previously unconscious material, a phenomenon referred to in the experiential STDP literature as "unlocking the unconscious" (Davanloo, 1990): it is as if a door opens to previously unavailable (dissociated, unconscious, split off, neglected, forgotten, ignored) perceptions, memories, and fantasies, organized around that core affective experience. Also unlocked are highly adaptive emotional resources which were previously unavailable to the individual; the enormous healing potential residing within them is released.
The shift from core affect to core state represents the second state transformation. This shift is invariably accompanied by positive affects. The full experience of core affect, unhampered by defense, culminates in the activation of another state, the core state, in which there is also no anxiety or defensiveness. The body is not rocked by any particular emotion. There is vitality, relaxation, ease, and clarity. Core state refers to an altered state of openness and contact, where the individual is deeply in touch with essential aspects of his own experience. In this state, experience is intense, deeply felt, unequivocal, and declarative; sensation is heightened, imagery is vivid, pressure of speech is absent, and the material moves easily. Effortless focus and concentration also are features of the core state. Relating is deep and clear, as self-attunement and other-receptivity easily coexist. Core state phenomena include but are not limited to (1) the sense of strength, clarity, and resourcefulness associated with the release of adaptive action tendencies; (2) core relational experiences of love, tenderness, compassion, generosity, and gratitude, relational experiences emergent from a state of self-possession; (3) core self experiences of what individuals subjectively consider to be their "true self"; (4) core bodily states of relaxation, openness and vitality that emerge in the wake of the body shift; and (5) states of clear and authentic knowing and communication about one's subjective "truth." Through such complete processing of affective experience, the experiencer of the emotions gets to a new place, fostering what Person (1988) describes as the "flux in personality, the possibility for change, and the impetus to begin new phases of life and undertake new endeavors" (p. 23). The core state which follows the experience of core affect is optimally suited for the therapeutic integration and consolidation that translate in-session changes into lasting therapeutic results. It is in the core state that the reflective self function can operate at its fullest potency.
I will focus on two of the affective change processes - the dyadic regulation of affective states and the experience and expression of the categorical emotions-- as they figure prominently in the case to be presented (see Fosha, 2002a, for a discussion of each affective change process). They involve the regulation of two types of core affective experience, the vitality affects and the categorical emotions, respectively.
The vitality affects (Stern, 1985; Siegel, 1999) are the micro-affects through which fluctuations in attunement are expressed. They refer to subtle, ongoing, moment-to-moment, qualitative shifts in arousal, energy, feeling, and rhythm (Siegel, 1999; Stern, 1985). Their "elusive qualities are better captured by dynamic, kinetic terms, such as "surging," "fading away," "fleeting," "explosive," "crescendo," "decrescendo," "bursting," "drawn out," and so on....[The vitality affects] are experienced as dynamic shifts or patterned changes within ourselves" (Stern, 1985, p. 54-57).
By contrast, the categorical emotions (Darwin, 1872), --fear, anger, joy, sadness, disgust-- macro-emotions initially processed subcortically, in the limbic system (Damasio, 2000), are big, distinct emotional experiences. Each categorical emotion has its own universal physiological signature (Ekman, 1983; Zajonc, 1985), as well as its own set of characteristic dynamics (Darwin, 1872; Lazarus, 1991; Tomkins, 1962, 1963). Unlike the fleeting, shifting nature of the vitality affects, the distinct bodily correlates of the categorical emotions are highly salient and an integral aspect of how we experience them.
Now the focus is on how the experience and expression of these two types of core affective experience become transformational vehicles for the individual.
THE DYADIC REGULATION OF AFFECTIVE STATES THROUGH THE VITALITY AFFECTS.
All affective change processes are dyadically regulated -in development and therapy-- until the dyad's regulatory strategies become internalized in the procedural repertoire of the individual. In four of the affective change processes, (# 2- # 5 in Table 1), dyadic regulation operates in the experiential background; however, in the first affective change process, the dyadic process itself is the experiential foreground.
The dyadic regulation of affective states through fluctuations in voice, gaze, rhythm, touch, and timing is a fundamental aspect of interpersonal interaction throughout the lifespan. In infancy, however emotional communication is communication. It is all there is. And vitality affects are to emotional communication what words are to verbal communication.
The research of the clinical developmentalists into the characteristics of moment-to-moment caregiver-infant emotional communication (Beebe & Lachmann, 1994; Emde, 1988; Gianino & Tronick, 1988; Trevarthen, 1993, 2000; Trevarthen & Aiken, 1994; Tronick, 1989; Tronick & Weinberg, 1997) reveals three phases in the psychobiological process of co-regulating affective states: attunement (the coordination of affective states), disruption (the lapse of mutual coordination), and repair (the reestablishment of coordination under new conditions). For example, attuned mutual coordination occurs when the infant's squeal of delight is matched by the mother's excited clapping and sparkling eyes. Now somewhat overstimulated, the baby arches his back and looks away from the mother, down-regulating through lowering arousal. A disruption has occurred and there is miscoordination: the mother, still excited, is leaning forward, while the baby, now serious-faced, pulls away. However, the mother picks up the cue, and begins the repair: she stops laughing and, with a little sigh, quiets down. The baby comes back and makes eye contact, a soft relaxation on his face. Mother and baby gently smile. They are back in sync, the new coordination now occurring around a different affective state than the one that prevailed few seconds before. In striving to reach and maintain mutual coordination, both partners regulate their own affect through interacting with the other.
The coordinated state has positive affective markers and motivational properties; both partners experience pleasure on achieving coordination, strive to maintain it and work hard to restore it when it is disrupted. The disruption of coordination has negative affective markers and also has powerful motivational properties; in healthy dyads, it activates reparative tendencies aimed at restoring affective coordination and a positive affective state. Even when the affects being coordinated are negative affects, the achievement of mutual coordination is associated with positive affect! This process is at work in the clinical situation when the therapist empathizes with the patient: as therapist and patient resonate with the patient's experience of negative affect, positive relational affects, even if fleeting, often come to the fore.
Mutually shared affective interactions, achieved through psychobiological state attunement, result in the amplification of positive affective states and the reduction of negative ones. Such experiences, which can "crescendo higher and higher," leading to "peak experiences of resonance, exhilaration, awe and being on the same wavelength with the partner" (Beebe & Lachmann, 1994, p. 157), deepen relatedness and security of attachment (Fosha, 2000b, p. 63).
The process of moment-to-moment mutual coordination and affect regulation is considered to be the fundamental mechanism by which attachment is established (Schore, 2000). Countless repetitions of the sequence of attunement, disruption, and repair lead to an affective competence, as the individual internalizes the affect-managing strategies of the dyad (Fosha, 2000b, 2001a, 2001b). The experience of being able to repair the stress of disrupted relatedness (i.e., transform negative affects into positive affects and disconnection into reconnection), leads to the individual's confidence in his own abilities, and trust in the capacity of others to respond (Tronick, 1989). Success with efforts to repair dyadic disruptions leads to a certain emotional stick-to-itiveness in the face of adversity which is at the heart of resilience (Fonagy et al, 1994).
Thus the transformation that occurs as the result of the optimal dyadic regulation of affective states, is twofold: (a) It leads to the establishment of increasingly secure attachment, which promotes optimal development and fosters maximal learning through the expansion of the range of exploration. (b) Furthermore, the maintenance of positive affective states associated with dyadic experiences of affective resonance has been shown to be crucial to optimal neurobiological development (Schore, 1996, p. 62). However, note that the amplification of the positive affects achieved is through the repair of disruption following miscoordination, and not through the exclusion of negative states. Disruption and its negative affects is as natural a phase of optimal functioning as is attunement. It is also as vitally important, as we will see below.
This has uncannily precise parallels in treatment (Fosha, 2000b, 2001b). Research shows that the therapist's attunement to the patient's affective state and the patient's experience of feeling safe, understood, and affectively resonated with are probably the most powerful contributor to the achievement of positive therapeutic outcome (see also Bohart & Tallman, 1999; Rogers, 1957; Rosenzweig, 1936). When both partners feel in sync and engage around their respective experiences, the individual feels deeply understood, the core state is activated and mutative therapeutic work can take place.
THE REGULATION OF CATEGORICAL EMOTIONS: THEIR EXPERIENCE AND EXPRESSION.
Fear, anger, sadness, joy, and disgust, the categorical emotions that appear on everyone's list, are biological forces to be reckoned with. Darwin (1872) was the first to describe their phenomenology and dynamics and fully appreciate their importance in human adaptation. The categorical emotions are processes of appraisal (Lazarus, 1991); they amplify and make salient that in the environment which is most important to the individual, and thus they heighten motivation (Tomkins, 1962-3). Through them, we are able to communicate to ourselves and to others that which is of importance (Bowlby, 1991). For Darwin (1872), as for Bowlby (1991), the most important function of emotional expression is communication among individuals.
There is something particularly powerful about the transformation inherent in the full visceral experience of the categorical emotions. As William James (1902) says: "Emotional occasions . . . are extremely potent in precipitating mental rearrangements. The sudden and explosive ways in which love, jealousy, guilt, fear, remorse, or anger can seize upon one are known to everybody. Hope, happiness, security, resolve . . . can be equally explosive. And emotions that come in this explosive way seldom leave things as they found them" (p. 198).
The full visceral experience of the categorical emotions leads to two kinds of transformations, both highly therapeutic: (1) Through the experience of the specific emotion, the individual gains access to the previously unconscious network of feelings, thoughts, memories, and fantasies associated with the emotion. This is what allows the deep working through of dynamic material related to the roots of the patient's pathology. In that way, core affect is the royal road to the unconscious (Fosha, 2000b). (2) Each categorical emotion is associated with an adaptive action tendency that "...offers a distinctive readiness to act; each points us in a direction that has worked well to handle the recurrent challenges of human life" (Goleman, 1995, p. 4). With the release of the adaptive action tendencies, the individual accesses deep emotional resources, renewed energy, and an expanded repertoire of adaptive behaviors. For example, the adaptive action tendencies released by fully experienced anger often include a sense of strength, assertiveness and power, which lead to the rediscovery of psychic strength, self-worth, and affective competence.
THE INTEGRATION OF THE DYADIC REGULATION OF VITALITY AFFECTS AND CATEGORICAL EMOTIONS WITHIN THE THREE PHASE MODEL OF ATTUNEMENT, DISRUPTION, AND REPAIR.
Discussions of the centrality of affect regulation in the establishment of attachment have focused on the vitality affects (Schore, 2000; Siegel, 1999; Sroufe, 1995). However, fundamentally, attachment is an evolutionary solution that counters the disorganizing effects of the categorical emotion of fear in the face of danger. Furthermore, the attachment classification system is based on whether the individual is able to manage the big categorical macro-emotions, (e.g., fear, grief, anger, joy), associated with the vicissitudes of attachment, (e.g., separation, loss, and reunion) or whether defensive strategies need to be instituted when the regulation of such categorical emotions is beyond the emotional resources of the individual. Any psychological model informed by attachment theory must include the regulation of the categorical emotions. The three phases of the dyadic affect regulatory process --attunement, disruption and repair-- provide a model for how change processes reflected in vitality affects and categorical emotions can be coherently integrated into the treatment of the sequelae of trauma and disorganized attachment.
The vitality affects are the affects of attunement: they both express it and are vehicles for its achievement. As a function of their ephemeral and fluid nature, they are well suited to dyadic coordination and mutual affective sharing. However, as discussed above, the categorical emotions are highly individual experiences. By their very nature, the categorical emotions belong to the second phase of the process of dyadic affect regulation, the disruption phase. A burst of tears, an explosion of anger, a paroxysm of laughter, disrupt the smooth surface of dyadic coordination. Take an ordinary interaction: Mother and baby are happily playing. Energized by the crescendo of affectively resonant states shared between them, with a big grin of delight, the baby enthusiastically yanks the mother's hair; the mother grimaces and, for a split second, shows a face of anger. The baby wails in fear and despair. Ordinary, but disruption par excellence.
If the dyad can contain and work with the affect storm, whether big or small, momentary or longer-lasting, then it will be possible to regain mutual coordination in a way that does not make the exclusion and curtailment of the categorical emotion necessary. If the dyad can process the categorical emotion, defenses against the emotion may not be necessary. The coordination that emerges upon the success of repair gives rise to a new coordinated state, which is more complex and more inclusive as it contains within it the initially divergent information of each partner's experience: through the dyadic processing of affective disruptions, an expanded state of consciousness emerges, which is how growth and learning take place for both partners (Tronick, 1998). Three transformational processes are activated: (1) adaptive action tendencies associated with the categorical emotion, (2) bond-strengthening and learning-promoting brain states resulting from positive resonant shared affects, and (3) the dyadic expansion of consciousness of each partner toward greater complexity.
In optimal development, affective change processes naturally unfold and the individual can reap their adaptive benefits. In pathogenic environments, affective change processes, instead of bringing psychic gains, bring aversive results as the experience and expression of core affective phenomena meets with disruptive, non-facilitating responses from the primary attachment figure. For instance, the expression of distress meets with the other's anxiety; desire for contact elicits the other's withdrawal; the offering of love is met with indifference; authentic self-expression evokes angry rejection. The caregiver is unable to maintain coordination in the face of the child's spontaneous emotional experience; some aspect of the child's emotional being triggers profound discomfort in the caregiver, who responds either inadequately, with errors of omission (e.g., withdrawal, distancing, neglect, denial), or attackingly, with errors of commission (e.g., blaming, shaming, punishing, attacking). The disruption in mutual coordination caused by core affect cannot be dyadically repaired.
These disruptive reactions on the part of the attachment figure (i.e., the errors of commission or omission), elicit a second wave of emotional reactions. The individual has to contend not only with the initial emotion-stimulating event; now he also has to contend with a second emotion-stimulating event, namely, the negative reaction of the figure of attachment. Fear and shame, the pathogenic affects (Fosha, 2002a) arise when the response of the attachment figure to the individual's core affective experience is disturbing and disruptive. When shame and fear are elicited by disruptive experiences with attachment figures and cannot be dyadically repaired, individuals find themselves alone, emotionally overwhelmed, unable to be real and unable to count on the safety of the emotional environment. Highly aversive, the hallmark of the pathogenic affects is that they are experienced by an individual who is alone, as the affect-regulating attachment relationship has collapsed.
The combination of (1) interrupted core affective experiences, (2) compromised self-integrity and disrupted attachment ties, and (3) the overwhelming experience of the pathogenic affects in the context of unwilled and unwanted aloneness leads to unbearable emotional states: these include experiences of helplessness, hopelessness, loneliness, confusion, fragmentation, emptiness, and despair, the "black hole" (van der Kolk, 2001) of human emotional experience, where the individual is at his most depleted, with no safety and no access to emotional resources. The attempt to escape the excruciating experience of these unbearable emotional states become the seeds for defensive strategies that, when chronically relied on, culminate in the development of psychopathological conditions (see top half of Figure 2).
The patient comes to rely upon defenses, denying, avoiding, numbing, or disavowing the affectively laden experiences that wreaked such havoc in the past and are expected to do so again. Psychic survival becomes possible only through the defensive exclusion (Bowlby, 1988) of the very processes that constitute optimal psychic health. Core affective experiences and their adaptive consequences are preempted, leaving the individual with terribly reduced resources to face the challenges of the world. The expanded triangle of conflict schematically represents how emotional experience comes to be structured (see bottom half of Figure 2).
Returning to the paradox between continuity and change and between vulnerability and resilience: All emotional experiences occur in a relational context. Precisely how experience is structured depends on that emotional environment. Any triangle of conflict is embedded within a particular self-other-emotion configuration (see Figure 3), which is AEDP's version of an internal working model (Bowlby, 1982), where emotion is prominently structured in. Different self-other-emotion configurations, give rise to different kinds of functioning.
By changing one element of the self-other-emotion configuration, the individual's experience can dramatically change and emotion can be processed quite differently (as represented by different versions of the triangle of conflict).
Regardless of the severity of psychopathology, each individual's functioning occurs on a continuum, with self-at-best functioning and self-at-worst functioning representing the opposite ends of the continuum. The structure of the self-at-best functioning, which arises in emotional environments experienced as affect-facilitating, is represented by one version of the triangle of conflict (see Figure 4A).
The other version of the triangle of conflict represents the structure of the self-at-worst functioning characteristic of psychopathology, the most severe version of which arises in emotional environments experienced as affect-aversive (see Figure 4B). The individual's experience continues to be responsive to the emotional environment throughout the life-cycle, which is why how we are with our patients deeply matters.
As all individuals have available to them higher or lower states of functioning, the goal in AEDP is (a) to create a psychotherapeutic environment that has the highest likelihood of facilitating the highest state of functioning where the patients' access to their resources is maximized and (b) to proceed to do the very difficult work of dealing with the trauma from such a position.
In AEDP, the goal is to lead with (Fosha, 2000b) a corrective emotional experience (Alexander & French, 1946). The therapist seeks to create a safe and affect-friendly environment from the get-go, and to activate a patient-therapist relationship in which it is clear that the patient is deeply valued and will not be alone with emotional experiences. If this is accomplished, the patient will feel sufficiently safe to take the risks involved in doing deep and intensive emotional work (Fosha & Slowiaczek, 1997). We want to be able to explore self-at-worst functioning from within a self-at-best structuring of emotional experience activated by the here-and-now patient therapist relationship (see the case in Part 2, for an illustration of this principle at work).
Trauma therapy in essence involves undoing the individual's aloneness in the face of overwhelming emotions. More specifically, the first phase of therapeutic work involves processing and dealing with all aspects of experience that are the result of either (a) defenses, such as dissociation, against emotional experiences, (b) pathogenic affects, such as fear and shame, and/or (c) unbearable emotional states, such as helplessness, loneliness and despair (see bottom half of Figure 2). Once (a) defenses are bypassed, (b) the destructive impact to the pathogenic affects is counteracted in the therapeutic dyad, and (c) the aloneness of the unbearable emotional states is transformed through the emotional sharing of the patient-therapist relationship, a state transformation occurs and the second phase of therapeutic work is ushered in: the individual can then access core affective experiences unhampered by either defense or pathogenic affects (see Fosha, 2002a, for a more detailed discussion of this). With the proper emotional support, fully accessing and dyadically processing the categorical emotions and other core affective experiences is not re-traumatizing but actually has the potential for being deeply restorative, if carried to completion. Like Gendlin (1981) says: "Nothing that feels bad is ever the last step" (p. 25-26)
The mourning process is a perfect example of flawless dyadic regulation of categorical emotions: the individual's immersion in the full experience of grief (core affect) is contingent upon the availability of a support system. Others demonstrate caring through assisting the mourner, validating the importance of grief work, and allowing him to become immersed in grief and ritual; those in the support system take over the responsibilities of daily life until the individual is ready to resume them. Aloneness in the face of overwhelming grief is traumatic and leads to pathological mourning or melancholia (Volkan, 1981). On the other hand, support allows the mourning process to move toward completion and healing: immersion in the grief and other affects involved in the processing of loss often leads to clarity and the ability to place the loss in the perspective of an entire life, allowing the eventual reengagement in life activities. Eventually, the individual can emerge with a new perspective, new clarity, deeper wisdom and a revitalized capacity to embrace and affirm life.
The three phase process of attunement, disruption and repair is fundamental to AEDP's mode of therapeutic action: it constitutes an integrated model in which both categorical emotions and vitality affects play a crucial role in the exploration of both affective and relational experience, and where disruption is part and parcel of the process of reaching a higher level of mutual coordination. Attachment involves moment-to-moment attunement, but also the capacity to integrate disruptive experiences, i.e., the macro-affects associated with attachment vicissitudes, into a coherent and cohesive narrative. Thus, therapeutic work of necessity involves both attunement to vitality affects and help in processing the categorical emotions until they can be integrated and their disruption contained, metabolized and repaired. The reintegration of the categorical emotions within the ongoing flow of dyadic interaction is at the heart of the treatment of trauma.
Attunement is maintained through vitality affects, the ripples of affect on the surface of ongoing interaction and affective communication. It is a going-on-being that just keeps moving forward. And then something happens. There is a disruption. Ordinary or extraordinary. The disruption is not just another ripple on the surface of the lake. The categorical emotions are upon the scene - big emotions, big reactions. Nothing subtle. Fear. Anger. Joy. Excitement. Passion. Disgust. All of a sudden something happens and the flowing, going on being nature of things is disrupted. And the disruption is registered in the categorical emotions. We go from the dimension of ongoing horizontal, to the dimension of the vertical: from flowing along the surface of ongoing relatedness, we are in the depths of big experience. The texture of shared-ness is replaced by the experience of vehement subjectivity and emotion.
Pierre Janet characterized the emotions of trauma as being "vehement." They demand attention and they are deeply personal. If these emotions--categorical, vehement, highly personal-- are processed, something profoundly transformative happens. All of a sudden, we have more than glimpses into the soul of the individual; rather a panorama opens before us. The unconscious is unlocked and the deep secrets of the soul, secrets organized around specific emotions, come to the fore. In their being fully processed, i.e., their somatic, cognitive, fantasy and motoric aspects are closely tracked, dyadically regulated and experientially explored, there is the opportunity to take advantage of their adaptive gifts. Fully feeling our fear, we can protect ourselves. Under the aegis of categorical anger, we can go to battle on behalf of the interests of our territorial selves. These are deep resources we want to access. And once there is the opportunity to experience and express these emotions, not only is the individual enriched by benefiting from the resources released by their adaptive action tendencies, but the wave of emotion, now spent, can now be re-integrated into the ongoing interaction. Through their dyadic regulation in coordination with a supportive other, the vehemence of the categorical emotions, born of disruption, becomes transformed into suppleness and grace, a modulated quality which allows them to be once again the nourishment for the vitality affects, around which the dyad can coordinate. Furthermore, the relationship becomes more structured by how disruptions are repaired.
Important insights about trauma work in therapy emerge from a model that integrates both vitality affects and categorical emotions within the phasic cycling through attunement, disruption and repair. In the affective sharing process, the individual is not alone with frightening and intense feelings. The process of emotional engagement can simultaneously foster the authenticity of self and deep sense of connection. And authenticity and connection, in turn, enhance the capacity to process intense emotion. In the realm of core affective experience, the difference between aloneness and the sense of being integrated in the mainstream of relational existence is created by the act of affective communication with one other person, who is open, attuned, sincere (see Ferenczi, 1931, p. 138) and willing to remain emotionally engaged through thick and thin.
In both trauma and disorganized attachment, the caregiver's absorption in and disorganization by her own unprocessed and unresolved emotional experience leaves the child frightfully alone with three overwhelming emotional challenges: (i) his own emotional experience that he needs help regulating (and which, instead of being met with empathy and help, disorganizes the caregiver); (ii) the disrupted attachment bond; and (iii) the second wave of intense and disturbing feelings in reaction to the direness of the situation he finds himself in. As discussed earlier, this nightmarish combination produces the unbearable emotional states, the "black hole" of trauma and disorganized attachment, and it is precisely in this turmoiled setting that defenses against emotional experience are instituted.
Affect-regulatory difficulties in the caregiver compromise the child's functioning. Unreliable caregiving necessitates chronic reliance on the defensive exclusion of emotional experience (insecure, but organized, attachment), or leads to the even more disruptive inability to maintain organization and coherence in the face of intense emotions, and instead, becoming disorganized and non-functional (disorganized attachment). This is precisely the process by which autobiographical narratives come to lack cohesion and coherence, with gaps where the thread of integrated emotional experience is broken (Hughes, in preparation). The individual survives, the attachment bond hobbles along. The price for this Faustian compromise, the defensive exclusion of adaptive emotion, eventually leads to the huge problems in living that produce the crises and suffering that bring people to seek our assistance.
Below, in part 2 of this paper, the ideas sketched out above encounter the reality of the clinical situation. The work involves the first and second affective change processes, the dyadic regulation of affective states and the experience and expression of core emotion. More specifically, the work shows patient and therapist tackling the problem of how the intense emotion of fear can be dyadically regulated and processed. It is an illustration of AEDP in action, albeit in the chaotic, complex, non-linear fashion of real-life, day-to-day clinical work.
The journey that you are about to witness involves the grappling of the therapeutic dyad with vehement, overwhelming fear, the fundamental emotion in disorganized attachment. The case provides an opportunity to examine and discuss: (1) the role of fear in disorganized attachment (Hesse & Main, 1999, 2000); (2) the patient/therapist moment-to-moment dyadic negotiation of the process of attunement, disruption, and repair (Fosha, 2001; Tronick, 1989, 1998); (3) differential strategies of intervention for dealing with categorical emotions vs. pathogenic affects (Fosha, 2002a); (4) the use of the therapist's affect in experiential psychotherapeutic work (Fosha, 2000a, 2001); and (5) the qualitatively different organizations that characterize functioning dominated by defense, core affect, and core state (Fosha, 2002a, 20002b).
What we first witness are patterns reflecting the intransigence side of the paradox, i.e., procedures established during childhood and repeated over a lifetime: a patient's maladaptive attachment strategies, and her concomitant inability to experience adaptive anger come into view. These become transformed in the course of one session and its aftermath, through therapeutic work that seeks to dyadically help the patient experience and process the fear that paralyzes her capacity to experience anger. Defensive exclusion of intense emotion no longer necessary, the patient's narrative becomes not only coherent and cohesive, but flowing and resilient.
The patient in this case, a 50 year old woman, exhibited the functioning characteristics of the preoccupied state of mind with respect to attachment in relationship to her husband. She used denial to avoid seeing her marriage for what it was, and relied on a variety of other defense mechanisms (e.g., dissociation, somatization, avoidance) to ward off intense feelings of anger, pain, and grief. Reliance on these strategies allowed her to maintain her highly problematic marriage. The price of these strategies included psychosomatic symptoms, anxiety, depression, and a compromised ability to mother her children. It also prevented the patient from effectively dealing with the marriage, thus unwittingly contributing to its disintegration.
At the time of the session, the patient, whom I shall call Emily, and her husband, whom I shall call Clay, had been separated for some months. The question pending was whether the separation was a prelude to getting back together, or to divorce. The fate of the marriage in the balance, despite major changes in other areas of her life, in relation to Clay, Emily was still prone to resort to preoccupied attachment strategies: though considerably weakened by treatment, the tendency to sacrifice the self at the altar of the relationship, and to avoid disruptive emotions was nonetheless alive and kicking.
Crisis disrupts defenses; in this case, the crisis unraveled the organization of the preoccupied state only to reveal the underlying tendencies toward attachment disorganization. But because it disrupts defenses, crisis can be a major transformational opportunity (Lindemann, 1944), if the individual is supported through it. The crisis this session deals with was in fact precipitated by the patient's exercise of her newly-found capacities, i.e., unprecedented clarity, assertiveness, and autonomy in response to her husband. This leap forward terrifies her. Within minutes of having taken a stand, she undoes her assertiveness, and reverts to hyperfocusing on the other at the expense of the self. The "problem" is that this strategy no longer works; her inability to tolerate her own assertiveness is now painful for Emily. She arrives at the session distressed, anxious, and confused.
It rapidly becomes clear that the problem is anger. We witness in vivo a pathognomonic pattern: when defenses are bypassed and the patient is on the brink of fully experiencing anger, she backs off, dissociates, and becomes confused. Exploring what stands between the patient and her experience of anger, we uncover the experience of pathogenic fear.
Some experiential STDPs, notably Davanloo's model (1990), use highly confrontational techniques to rapidly break through defenses. AEDP's conceptualization of pathogenic affects leads to a different clinical strategy: Instead of pushing past the fear so as to gain access to anger as rapidly as possible, here, the experiential focus of the session switches to fear itself. The visceral experience of fear unlocks the door to the past: encapsulated in it is a history of trauma, i.e., abuse, helplessness, and terror.
Like all categorical emotion, the full visceral experience of fear releases adaptive action tendencies which give the organism an evolutionary edge. Two adaptive action tendencies are released by fear: one is to flee from the danger situation; the other is to seek protection of the attachment figure. Both adaptive, the prototype of these tendencies coming together is a little child running away from a fierce dog and into the arms of his mother.
However, deep problems arise when the figure of safety and the source of the danger are one and the same: when the primary caregiver is also the source of danger, as is the case with an abusive caregiver, the child is placed in an irresolvable dilemma, what Hesse and Main (2000) call "fright without solution:" it is impossible to simultaneously run toward and flee from the same figure. To flee from the source of the danger means to abandon the attachment relationship and be exposed to loss and the fear of utter aloneness. To flee into the arms of the caregiver means to rush headlong into the tidal wave of abuse, which threatens the self with annihilation. This is the paradigmatic emotional situation which underlies disorganized attachment and which predisposes people to reliance on dissociative mechanisms (Liotti, 1999), and it is the essential experience revealed in the session. As the first layer of defenses/coping strategies ebbs, what comes to the fore is the phenomenology of disorganized attachment, with confusion and paralysis as its two experiential hallmarks, and with dissociation as a dominant defense mechanism.
FEAR AND THE PROCESS OF ATTUNEMENT, DISRUPTION AND REPAIR
Dyadic affective processing involves countless cycles of attunement, disruption and repair. The therapist's emotions are used throughout to empathize, to affirm and support, but also to challenge. Early in the session, defense work is accomplished through attunement and affective coordination: through vocal and rhythmic entraining, and through affective mirroring and resonance, defenses naturally fade and the patient has increasingly greater access to authentic emotional experience: her language becomes increasingly vivid, imagistic, and somatic. Right-brain mediated processing is in ascendance.
However, while attunement is necessary, it is not sufficient to fully render defenses vestigial: with deepening affect, and the heralding of angry feelings on the experiential horizon, dissociative defenses re-assert themselves. The therapist ups the ante: continuing to make use of her own emotions, here anger on the patient's behalf, she begins a more direct challenge to the patient's defenses. By definition, head-on defense work is disruptive. During the challenge to the defenses, patient and therapist are definitely not on the same page. Feeling safe in the relationship with the therapist allows the patient to not withdraw from difficult emotional experience, but to remain emotionally engaged and keep struggling. The challenge to the patient's defenses eventuates in the visceral breakthrough that "unlocks" the unconscious: the patient relives her fear of her husband and of her mother, triggered by vivid memories of being subjected to the uncontrollable rages of both. What happens next provides the opportunity to reflect on the nature of disruption in the psychotherapeutic process.
As there are two dyadic partners, there are at least two sources of disruption: disruptions of mutual coordination initiated by the patient and therapist-initiated disruptions, which can be either deliberate or inadvertent. In this case, the disruptions of mutual coordination initiated by the patient, that is, her shifts of states, are seamlessly repaired. Therapist-initiated disruptions that are the outcome of technique are part-and-parcel of strategic intervention. However, not all disruption is the result of willed and mindful clinical risk-taking. Disruption also occurs as a result of the therapist's lapses, such as not understanding, being on a different page than the patient, etc. The session presented here has examples of all three types of disruptions: patient-initiated, therapist-initiated/deliberate, and therapist-initiated/ inadvertent. The disruption just described, i.e., the therapist's use of her own emotion of anger on the patient's behalf to do defense work, is an example of a deliberate disruption.
The next round of the work involves an inadvertent disruption, but one that eventually turns out to be productive once it is repaired and coordination is restored. Having gotten the breakthrough, the therapist is working to facilitate the emergence of the adaptive action tendencies of the fear. But it is precisely at the point that another wave of defenses comes to the fore. This happens several times: with each cycle, the visceral experience of the emotion deepens, but leads to defense, rather than the release of adaptive action tendencies. The problem is that the therapist is mistakenly assuming that the patient's fear is functioning as a core affect. In fact, Emily's fear is operating as a pathogenic affect: it triggers are contradictory adaptive action tendencies, thus the patient's paralysis, confusion, and dissociative deflating. It is an in-vivo instance of how defenses arise to compensate for caregiving lapses, in this case of the therapist. Sufficient iterations of this "stuck" sequence occur; the therapist realizes that the reparative experience must take place within the therapeutic relationship before further progress can be made. Once again making use of her own self, the therapist removes pressure from the patient to act in any particular way, thus affirming, through action, a stance of unconditional support for the patient, regardless of whatever particular choice she might make. The disruption repaired, the restored mutual coordination and the ushering in of core state are heralded by the appearance of the affect of relief.
The irreparable disruption that intense emotions invariably caused in the patient's past relationships does not occur within the patient-therapist relationship. Liberated from its being embedded in a pathogenic self-other-emotion configuration (patient - mother/husband - emotion) through being part of an adaptive self-other-emotion configuration (patient - therapist - emotion), the patient's fear as a pathogenic affect is transformed and its emotion-inhibiting effects are no longer in operation. There is a dyadically expanded state of consciousness (Tronick, 1998). In the new state, the patient is able to include previously disowned aspects of her affective experience. Instead of defensive exclusion (Bowlby, 1980), we see affective inclusion (Fosha, 2000b) and thus, expanded and enriched functioning. But as this is a dyadic process, the therapist is also changed by the experience: from this struggle emerges a deeper understanding of the different technical strategies work with core affect and pathogenic affect requires, an understanding which informs this chapter.
In experiential work, we always want to work with concrete situations and specific details, so as to maximize emotional immediacy. As the patient comes in with a ready made specific example, we are off and running. This is how the session begins:
Pt: I am really confused.
Pt: I'll tell you what I'm confused about. Clay called me this morning and he said, "How would you like to go to the museum Saturday afternoon for a couple of hours?" And, umm, it was like...where is that coming from?! (rapid speech, shallow breathing) And, I said, 'Oh!' And he said, "I thought it would be nice." And I said, "Actually, I have plans." So he said, "Oh. OK." So I said, "Well, it's a nice thought. Maybe we can do it another time." And he said, "Well, I'll have to think about what the other time might be." And I said, "OK." And he said, "Good-bye." And I said, "Good-bye," and I hung up the phone. (Big sigh). ..... I'm really upset about all this. What I'm really upset about is Clay and how I really... I just don't understand. I mean, I said 'No'! I said 'No'! I said, "I'm sorry. I have other plans." And five minutes later (exasperated) I had to call him up and tell him I changed my plans and that I could meet with him.....
The patient sets up the problem here most explicitly: having asserted herself with her husband and said a clear, declarative 'No,' she is unable to tolerate the resulting anxiety: five minutes later she has to undo it. The session becomes devoted to investigating what happened in the 5 minute gap between the saying of the "No," and its withdrawal.
Pt: .... I don't know why I did that! I don't know why I didn't leave it alone. [I didn't leave it alone] because I knew Clay was sort of...I felt like he would be angry at me. He was angry with me. (as patient engages in self-dialogue, her speech becomes quite pressured). So, what if he's angry at me?! ... I don't want him to be angry with me... I don't understand why I had to take it back. But I did. I don't know. I don't know why I didn't ask him anything.....I don't know. (starts sounding and looking quite upset here, as if she's fighting back the tears) [note the back and forth between the two sides of the dissociation: knowing and not knowing, caring and not caring].
Th: What's sooo upsetting to you right now? [therapist focuses on the most immediate and intensely upsetting feeling in the here-and-now: setting up the experiential immediacy of the work]
Pt... There's no way that Clay is ready to do whatever he thinks he's going to do on Saturday night because he isn't ready to be in a relationship with me. He's just not ready. And, I don't want to be with him. I don't want to disappoint him, I guess. I don't want to hear about how I didn't do or say right, or I didn't do this right. I don't want to....be disappointed by him. I don't want to feel isolated. I don't want to sit there in the museum with him sitting over here and me sitting over here (makes the motion of a huge distance between them). ...I don't want to be at the museum with us the way we are. I don't want to have a drink with him. I don't want to have a glass of wine with him. .... I don't know anymore.
The patient speaks of her awareness of her husband's anger. "I felt like he would be angry at me. He was angry with me. So, what if he's angry at me?! ... I don't want him to be angry with me." The patient's focus on her husband's anger might suggest the operation of projective mechanisms for dealing with her own anger. From within AEDP's adaptation-centered perspective, however the therapist hears the patient's concerns about her husband's anger as evidence of the patient's experience of the other. While the two are not contradictory, when there is a choice to be made, the therapist goes with the more experience-near alternative.
The moment-to-moment tracking of the patient's emotional experience leads to an in-session enactment of the presenting problem of assertiveness and its immediate undoing: As Emily builds to an affective crescendo and is poised on the brink of a breakthrough of her angry feelings, she deflates, undoing her good work with an "I don't know anymore." Confusion replaces the clarity and decisiveness she experienced only seconds before. This sequence occurs a few more times in material not included here.
Pt: What? (laughs nervously)
Th: Wait! Because it seems to me that you know a lot about how you feel. [feedback about strengths and adaptive capacities] But there's something about putting it together and staying with it, that's difficult for you. [identification of defense against affective experience] ... I mean, when you talk about how Clay is always disappointed by you, what does that feel like for you? What do you feel like inside when he makes you feel like you're not doing the right thing, or you're saying the wrong thing, or you're saying it the wrong way....He's always telling you you're shutting him down, you're putting him down.... What's that like for you??? (impassioned rhythm); [the therapist makes use here of a crescendo of affective intensity after identification of defense to prime the affective pump]
Pt: It feels crappy. ....It's depressing. It makes me feel sad. You know, on some levels, it makes me feel bad about myself. I end up doubting myself. I end up not feeling good about myself. And I don't seem to be able to get pissed at him. I end up feeling bad about myself when what I should be is pissed at him. And I was starting to get pissed about it when I finally left the house and I thought... 'What the fuck do I need that for?!' Why do I need to be... With most everyone else, I can say pretty much what I want to say. ...and with Clay I pretty much have to bite my tongue all the time. I feel like whatever I do or say is the wrong thing. Now, feeling that way, why would I want to go out with him Saturday night?
Affective contagion and the dyadic process of entraining vocal rhythms and coordinating affective states are powerful tools of affective transformation and can often be successfully used to bypass defenses against affect (Fosha, 2001), as happens here. Affect (the therapist's) begets affect (the patient's).The patient gets into a deeper state where she is emotionally in touch with the self-thwarting consequences of her defenses, as well as with the core affect, i.e., anger, that she is defending against. "And I was starting to get pissed about it when I finally left the house and I thought... 'What the fuck do I need that for?!' " Articulating her reasons for not wishing to get together with her husband, Emily declares that she feels angry.. Awareness of the negative consequences of her defensive strategies, e.g., bad feelings about herself, an inability to speak in her own voice, heightens the patient's motivation to do the difficult work ahead. The stage is set for the wave of experiential work, the goal of which is, at this moment, to help the patient get visceral access to her anger.
Th: So let's look at what happened in the five minutes between your saying 'I have plans Saturday and... (pt interrupts)
Pt: I got nervous.
Th: What did you get nervous about?
Pt: Well....that Clay was gonna think that maybe everything is not OK. Because somehow I led Clay to believe that if he could find himself, I would be there for him. That's what I led Clay to believe. That when he's ready to come back to me, I'm ready for him. [patient spontaneously describes in greater detail her strategies of appeasement and denial]
Th: So what scares you about his entertaining the possibility for one second that maybe that's not the only thing that's going on with you? [continuing to challenge]
Pt: Because I feel like I'll lose the opportunity to reconnect with him in the future if, in fact, he's able to turn himself into a giving human being. (highly resigned, matter-of-fact tone of voice).
The psychodynamic formulation of the problem in the terms of the triangle of conflict is complete: the patient is afraid (inhibiting anxiety), that if she allows herself to feel angry (core affect), she will lose her husband (aversive consequences of affective experience); thus, she denies her feelings and appeases him (defense). Authentic emotional experience is relinquished to preserve the bond and avoid the loss of her husband. As Emily says this, the tone of matter-of-fact resignation in her voice is striking. Given the powerful therapeutic alliance in operation with this patient, the therapist opts for a high risk intervention: affective self-disclosure to bypass defenses, and heighten affective experiencing. Such high-risk strategies represent in-the-moment disruptions in dyadic coordination: patient and therapist are not on the same wavelength, as the therapist's aim is to help the patent experience the very emotion she most wants to avoid. The intervention elicits painful affect, with which the therapist empathizes. The patient's feeling deepens. This disruption now repaired, a new coordination comes into being. We witness a state transformation, the emergence of core state phenomena and the beginning of mutative work.
Th: I want to tell you a reaction I'm having because if I don't say it, I think I'll try to spend too much energy trying to suppress it and that's no good for our work. (impassioned tone) This is soooo upsetting to me. Like, I think that this is about abuse of some sort. [this is telegraphic for saying "I think your inability to stand by your 'no' can only be explained by your prior experiences of abuse"] There's this terror that takes you over and I can't stand watching it. It's very difficult. It makes me mad. It makes me mad on your behalf. [affective self-disclosure of the therapist's experience]
Pt: Well, what is he doing?
Th: It doesn't make me mad at Clay. It makes me mad at you. It makes me mad that you're doing this to yourself.
Pt: And, I'm really reaalllly upset (starts to cry here, and holds her open hand over her chest as though she's holding something in)! Because I can't understand. I can't understand what hold he has over me. I can't understand why I can't let go. I just....I can't... I cannot figure out. I cannot understand what motivates me to hang onto something that doesn't feeeeel good. I cannot explain it. I have explained sooo many things... [emergence of painful affect, as patient articulates her distress about her own impotence, paralysis, and confusion]
Th: (in empathic tone, the therapist mirroring patient's gesture of putting her hand over her chest) What's inside, Emily? What's inside? [empathy in response of emergence of painful affect; repair and restoration of attunement; beginning of experiential somatic focusing]
Pt: (clutching her chest, poignant voice) There's something soooo....It feels soooo wrong. But I cannot figure out why I can't let go of this fantasy of this life that we're gonna have together [the defense of denial is becoming deeply ego-dystonic to the patient].
Th: What's inside right now? What's in your chest? What are you holding in with your hand? [experiential somatic focusing; inviting the right brain to speak]
Pt: It just....it's like a giant.... it's not a knot, it's just like a great...
Pt: (with deep engagement and very feelingful emphasis, more declarative tone) It feels like a piece of phlegm or something. It's just something... it just feels heavy. It's just like all this suppressed reaction is creating this giant mass and I feel like I'm choking on it right now. And I don't understand why I can't get it out. I don't understand why I can't... [Note how, as the affective experience is deepening, and the patient's language is changing; it is becoming more graphic, more image-laden, more experiential; the right brain is speaking back]
Th: Focus in on what's in your chest. Focus in on how you're feeling. What's in your body?
Pt: I feel like I'm gonna choke. I feel like I'm choking on something. I swear. I feel like I'm choking on...(dramatic shift: sits up tall; speaks in clear, strong voice, very emphatic) ... I mean, so I said "No!" Why did I have to call him up and say "Yes"?! Because you know what? As much as I've been honest with you, and as much as I've been honest with everybody. I've been completely dishonest with Clay. (assertive, strong, declarative tone; slightly incantational quality) [core state: reflective self function in operation]
Th: Yes, you have (echoing slight incantational quality of patient's speech) [therapist matches patient's vitality affects; reestablishment of coordination]
Pt: Completely dishonest with Clay! I have led him to believe that he is still the only person in the world for me. And that I will be ready for him. Because I really thought I would be.... [full dyadically expanded state includes awareness of, and responsibility for, defenses]
Th: What's in your chest? What are you choking on? What are you choking on and what are you afraid of? [re-focusing on somatic and affective experience]
Pt: (continues in straightforward, clear, strong voice with slight incantational quality) I had this dream of my life. I liked the illusion of my life. I liked the way my husband looked. I liked the way my husband sounded. I liked that my husband was successful. I liked the trappings of my life. I liked the way it looked. Even though everyone knows that it was an illusion, so it's no longer what it looked like to everybody else because I've been extremely honest about how it was an illusion....I'm still in love with the illusion of this life. I still... [patient strongly articulates the denial at the foundation of her entire existence]
Th: So, what's in the phlegm? What's in the mass of phlegm that's in your throat? [speaking a somatic language; keeping affective pressure on]
Pt: I'm very, very.... I'm really pissed at Clay. (angry tone of voice, almost with something of a hissing quality) I'm really pissed off at him! [beginning of affective breakthrough of anger]
The combination of the therapist's affective self-disclosure, empathy, affective matching, somatic focusing and keeping a tight focus on the patient's affective experience leads to the first mini-breakthrough: in the here-and-now, in the present tense, the patient declares that she is angry and sounds it: "I'm very, very.... I'm really pissed at Clay (angry tone of voice, almost with something of a hissing quality). I'm really pissed off at him!"
In the experiential STDPs, this is not an endpoint, but the beginning of the next phase. Now the aim is to facilitate full visceral access and deepen this experience of anger through exploring its somatic correlates and accompanying fantasies. This is done through using the technique of portrayal, i.e., asking the patient to imagine what she would do, and what she would feel like if, in thought and fantasy, she were to let go of her inhibitions and fully allow herself to go where full satisfaction of her anger and rage would take her.
Th: (emphatic tone of voice) If you get rid of this heavy thing that's oppressing you, what's the anger inside you like? What is it like? What are you clutching inside? (in response to the patient pressing her hand against her chest and clutching her shirt) [the therapist takes the newly expanded coordination as a green light to continue to press toward greater experiential focusing; emphatic tone, somatic language]
Pt: (very dramatic tone) It feels like bile. Like green bile. Like something really, really venomous. It's like..... (pronounced shift of tone, posture and direction of gaze) ... I don't know (patient deflates, spaces out) ... [after somatic, charged, highly experiential, primary process account of venomous anger inside her chest, as she is on the verge of exploring the full expression of her anger, i.e., what happens if the bile comes out, patient dissociates the affect in the very moment and deflates]
Th: What's the matter? (concerned tone, soft) [re-coordination through tone matching]
Pt: I don't know. I just...I really can't...(shift, back in contact) I can't really meet with Clay.
Th: What happened, Emily? What's coming up when you say you can't meet with Clay? [therapist is closely tracking the moment-to-moment shifts in patient's vitality affects]
Pt: (return of emphatic tone of voice) Every time I get together with Clay I completely forget everything. I forget who I am. I'll give you a perfect example. (gives example of her relinquishing her own desires and acceding to his wishes) How did he engineer that?! How did that happen? And how did I let that happen?
Th: It's not how did he engineer it. Let's look at what you're doing because you can't tolerate displeasing him for five minutes! [matching patient's returning determination, the therapist ups the ante and continues challenge]
Pt: No (she says in agreement). I don't want him not to like me (ironic tone; contemptuous toward her own defenses). And he doesn't like me anyway (laughs). It's pretty stupid. I think that's the part that really gets me. (angry tone of voice) That I have tried to be as flexible and agreeable, and as accommodating as I can and he's still sits there and tells me....(makes big dismissive gesture)
Th: (mirroring patient's dismissive gesture) What's that? [affective resonance around rising anger; matching vitality affects]
Pt: He tells me that he can't talk to me. You know, that I shut down the conversation. That I don't...
Th: Everything that you do is wrong. (Long pause). I mean, why don't you just give up on yourself altogether)?! (said provocatively) Why don't you go to the museum...and sit there....and take crumbs?! (Long heavy pause).[ increase of pressure through paradoxical siding with defenses and their consequences as patient's visceral experience of anger seems closer to the surface again; therapist-initiated disruption]
Pt: (momentarily deflates) I can't imagine. I mean, the only thing that could happen was that he was in therapy yesterday. That's the only thing that happened [dissociation of affect]
Th: But look! You're saying "what happened?", "what happened?," "what happened?" ... [another high risk, high affect intervention: therapist continues to be contemptuous of patient's defenses, while tracking very closely the patient's response to her interventions; maintaining disruption of coordination] HOW DID YOU FEEL?! What happened to this venomous bile?! What happens if it comes out instead of its sitting inside you choking you?! I mean, what happens if this fire in your eyes---if you give it permission ... [pressuring toward expression of the anger]
Pt: (voice becoming stronger) I don't know. You know, I have let it out in every other way. I'm telling you, I really, really....But when it comes to Clay I'm like--- [repair of disruption in progress]
Th: ... You do not exist. You are annihilated (again said softly, deliberately, yet gravely). You're pleasant. You hide your feelings. You can't tolerate displeasing him. God forbid that he should spend three minutes feeling insecure (said in a provocatively sweet tone of voice). WHAT HAPPENS if this bile comes out? I mean, you have a choice. Or, let's put it this way. You ARE making a choice..... You are choking on your own bile. WHAT are you gonna do about it??!! ..... What happened in these five minutes that you couldn't tolerate---what happens if Clay sees what you really feel? (long pause) [application of pressure through challenging defenses and graphically spelling out their operation and consequences]
Pt: (clear, declarative, deliberate, no-nonsense tone of voice) I guess my whole life is gonna change. Even though my whole life has changed, it hasn't completely changed. It's like I have a lot of privacy now and I can do what I want. And, I'm gonna have to start dealing with Clay big time..... And I'm really afraid of Clay. I really am afraid of him. [reestablishment of coordination through direct declaration of emotional experience: core state]
The toxic labeling of defenses and the application of challenge and pressure in the context of dyadic relatedness, AEDP's modification of classic ISTDP technique (Fosha, 2001, 2002a), succeeds in getting past defenses (initially denial, then dissociation) and anxiety and gets the breakthrough. Interestingly, what breaks through is not core affect but rather core state. The patient sits up and, with unhampered access to reflective functioning, the patient can clearly declare her subjective emotional truth. From core state, there is a breakthrough of core affect. But it is not anger that breaks through. Another emotion comes to the fore: fear.
Pt: I really am afraid of him.
Pt: And, I'm not afraid of Arnie. And I don't even know Arnie. I'm really not afraid...I really...I trust Arnie more that I trust Clay, and I've known Arnie for 10 days! (long pause).
Th: That's a huge...
Pt: (continues in declarative tone of core state; gathers momentum as she goes) Maybe I don't' want to mess with Clay. I don't want to start with Clay. He can be a very nasty guy. I mean, he turned that venom on Robin. He's a...He's very smart. He can twist things around. He can twist you up in a knot. And he has so much....He can be very venomous. There's a lot of hate inside of him. You know, he's got a lot of---whew! (shift from core state to core affect: patient's eyes widen, her face is pale, her breathing is fast and shallow) I think I don't want to be on the receiving end of that. And maybe that's changed, but...
Th: (feelingfully) That's very scary! [empathic elaboration of affective experience; maintaining attunement]
Pt: (nods in agreement) I'm really afraid to get Clay going (looks frightened).
Th: What's the fear like? What happens inside of you when....
Pt: ...( winces, closes her eyes, and puts her hand over her eyes, frightened, sobbing, gasping) I just thought of my mother. [unlocking of unconscious material; associative link between husband and mother]
Th: (soothing tone) Mmmm. You're scared.... [maintaining empathic contact while patient is in the deep experience of core affect]
Pt: (sobbing) Yes.
Th: (empathic tone) You're really scared [maintaining empathic contact]
Pt: (continuing to sob) I really am.
Th: She hurt you. [empathic elaboration]
Pt: They both have this same quality to their anger. It's very irrational. And it's very, very venomous. There's an enormous quality of.....of venom. It's venomous. It's venomous.
Th: (soothing tone) Mmmm.
Pt: It's very, very intense. It's very mean spirited---and it's very nasty.
Th: What came up about your mother?
Pt: I just had this image of my mother being very angry at me [right-hemisphere mediated experiencing].
Th: What do you see?
Pt: I don't know. It's just she...All of a sudden she came up in my mind. This feeling of being terrified.
Th: Just terrified. What's the little girl feeling?
Pt: Well, you know, I told you that the way I could... just not making any waves was the way to avoid it or to keep it from getting any worse. So, I guess I don't want to make any waves with Clay. [in previous sessions, the patient has used the metaphor of a tidal wave to capture the quality of her mother's irrational anger, and the metaphor of not making waves to describe her coping strategies]
Th: What happens if you let yourself, if you keep looking at your mother? It's scary. I know it's scary [encouraging further exploration while maintaining empathic support]
Pt: I don't....I mean I can't really come up...I don't.... [re-emergence of dissociative defense]
Th: You let it go
Pt: (defensive laugh) Yes!
Th: You had it. It's not that you can't come up with it. You came up with it and were terrified and you let it go. . [identification of operation of dissociative defense]
Pt: I just can't put a place to it. I can't.... I was thinking of Clay and his anger and I just... All of a sudden I just remembered my mother. And I'm not remembering a specific time. I'm really not.
Th: I understand. I understand. (pause).
The patient goes back and forth between husband and mother, between past and present, without marking the shifts; in the unconscious material that core emotion unlocks, accessing material mediated by the right hemisphere. Connections are affective. The patient's mother and husband are affectively linked through the similarity of their terrorizing anger and its impact on the patient.
Pt: .... I was just thinking about being in the museum with Clay....(long pause)
I have done nothing, nothing!---- I've done nothing to cross Clay. .... You know, if I told him that I was gonna change the lock on the door.... (her eyes widen with fear) whewww... Someone said, "just have your husband announced when he comes into the building. You should tell the doorman that if your husband comes to the apartment he needs to be announced. At least you would know if he's coming up at any point." I said, "Oh, I couldn't do that." [patient self-regulates during the pause; comes back organized; back on track]
Th: So we're talking about terror. [affective resonance, and amplification]
Pt: Yeah, because..
Th: We're talking about terror. We're talking about...how so utterly terrorized and frightened you are. And then this picture of your mother came into your mind and you let go of that. It's like you can't let yourself know what a state of siege you have lived under. What a Holocaust of destruction--of annihilation. [earlier in session patient brought up material related to the Holocaust, spontaneously making a link with her experience with Clay]
Pt: I don't know what I'm gonna do about Saturday night. [clashing adaptive tendencies, lead to confusion and the patient resorts to "I don't know"]
Th: Stop for a second. . [therapist-initiated disruption, inadvertent; having gotten the breakthrough, the therapist expects further unfolding and/or the release of adaptive action tendencies, and is taken aback by the resurgence of defense]
Pt: (laughs nervously) OK
Th: This is part of what you do. You dissociate
Pt: I don't know (voice starts to crack and tremble)... I don't know if you're ever had anyone... so furious at you, making no sense whatsoever (big gulp; starts to sob). There's absolutely no way...to turn that person away from the assault that follows because it isn't based on anything that you've really done. It's all imaginary. If somebody...If somebody goes on the attack and it doesn't matter what it is, it's immaterial what the reason is... [another wave of affective breakthrough; the patient repairs the disconnection by deepening her communication, and, in the process, deepening her own self experience]
Th: Mmmm. [expressing sorrow, compassion]
Pt: [continuation of affective breakthrough] It's not about what you've done. It's about this anger. It's about their letting off and just directing it at you. And because it's irrational, you don't really know where it's gonna go. You don't really know when it's gonna be spent. You don't really know....It's so....The intensity. It's like being near a fire. It's a feeling of---that you're gonna get burnt if you're not careful. It's doesn't help that it's not about you because you're there. And it's being directed at you. And it felt that way with my mother. And it always felt that way with Clay when he got angry...
Th: (calm voice) I mean, you've been living under a reign of terror and you still are. Right? That's what you're telling me. And you are telling me, you know, that it's bullshit about the idyllic life. It's not the idyllic life. It's fear. It's utter and total fear. That's why you don't get angry. That why you don't make waves. That's why you cannot tolerate five minutes. There's an enormous, enormous, enormous fear. (long pause)
Pt: (declarative tone) When I told Clay that I couldn't meet him ---that I had plans--- I knew that that upset him. Because I said "Can we do it another day?" and he said, 'Well, I'll try.' You know? And I knew that he was angry ---whatever. ..... Uhhh. I don't know. [clashing adaptive tendencies; the return of the "I don't know"]
Th: You know, in my experience, we go back and forth and we sort of like
elaborate, and there's momentum and it makes more and more sense, and there are deeper and deeper feelings. And I feel I understand you better and better. And we're getting to a deeper place. And then there's that moment when you pull it together, which is, 'Oh my God! You've been living under a reign of terror. No wonder you're utterly paralyzed and in total fear" And....that's when you space out. After you make link after link after link between Clay's rage and your mother's rage, after this utterly poignant heartbreaking way in which you describe being at the mercy of this utterly irrational attack and venom, and you're terrified, but then there's a little way in which you disconnect. ... [articulation of alternation between deep affective experience and dissociative defenses]
Pt: But that's how I get through the anger. [elaboration of reason for defenses]
Th: That's how you survived. [empathic affirmation]
Pt: That's how I deal with anger like that.
Th: Whose anger?
Pt: My mother's anger. Clay's anger. That's the way I deal with that anger. I have to---I just zone out. I can't take it anymore.
Th: Because....what happens if you let yourself know.....what happens if you let yourself really know---everything we've done tonight. What happens?
Pt: What happens if I acknowledge it?
Pt: (big sigh) I guess I would want to keep myself away from it. Or I would want to get angry back. I don't know (laughs nervously). [again articulation of anger followed by backing away through "I don't know"]
Th: All I know is that you step away. Because what you've articulated to me is that if you dare, dare take this on, you will be annihilated.
Pt: Oh, it's dangerous! [confirms interpretation]
Th: Utterly. Utterly. Utterly dangerous [affective mirroring, echoing]
Pt: I tell you when I start to turn away from Clay it's gonna be really, really nasty....And I haven't really been able to find the strength to do that.
Pt: It's really been too much of...(laughs nervously)
Pt: The pain that I've suffered in my life. I want to get away from that. I don't want to move towards it. And I guess everything I've done is to avoid having to experience anymore of that anger and venom. [articulation of the unbearable emotional states that have made defensive strategies seem like the only solution]
Pt: And that's why I keep the peace with Clay.
Pt: Because I don't want to have a conversation with him about when I change the locks with him. (shudders) I don't want to be around that kind of reaction.
Pt: 'Cause it's just be sooo devastating every time in my life that I've had to deal with that reaction. I don't want to go there again. I don't want to revisit it...
Th: How are you feeling? Tell me what you're feeling right now.
Pt: I'm just frightened (laughs nervously). Pt: Well...I really am frightened. I mean, the strongest feeling I have right now is in acknowledging how frightened the feeling of being frightened is.... And I'm afraid to tell Clay that I really don't want to go on Saturday night. [patient is finally able to articulate which action tendency she favors and the reason which she can't do it]
The long sequence above demonstrates how, with each wave of the visceral experience of fear, there is a further elaboration of the patient's experience and the unconscious links between her abusive mother and Clay. However, while there is an unlocking of previously unconscious material, there is no resolution: there is no transformation from core affect to core state, there is no release of adaptive action tendencies. With every new round of work, the deeper affect brings to life more trauma and invariably leads another round of "I don't know"s. Nevertheless, it is important to note how patient and therapist strive towards repair: it is as if they both know that the patient needs something from the therapist, and that as soon as it is provided, the calm of reestablished coordination will ensue. It is only in retrospect that I, the therapist, realize that the patient's visceral experience of fear is activating clashing adaptive action tendencies, and that what she is experiencing is a fright that feels without solution (Hesse and Main, 2000). A corrective experience has to occur in the here-and-now patient-therapist dyad. In the next sequence: the therapist offers unconditional support, the patient feels relief, the vicious cycle of affect (fear) and dissociation ("I don't know") is broken, and the patient can leave the session.
Th: Emily, what you did with me tonight is so brave. It takes a lot of courage to know that you're afraid. It's very important.....
Th: This is what I have to say to you. Live with this session....for tonight. Just live with it. Sleep on it. Don't put any pressure on yourself to decide or not decide. Or do. Or not do. No pressure. Live with this session. And let's see where it goes. You don't have to know right this second about what you're gonna do Saturday. Give yourself time to live with it. I think feeling the fear, and knowing it, and knowing what you're afraid of, and knowing how deep it is, and how life-long it is, and how it has shaped your life, you know, as I said, it's taken enormous courage---to be here. It's OK. You don't have to decide anything this moment. [empathy for where patient is; validation of the patient; taking off the pressure for action]
Pt: (big sigh). Good (nervous laugh)
Th: You don't have to do anything. You do not have to do one single thing---except give yourself credit for what you have done---and make room---for things going where they need to go. That's all.
Pt: (relaxes, direct, declarative tone) That feels right.
Pt: Yeah. Yeah. Yeah, that feels very right. [affective marker of state transformation].
The therapist affirms the patient's courage and lends a helping hand through taking the pressure to act off the patient. In the context of the therapeutic relationship, the feeling of safety is reestablished: Fear can function as a core affect and its adaptive benefits can be adaptively reaped. Unfortunately, because of time constraints, the session did not allow what would have been optimal: another round of the experiential exploration of "that feels very right." On its own, it would not be overwhelming evidence of the state transformation. However, the next session provides ample evidence of transformational processes having been, in fact, fully engaged.
The session above documents how work that seeks to access sensory, somatic, motoric right-brain mediated experience can access the emotional experiences at the core of traumatic and attachment disorders. It is just as important to document the phenomena of the process of change and its aftermath. To this end, I include some vignettes from the session the next session. Core state is an affective genuine state, a state of balance, and perspective, and truth-telling. In core state throughout the session, Emily has access to her experience and the benefit of a fully operant reflective self function. We hear about the aftermath and consequences of the affective/experiential work of the previous session, and we also hear the patient's experience of the therapeutic process and her reflections on the process of change.
The next vignette is of the opening moments of the second session. Emily looks different: her face is animated, her eyes are bright and there a liveliness, engagement and lightness in her manner. There is a relaxed, happy smile on her face. It is the first exchange between the patient and therapist since last session.
Pt: Last Thursday was really amazing! It was amazing, because it made an amazing difference. An amazing difference!
Pt: And, I thought it's interesting because I was like desperate to find out what to do. I needed to know what to do about Saturday night. And your advice was ...so good. "Just...forget it! Throw the question out! Don't think about it. Just stick with how you feel." So, since I clearly didn't have an answer, I did just what you said. And I kept thinking about how I felt. And about our conversation about being afraid of Clay, and then that triggering me back to being afraid of my mother and my father. [note that not a word had been said about the patient's father in the previous session; but clearly a lot of processing went on, both conscious and unconscious, between the sessions]
Pt: And that intense feeling of fear. And I just kept thinking about it and thinking about it. And it was ringing truer and truer. And...I just stayed with it. And the next morning I woke up. So, it was Friday. And it was getting close to having to decide what to do. And then I thought, you know what, I'm just gonna go. I'll go. And, it's very possible that... And I'll see what happens... I mean, I wasn't feeling frantic anymore. And, I wasn't really feeling frightened anymore. [the patient's state transformation is marked by a resolution of the fear, the accessing of emotional resources, e.g., self-confidence resilience and the calm of core state]
Pt: And, ummm...I thought, I'll go. And maybe I can go and I can be real. Maybe if I'm not afraid...Maybe, if, in fact, you take this fear out, and you examine it in the light of the day and you say, "Well, exactly what are you afraid of? What are the things you're afraid of? So, you're afraid that you won't be married anymore? You're not! You're afraid that he'll leave you.? He did! You're afraid that he'll be angry at you? He is! Are you afraid that he's gonna hit you? No! Did he ever hit you? No. So, he's not gonna do bodily harm. And, if anything, the anger that he's had in the past, he doesn't even have now. So... what are you afraid of exactly? [an extraordinary example of the affective processing of the reflective self function at work]
Pt: So, what you're afraid to do is to say how you feel. So... (laughs ruefully) ... do it! See if you can just do it since there's nothing to be afraid of.
In clear language, the patient documents that the fear is gone. With its resolution, the patient gains access to emotional resources which allow her to put the situation in perspective, differentiating between the past and the current reality, which the patient feels amply able to face. After the frightened paralysis and immobility of last session, it is quite an experience to hear the patient say to herself "So, what you're afraid to do is to say how you feel. So, see if you can just do it since there's nothing to be afraid of." The unconditional acceptance of the patient's emotional reality in the previous session enables Emily to reframe the issue of fear as having been afraid to be real, to be her real self.
In the next vignette, the patient relates how her meeting with her husband actually went. She describes a process where she is able to be emotionally present and authentic, and has access to her emotions in an adaptive and appropriate manner. Patient and husband engage in genuine conversation. Gone are the tactics of appeasement and the strategies of denial. The patient is honest and comes clean, taking responsibility for her own contribution to the marital difficulties.
Pt: ...And I really told him about this discovery that I had made. And how I felt about it. And I started to explain to him, not our history, but our recent past in the last year. How I had not really been honest with him.
Th: Uh huh.
Pt: And that I always knew how I felt before I saw him and I knew how I felt after I saw him. But I never seemed to be in touch with how I felt while I was with him. And that I was so desperate to keep from losing him that I....chose not to really be real. And that a lot of it was a sham, really. And that I, you know... [patient acknowledges how defenses prevented her from being authentic in the couple's interactions]
Pt: And that, I never told him that I didn't want him to pick up my phone. And that it bothered me that he called me on the cell phone and s, I told him inadvertently. The thing with, you know, the lock on the door...And just coming to the apartment. And I said, 'I know you may think that I told you how I felt... but I never really got angry about it. But I was very angry about it. But, somehow, in front of you, I lost it. I lost my real feelings about what was happening.' And I just told him about it. I just shared it with him. [no longer afraid, the patient is able to be assertive and direct about her feelings with her husband] (Both patient and therapist sigh deeply).
Clay asks Emily her to go out with him the following Saturday night, in an uncanny real-life version of a controlled experiment, giving us a chance to compare before and after. This time, Emily is direct and she declines. Self assertion and adaptive action tendencies are smoothly in operation, she faces her husband's anger without missing a beat.
Pt: ...And he said, 'OK. I'm not angry about it.' And I said, 'I don't give a shit whether you're angry about it or not! ' I said, 'It has nothing to do with how you think or feel about it. It has to do with the fact that I don't want to do it. And you know what? If I lose you because I don't want to do it, I already lost you" (laughs). It's like, what am I losing here?!
There is an enormous opportunity to learn from the patient's experience of the therapeutic process about what makes a difference and about how interventions are received. Here, the patient spontaneously offers her take on and response to the therapist's affective self-disclosure the previous session, when in response to patient's self-sabotage, the therapist tells the patient that the patient's abandoning of her own self makes her (the therapist) angry.
Pt: ...This process is incredible! It's just incredible. This whole thing about why... ...I thought it was really interesting... when you said to me, 'You know what? I have to stop (puts her hands out in front of her to accentuate stop). Maybe this is not professional. And maybe this is not what I should be doing. But if I don't, we won't be able to finish this session." ... And then you said, 'You know what? I used to be mad at Clay. I'm not mad at Clay anymore. I'm mad at you!" And I thought, ooooohhh! (laughs nervously).
Th: So, how did you feel about that?
Pt: Then I thought, 'Yeah! Right on Diana! (laughs loudly). Now you got it!" Really!...The interesting thing is I felt that some of your anger at Clay has been misplaced. But, I didn't want to divert it.... because I was happy somebody was feeling it ... Because I couldn't get angry at Clay, I was so glad that at least you could get angry at Clay. In some respects, I felt like you were my surrogate.
Th: Uh huh.
Pt: I also felt that you were trying to say, "Look! This is how you do it. You wanna know how to do it?"....I was never really sure how angry you were. But, the truth of the matter is that's exactly the truth. ....People just have the power you give them. You say, 'I'm sorry, but you don't have that power anymore'. It's like, 'Ahhhhhh! ' (makes motion of someone being strangled) They don't have it anymore. They can't do it. [spontaneous undoing of projective mechanisms]
Pt: They cease to be a threat. They cease to be the enemy. They cease to be important. I mean, they can still be the problem. But, who cares?! (She's talking fluidly, directly, and purposefully here). [projection undone]
Pt: So, it was very interesting...But this fear! And then being able to sit there and talk about Clay and then have the feeling go back to its source.
Pt: It really seems to be if it doesn't go back to its source, it doesn't really get understood or resolved. [patient's spontaneous reflections on the healing mechanisms of the therapeutic process] And I'm telling you when I....It took me a while for everything to settle. And that great advice..."Just stay with it"...
Th: Uh huh.
Pt: ..."You don't have to do anything else." And I trust you, so I said, 'OK. I'm not doing anything else but staying with this." And when I woke up in the morning it was like this giant cloud had been lifted. [subjective experience of state transformation and the emergence of core state]
From within core state, the patient reflects on her experiences of the past session, and addresses three issues: her experience of the therapist's use of affective self-disclosure of anger; her clear awareness that, in the abusive relationships in adulthood, it takes two to tango; and her subjective experience of the state transformation marking the arrival of core state. An excellent example of working on the self-at-worst state from the perspective of self-at-best functioning, this is the therapeutic equivalent of a cohesive and coherent autobiographical narrative: In a calm, related fashion, the patient articulates her perspective of the vehement affective experiences of the previous session.
Pt: And, you know what Clay said to me (laughs proudly and with ironic awareness) which is really funny? He said, 'I see so many changes in you, and they are sooo appealing."
Pt: So, here it's like...all my life I wanted this guy to be crazy about me (laughs ruefully). And um ....And forget about this guy, but life in general. Now that I am myself, I can have what I want. I have to decide what I want. But, I can have what I want. I can make things happen because in being myself, I'm....it's very desirable. [in touch with her deep and genuine sense of self, she has access to the emotional resources required to make decisions and live a full life, which only gives rise to greater confidence and ease and relaxation]
Th: Uh huh.
Pt: The realness is very desirable.
The patient's assertiveness and capacity to make constructive use of her anger continued to unfold. These gains were maintained, bolstered by a few sessions of intensive experiential work with the core emotion of anger and rage. But the mutative work occurred in the sessions presented above. The visceral unfolding and exploration of the fear, and the undoing of its pathogenic status through a corrective experience within the therapeutic relationship, were at the core of the transformation of a life-long pattern, where a life-long inability to experience and express anger was reversed within one session and its aftermath.
Throughout both sessions, moment-to-moment tracking of the patient's affective experience, reflected in ever-shifting vitality affects, underlies the therapeutic work. Together, the two sessions illustrate the three states and two state transformations characteristic of AEDP work:
1. Defense. In the early part of the session, the patient's core experience can barely be glimpsed through the haze of defenses and anxiety.
2. Core affect. Then, the first state transformation occurs. There is a breakthrough: rather than experiencing defensive distractions, there is a breakthrough of core affect. Eventually, dyadic conditions are co-constructed that allow a solution to the fright that previously had no solution. Adaptive action tendencies can come to the fore and inform the patient's experience.
3. Core state. The deep experience of core affect and the consequent activation of the patient's adaptive action tendencies lead to the second state transformation: a move into core state. Core state --with its characteristic embodied and mindful experiencing-- comes online and the patient's experience is suffused with a sense of efficacy, agency, clarity and calm. The patient comes into her own.
To pick up the theme of continuity vs. plasticity articulated in the introduction: The continuity of pathogenic patterns, set early in life, is evident as soon as the session begins: the patient reacts to a seemingly innocuous present-day incident with an intensity befitting the child faced with her mother's out-of-control rages; the patient reacts virtually as though her mother were present and she (the patient) were a small child.. The patient's affective experiences come forward with a vehemence unmodulated by time, experience and reality (Siegel, 1999; van der Kolk, 2001).
But then, the evidence of therapeutic impact reveals a major degree of plasticity: a sudden and deep transformation reverses a life-long pattern; emotions that were till then vehement become graceful and supple, and are able to inform reflective self functioning. Defensive exclusion is dyadically undone, making way for a much more inclusive and differentiated coordination: motivated gaps in the autobiographical narrative of the individual can be filled in, dramatically improving narrative coherence (Hughes, in preparation; Hesse, et al (2003). Unlike in disorganized attachment where, at crucial moments, the individual can neither feel nor deal, after the work, the patient can now both feel and deal. And, as she adds, she therefore feels real, present and very much herself in the process.
While the vehement aspect of trauma is most dramatic - the flashbacks, the dissociative phenomena-- the greatest cost of trauma comes from how it rents the fabric of relatedness, creating isolation, alienation and despair (van der Kolk, 2001). The goal of this paper has been to show how the vehement emotions can be dyadically regulated, so that the individual can benefit from the adaptive transformational power of the categorical emotions. AEDP engages a dialectical process where the transformational potential of both categorical emotions and of empathy-based, affect-regulating, attuned relatedness (monitored through vitality affect shifts) can be therapeutically harnessed and applied to therapeutic purpose through experiential work. In therapy, these right-brain mediated processes --processes involved throughout development in attachment and emotion regulation-- are entrained and brought to the experiential fore. Thus, they become a felt part of the individual's experience, forces that the patient can feel at work in body and mind. The experiential, imagistic, sensorimotor, and somatic nature of the present approach are central to its effectiveness: their importance cannot be sufficiently emphasized.
That which is first felt can then be reflected upon and known; it is out of such lived knowledge that a coherent and cohesive autobiography can be constructed from the ground (of experience) on up, so to speak.
Our understanding of the neurobiology of attachment and trauma is unfolding with increasing pace. Our understanding of the neurobiology of healing has to catch up so that the therapeutic interventions by which the suffering of trauma and disorganized attachment are relieved can continue to grow in precision and effectiveness.
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 Disorganized attachment in the child is not a function of trauma or loss suffered by the caregiver; disorganized attachment in the child is the function of unresolved and unprocessed trauma or loss in the caregiver, which then interferes with that caregiver's capacity to sustain coherent and integrated autobiographical reflection. The capacity to process trauma is reflected in the capacity for constructing a cohesive and coherent autobiographical narrative (Hesse, et al (2003)) or, differently expressed, having a high reflective self function (Coates, 1998; Fonagy, 1997; Fonagy & Target, 1998). Parents with a high reflective self function, independent of their own attachment status or trauma histories, tend to have securely attached children (Fonagy et al., 1995; Main, 1995).
 Existing within a tradition devoted to enhancing the effectiveness and efficacy of psychotherapy, the experiential STDPs (e.g., Davanloo, 1990; Fosha, 2000b; McCullough valiant, 1997; Solomon et al., 2001) are models of treatment that have pioneered techniques designed to shorten the length of psychodynamic treatment without losing any of its depth through a systematic focus on the patient's visceral experience of emotion (see Fosha, 2000b, appendix).
 In dyads where pathological processes are dominant, the negative affect motivates more than momentary disengagement, leading to the establishment of pathological affect-regulating strategies. For instance, the babies of depressed mothers favor withdrawal into the self as an affect regulating strategy (Tronick & Weinberg, 1997).
 A technical note: The vitality affects are the surface manifestations of categorical emotions when these latter are not at their most intense. Stopping the action and focusing on the individual's experience at any point of the emotion-laden dyadic process can lead to the unfolding of a categorical emotion. It is a clinical judgment call as to which source of therapeutic healing will most benefit the patient at any given moment: that which comes as a result of reparation and restoration of attunement and its positive affects, a dyadic process, or, that which comes as a result of accessing the adaptive action tendencies associated with each categorical emotion and the emotional resources it unlocks, a deeply intrapsychic process. Of course, it is in those therapeutic moments, when both of these processes are optimally engaged that a deep transformation, on the order of a paradigm shift of procedural strategies happens for the patient. It is that that we strive for and that which occurs over the course of the 2 sessions I will present.
 There is a crucial distinction to be made between fear and shame as core affective experiences (core affects, for short) and fear and shame as pathogenic affects. As core affect, fear provides important adaptive information about the dangerous aspects of the situation that elicits it and triggers the adaptive action tendencies associated with it, i.e., flight, immobility, but also notably, attachment-seeking behaviors. A child who is afraid of a dog or of a stranger runs to the caregiver for assistance. Similarly, shame as a core affect arising in response to a specific event or behavior is an essential tool for social learning. That kind of shame can be metabolized in the context of an affect-facilitating environment (Hughes, 1998; Schore, 1996), as the attuned caregiver repairs and re-establishes the feeling of connection. Fear and shame become problematic only when they are elicited by the attachment relationship itself and their disruptive effects cannot be dyadically repaired. It is then that they function as pathogenic affects. Fear about the very person who is supposed to be the safe base disrupts the attachment relationship and its essential protective function (Hesse & Main, 1999, 2000). Shame which is not about a specific behavior but which, instead, is about the essential nature of the self disrupts the very integrity of self experience and of the individual's ongoing sense of being (Hughes, 1998; Schore, 1996).
 The inclusion of the pathogenic affects and the unbearable emotional states at the bottom of this schema differentiates the triangle of conflict AEDP relies upon in its moment-to-moment tracking of the patient's experience from the triangle of conflict usually relied upon in the other experiential STDPs. The representation of these types of experiences at the bottom of the triangle of conflict signals the importance AEDP accords to their full experiential exploration. That these types of experiences are experientially explored in AEDP and not bypassed as rapidly as possible on the way to the exploration of the categorical emotions is one of the differences between AEDP and the other experiential STDPs.
 It is beyond the scope of this paper to discuss how the respective emotional environments conducive either self-at-best and self-at-worst functioning are in fact co-constructed. Interested readers are referred to Fosha (2000), where such issues are discussed in depth. Suffice it to say here that how the individual experiences the emotional environment plays an important role in which self configuration is activated, as does the nature of the environment.
 As attachment theorists make clear (Main, 1995), the insecure attachment phenotype is the result of defensive strategies. These strategies represent best efforts to protect against unbearably painful feelings of fear and loss, rendered all the more unbearable by the attachment figure's inability to feel and deal, and maintain affectionate connection (Fosha, 2000). A secondary sense of safety is achieved through the application of these defensive strategies (Main, 1995). The attachment bond survives, but the cost of the defensive exclusion of adaptive emotion required to maintain it is high; it takes a toll on the individual.
 The profoundly therapeutic transformational potential of crisis through its making entrenched defenses much more fluid was clearly recognized by Davanloo, who made the iatrogenic creation of "an intrapsychic crisis" the hallmark of his technique (1990).
Pt: Well, there were all these pictures of all these people that died in the Holocaust, like a yearbook, but all the pictures were of these people, but before the Holocaust. Before Hitler came into power. So, they were all smiling and dressed in their Sunday best. And looking very fresh, and very young and very happy. Filled with promise. But, it was actually a catalog of death. And of disappointment. And of despair. But it was before they realized how their life was going to end up. And the image of all these.....(starts getting choked up)....shining, happy faces (puts her hand over her eyes to hide her tears)....filled with all this promise. And when you realize the reality of what happened to them.... Soooo many pictures! It just goes on and on and on. It's sooo sad....that I just started to cry. It's just....very powerful. It's more powerful than looking at emaciated bodies with tattoos on. It's much more powerful because these seem like people that you can identify with. But, you can identify with people who, page after page, that ended up annihilated (long pause). Oh God! You know, this is something that I have not been able to really...what happens between Clay and me is not right. And I know it. And I haven't been able to help it.