Healing Trauma, page 39
In the next part of this chapter, 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, nonlinear fashion of real-life, day-to-day clinical work.
FRIGHT WITHOUT SOLUTION: ITS (RE)SOLUTION IN EXPERIENTIAL-DYNAMIC THERAPEUTIC 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, that is, 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.10 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.11 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.12 The crisis this session deals with was in fact precipitated by the patient’s exercise of her newly found capacities—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—abuse, helplessness, and terror.
On Fear
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) called “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.
On Disruption
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 or being on a different page than the patient. 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, that of 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 to 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 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’s. 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–fear) through being part of an adaptive self–other–emotion configuration (patient-therapist-fear), 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 to work with core affect as opposed to pathogenic affect an understanding that informs this chapter.
In the material that follows, text in parentheses describes the nonverbal aspects of the patient’s communication, while the text in brackets reflects the author’s micro analysis of the ongoing interaction.
The First Session: An Investigation of the 5-Minute Gap
Setting Up the Focus of the Work
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.
Th: Hmm.
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 5 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.
Identification and Clarification of Defenses Against Affective Experience
Th: Wait!
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?
