Healing Trauma, page 37
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 retraumatized 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)
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 (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 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 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 arrive at core affect informs all AEDP therapeutic stance and techniques, an aspect of AEDP deeply informed by the experiential STDP (Short-Term Dynamic Psychotherapy) tradition (Davanloo, 1990; McCullough Vaillant, 1997; Neborsky, this volume; 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 et al., 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
Optimal Development
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, 1989), 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, in other words, 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.
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 6.1.
Therapeutic work with the affective change processes is a three-stage process (see Figure 6.1), 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, nonlinear. There is also much greater access to previously unconscious material, a phenomenon referred to in the experiential STDP3 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 described as the “flux in personality, the possibility for change, and the impetus to begin new phases of life and undertake new endeavors” (1988, 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, pp. 54–57).4
By contrast, the categorical emotions (Darwin, 1872)—fear, anger, joy, sadness, disgust—macro-emotions initially processed subcortically (Damasio, 1999, 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 6.1), dyadic regulation operates in the experiential background; however, in the first affective change process, the dyadic process itself is in 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 coregulating 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.5 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, 2001, 2002a). 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, 2001). 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 contributors to the achievement of positive therapeutic outcome (see also Bohart & Tallman, 1999; Rogers, 1957; Rosenzweig, 1936; Safran & Muran, 2000). 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 (1872/1965) 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, 1963). Through them, we are able to communicate to ourselves and to others that which is of importance (Bowlby, 1991). For Darwin (1872/1965), as for Bowlby (1991), the most important function of emotional expression is communication among individuals.
