PDF- AEDP Confidential Handouts April 8, 2016 Dopamine

AEDP

Being Seen & Dopamine The Neurobiology of Vitality and Recognition: A Framework for Working with Dissociation in AEDP

DIANA FOSHA, PH.D.

AEDP NE Seminar Series April 8, 2016

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A theory of therapy needs to be rooted in a theory of change. AEDP, a healing-oriented, transformation-based model, is.

“A model of therapy needs at its essence to be a model of change (Fosha, 2000, 2002). This metapsychology of the therapeutic process should not be derivative --a poor cousin-- of the theory of psychopathology, but function as a strong explanatory framework in its own right. My goal here is to begin to articulate a transformation- based, healing-oriented metapsychology of therapeutics. AEDP (Accelerated Experiential Dynamic Psychotherapy) --a model that integrates experiential and relational elements within an affect-centered psychodynamic framework, and places the somatic experience of affect in relationship and its dyadic regulation at the center of how it clinically aims to bring about change (Fosha, 2000)-- roots its understanding of how therapy works firmly in transformational studies (Fosha, 2004; Fosha & Yeung, in press), fields of endeavor devoted to investigating naturally-occurring progressive transformational processes that operate powerfully, often rapidly and dramatically, yielding substantive changes that are often lasting. The evidence from transformational studies (see below) points to affective processes experienced within the context of an affirming relationship as being central in such quantum transformations. How to systematically activate these affective change processes in treatment so that their transformational powers can be harnessed to actively foster therapeutic change has guided the development of AEDP and has led to [AEDP’s] being fundamentally healing-oriented in its theory, metatherapeutics, and clinical practice, and experiential in its technique. And it is precisely this rootedness in transformational studies rather than in pathology-based theories that distinguishes AEDP from other psychodynamic approaches, short- and long- term” (Fosha, 2005, p. 517; emphases, here).

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TRANSFORMANCE: The Motive Force of Therapy

"People have a fundamental need for transformation. We are wired for growth and healing. And we are wired for self-righting, and resuming impeded growth. We have a need for the expansion and liberation of the self, the letting down of defensive barriers, and the dismantling of the false self (Ghent, 1990). We are shaped by a deep desire to be known, seen, and recognized (Sander, 1995, 2002) as we strive to come into contact with parts of ourselves that are frozen (Eigen, 1996) ...." (Fosha, 2008, p. 290).

Transformance (Fosha, 2008, 2009) is the term for the overarching motivation for transformation that pulses within us. Wired for transformance, we naturally seek contexts in which we can surrender to our transformance strivings. Transformance drives processes that, in the right environment, eventuate in healing and thriving. AEDP seeks to harness the motive forces of transformance and facilitate therapeutic change. A felt sense of vitality & energy characterizes transformance-based emergent phenomena. These positive vitalizing experiences are also the correlates of a neurochemical environment in the brain that is most conducive to optimal learning, development, and brain growth.

The Forces of Transformance ...

➢ are always present as dispositional tendencies ➢ require conditions of safety in order to come to the fore ➢ are the motivational counterpart of resistance ➢ are fueled by hope ➢ power the search for the vitalizing positive affects that characterize all adaptive affective transformational processes

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What is AEDP?

There is no better way to capture the ethos of AEDP than to say this: we try to help our patients—and ourselves—become stronger at the broken places. By working with trauma, loss, and the painful consequences of the limitations of human relatedness, we discover places that have always been strong, places that were never broken.

Crisis and suffering provide opportunities to awaken extraordinary capacities that otherwise might lie dormant, unknown and untapped. AEDP, as a therapeutic approach, is about making the most of these opportunities for healing and transformation. Key to this experiential enterprise is the establishment of the therapeutic relationship as safe, secure base.

Through the in-depth processing of difficult emotional and relational experiences, the AEDP clinician fosters the emergence of new and healing experiences for the client.

Short History of AEDP: Beginning to Now to…. Accelerated Experiential Dynamic Psychotherapy (AEDP), developed by Diana Fosha, had its official beginning in 2000, with the publication of her book, The Transforming Power of Affect (Basic Books, 2000). Since then, AEDP has grown, further developed enriched by Diana Fosha’s ongoing work as well as by the contributions of other leading AEDP practitioners and theorists. An emergent model, AEDP is ever-growing, deepening, and expanding. AEDP has roots in and resonances with many disciplines — among them attachment theory, affective neuroscience, body-focused trauma-based approaches, psychodynamic psychotherapy, humanistic psychology and transformational studies.

AEDP is Healing-Oriented (Not Psychopathology-Based).

Shaped by a deep desire to be seen, known, and recognized by others, all human beings share a fundamental human need to connect. When we feel safe,

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we let down defensive barriers and when those barriers are down, our innate ability to grow and expand comes to the fore and also helps us heal.

Meaningful change involves the activation of naturally occurring, adaptive affective change processes.

The aim of AEDP is to release these innate healing tendencies, to follow the positive somatic/affective markers that identify naturally occurring adaptive changes, and to harness their potential for healing, all in the context of an healing therapeutic relationship.

A theory of therapy needs to be rooted in a theory of change. AEDP is. “A model of therapy needs at its essence to be a model of change. This metapsychology of the therapeutic process should not be derivative --a poor cousin-- of the theory of psychopathology, but function as a strong explanatory framework in its own right. AEDP articulates a transformation-based, healing- oriented metapsychology of therapeutics. AEDP (Accelerated Experiential Dynamic Psychotherapy) roots its understanding of how therapy works firmly in transformational studies , fields of endeavor devoted to investigating naturally-occurring progressive transformational processes that operate powerfully, often rapidly and dramatically, yielding substantive changes that are often lasting. How to systematically activate affective change processes in treatment so that their transformational powers can be harnessed to actively foster therapeutic change has guided the development of AEDP and has led to [AEDP’s] being fundamentally healing-oriented in its theory, metatherapeutics, and clinical practice, and experiential in its technique. (Fosha, 2005, p. 517; emphases, here).

Healing from the Get-Go

We are not just bundles of pathology. Lodged deeply in our brains and

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bodies, there for the awakening and activating in facilitating environments, lie innate, wired-in dispositions for self-healing and self-righting, as well as for core state, a state of calm, flow, ease, clarity, confidence, generosity, and true self being.

Healing oriented, rather than psychopathology-based, AEDP privileges these innate motivational tendencies and sees change as involving the activation of naturally occurring, adaptive affective change processes: our aim, guided by the positive markers that identify them, is to entrain them, and harness their healing potential.

AEDP Heals Unbearable Aloneness

Dyadic affect regulation is key to undoing unbearable aloneness. The therapeutic relationship provides the secure base from which fear, shame, and distress can be shared, and therefore dyadically regulated and where the explorations of deep, painful emotional experiences can be risked.

A fundamental tenet of AEDP is that the patient is never alone with overwhelming emotional experiences. —Diana Fosha

AEDP therapy provides opportunities for new corrective emotional experiences. This experiential method involves facilitating the patient’s having an experience in which the body must be involved through tracking moment-to-moment fluctuations in the emotional experience of patient, therapist, and dyad.

Wired to care: AEDP Therapists Seek to Foster Conditions Necessary for Healing. We are wired to connect and we are wired to care. The AEDP therapist facilitates and seeks to co-construct a patient- therapist relationship characterized by secure attachment., i.e., one where the patient is never alone with overwhelming emotional experiences.

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Such a relationship is dyadic, explicitly empathic, affirming, affect-regulating, mutually enjoyable, and emotionally engaged.

The therapeutic relationship aims to be the secure base from which fear, shame, and distress can be dyadically regulated, and from which the experiential explorations of deep, painful emotional experiences can be risked.

Love on the Brain: Dyadic Resonance is Transformative “When you and another truly connect, love reverberates between you. In the very moment that you experience positivity resonance, your brain syncs up with the other person’s brain. Within each moment of love, you and the other are on the same wavelength. As your respective brain waves mirror one another, each of you— moment by moment— changes the other’s mind.” Barbara Fredrickson (2013, p. 41).

The Experience of Change for the Better Feels Good

Positive, resonant, attuned, dyadic interactions have been shown to be the constituents of healthy, secure attachments and they correlate with neurochemical environments conducive to optimal brain growth. Positive core affects and interactions are both the constituents and hard-wired markers of healing. AEDP is guided by these moment-to-moment signals and markers and facilitating their occurrence is its aim

AEDP Builds on Transformation and Positive Core Affects.

The visceral experience of core affects in the here-and-now of the patient- therapist relationship is the central agent of change in AEDP. Core affects are wired-in adaptive experiences. When activated, tracked moment-to-moment and worked through to completion, core affects access inner resources and activate healing resilience. The experience of transformation of self—particularly in the context of a healing relationship—informs the affective change process.

Transformance is AEDP’s term for the overarching motivational force that strives for maximum healing, vitality, authenticity and genuine connectedness in every human being.

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Metaprocessing is Central to AEDP

Focusing on the experience of change is transforming in and of itself. AEDP works to process transformational experiences as rigorously as all other emotional experiences. Affirming and exploring the experience of these healing changes releases a cascade of transformations with characteristic somatic affective markers, which are invariably positive.

AEDP: An Emergent Model in Ongoing Dialogue

As an integrative framework, AEDP shares various basic assumptions and deep resonances with neighboring disciplines and the bodies of work of many different modalities. Some of the approaches that AEDP dialogues with are: ▪ Emotion theory

▪ Affective neuroscience & interpersonal neurobiology ▪ Polyvagal theory

▪ Attachment theory & developmental studies of dyadic interaction

▪ Trauma studies & body-focused treatments

▪ Other experiential and emotion-focused therapies ▪ Existential integrative therapies

▪ Developmentally-informed and relational psychoanalysis ▪ Self psychology & humanistic psychology ▪ Mindfulness & contemplative traditions, broadly defined to include different traditions of wisdom, east and west. ▪ Transformational studies

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THE CREDO OF AEDP: H-E-A-R-T A-M-P-L-E “What we are fighting for is that a moment of transformation not be missed” (Eigen, 2002)

“…. only connect” (E. M. Forster)

HEALING: Transformance from the get-go

EXPERIENCE & PHENOMENOLOGY & moment-to-moment tracking

ALONENESS UNDONE: (i) ATTACHMENT (sprinkled with Intersubjective Delight); (ii) DYADIC AFFECT REGULATION

RELATIONAL WORK, experientially working with relatedness as a category of experience

TRANSFORMATION as an experience, and as a transformational affective change process (not only a desired goal and outcome)

AFFECTIVE CHANGE PROCESSES in ACTION: The Processing of Emotion, Sensation, Self-Experience, Ego States and other aspects of authentic, somatically rooted experience

METAPROCESSING and the TRANSFORMATIONAL SPIRAL: Energy & Vitality, Fuel for Life: The Processing of Transformational Experience, and of the Transformational Affects that Characterize it; Release of Energy & Vitality, Fuel for Life

POSITIVE AFFECTS & POSITIVE AFFECTIVE INTERACTIONS

LOVE ….. Actually

EMERGENCE: The Edge of Neuroplasticity

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AEDP THERAPEUTIC STANCE “Security Priming”1 in Action: Qualities to Counter Dissociation

➢ be kind

➢ be real

➢ be present

➢ be generous (Pizer, 2012)

➢ be with

➢ be tender, and own lapses with sincerity (Ferenczi, 1933)

➢ “put out the welcome mat” (Kabat Zinn, 2013) for all experiences

➢ meet experiences with openness and curiosity, as well as phenomenological discernment

➢ delight in and heighten positive affective experiences associated with resilience, transformance, vitality

➢ foster positively toned interactions, and metabolize and repair stressful, negatively toned interactions (Schore, 2001);

➢ go beyond mirroring (Fosha, 2000); help, teach

➢ behave in oxytocin engendering ways, making use of and regulate gaze and eye contact (MacDonald, 2012);

➢ engage in dyadic affect regulation

➢ undo the patient’s aloneness in the face of unbearable experience

➢ foster the patient’s sense that she or he exists in your heart and mind (Fosha, 2000, adapted from Fonagy)

1 Mario Mikulincer’s studies on “security priming” show that it to enhances resileience, enhances affect regulation, and decrease combat fatigue

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What is AEDP? In Polyvagal language…

➢ a bidirectional brain–body model ➢ a mind-body therapy that cultivates interpersonal rhythms, nurtures the capacity for people to use their voices and faces to regulate emotional states and uses experiential methods to regulate intense emotions – both negative (trauma) and positive (transformation) – via the integration of visceral and emotional experiences with relational and reflective capacities ➢ an experiential method that promotes the neuroception of safety ➢ has developed interventions that promote the activation of the social vagus ➢ a means of shifting people out of “ fight-or-flight” reactions into loving and mutually engaged mobilization” ➢ a therapeutic method that seeks to use the active promotion of social bonds to reduce stress and promote emotion regulation, and to expand the realm of transformational experiences ➢ has a detailed methodology for entraining/recruiting “the evolutionarily more advanced neural circuits that support the prosocial behaviors of the social engagement system,“ (Porges, 2011) and then using that co-constructed safety and the social engagement system to process the intense emotions of both trauma, and then transformation ➢ is identified by a number of experiential methods that make use of the integration of visceral and emotional experiences with relational and reflective capacities to regulate both the intense emotional states associated with the “heart-breaking, gut- wrenching” emotions of intense emotional suffering, AND with the tremulous positive emotions associated with transformation and healing

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ATTACHMENT The Three Behavioral Systems of Attachment (Bowlby) and Their Affective Markers (Fosha)

1. THE ATTACHMENT BEHAVIORAL SYSTEM -- cued/activated by fear CT Affective marker: distress when activated CT Affective marker: safety feeling when quiescent: receptive affective experiences of feeling taken care of, nurtured etc Adaptive action tendency: crying, proximity seeking, evoking care, expressing distress Adaptive function: wired to seek care to survive

2. THE CAREGIVING BEHAVIORAL SYSTEM -- cued/activated by the activation of attachment system – the fear and distress—of the immature organism. Thus responsiveness to distress is essential. • Affective marker: caring, wanting to help (adaptive action tendency): the emotions of caretaking: “I want be there, with you and for you;” “I’ll hang in there with you for as long as it takes;” “Can I help?” Adaptive action tendency: wanting to help, comfort Adaptive function: wired to care The caregiving system is cued by the activation of the attachment

3. THE EXPLORATORY BEHAVIORAL SYSTEM • Affective marker: exuberance, curiosity, excitement and joy Adaptive action tendency: explore Adaptive function: wired to learn and grow

Secure attachment promotes an expanded range of exploration. The greater the security of attachment, 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).

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Aspects of ATTACHMENT Through the Lens of Affect

1. Building Safety & Supporting Exploration The Three Behavioral Systems of Attachment (Bowlby) & Their Affective Markers (Fosha) ➢ Attachment: the safety feeling, receptive affective experiences ➢ Caregiving: care and empathy in response to distress; wanting to help ➢ Exploration: exuberance, curiosity and joy

2. The Dyadic Affect Regulation of Emotions The Internal Working Model (Bowlby) & The Intergenerational Transmission of Affective Competence (Fosha) ➢ Feeling and dealing (while relating): Secure attachment ➢ Not feeling, but dealing: Insecure, Avoidant/Dismissive Type ➢ Feeling (and reeling) but not dealing: Insecure, Ambivalent/Pre-Occupied Type ➢ Not feeling and not dealing: Disorganized attachment

3. Metaprocessing & Integration The Reflective Self Function (Fonagy), the Construction of a Coherent and Cohesive Autobiographical Narrative (Main) & The Metaprocessing of Emotional Experience in the Context of the Dyad (Fosha) ➢ Existing in the heart and mind of the other -- as oneself ➢ The processing of receptive affective experiences: feeling seen, feeling understood, feeling felt

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ON RECOGNITION – the Glimpse of the Core

"Two truths approach each other. One comes from inside, the other from outside, and where they meet we have a chance to catch sight of ourselves." (From “Preludes” Tomas Transtromer)

Recognition is the phenomenon through which we glimpse the patient’s core self and truth prior to the patient’s being in core state. Recognition is: “I see you.” And I see –and feel—you, even before you see –and feel—yourself

Recognition, via the self-related processing (see below) it evokes and is guided by, sometimes offers us a glimpse –and sometimes more than a glimpse-- into experiences and fundamental understandings that we usually only have access to in core state: core self, truth, and the sense of knowing. The clouds part and there it all is.

Recognition, i.e., re-cognition, is not a primarily left brain phenomenon, rather it is deeply integrative re-cognition— probably involving one’s own SRPs, as well as the pre-frontal cortex and the mirror neuron rich insula

The Neurobiological Core Self The work of Panksepp & Northoff, and of Damasio

“[The core self is] a dynamic collection of integrated neural processes, centered on the representation of the living body, that finds expression in a dynamic collection of integrated mental processes” (Damasio, 2010, p. 9).

“The core-self is a process through which we gain knowledge about ourselves and our environments. It is this emergent coordination of internality and externality, of a mind-body-world connection … which [enables us] … to become intentional and … empathic agents in the world” (Panksepp & Northoff, 2008, p. 11; emphasis, mine).

“The True Self comes from the aliveness of the body tissues and the working of the body functions, including the heart’s action and breathing. ……[It is] at the beginning, essentially not reactive to external stimuli, but primary… (the True Self) collect[s] together the details of the experience of aliveness….. [and is] the summation of sensori-motor aliveness” (Winnicott, 1960, p. 148-9).

“I have the intuition that one's feeling of a normal self as well as all the energetic- euphoric vitalities of our life are closely affiliated with the health of the SEEKING system. “ (Panksepp, 2012, personal communication, capitals in the original).

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The Neurobiological Core Self & Self-Related Processing (SPR) – The work of Panksepp & Northoff, and of Damasio

The neurobiological SELF ➢ is constituted of the coordinated functioning of subcortical midline structures in conjunction with cortical midline structures (with the periaqueductal gray at the relay center, massive interconnections link upper brainstem regions to higher medial regions of the frontal and prefrontal cortices, and vice-versa) ➢ fundamental integrative function ➢ automatic, affective, and action-based ➢ coherence ➢ self-related processing (SRP) and the self-related valuation of stimuli ➢ seeking (motivation): drive (energy), direction, reward (dopamine)

The bidirectional coordination of subcortical and cortical midline structures that constitutes the neurobiological core SELF is manifested through the fundamentally integrated affective/cognitive processes that give rise to ➢ identity ➢ agency ➢ ownership of experience ➢ behavioral coherence

The Midline Structures of the NEUROBIOLOGICAL CORE SELF: Subcortical (Limbic) & Cortical: The coordinated functioning of subcortical midline structures in conjunction with cortical midline structures is what constitutes the neurobiological self ➢ periaqueductal gray ➢ superior colliculi ➢ brainstem region connect to ➢ medial regions of the prefrontal cortex ➢ medial regions of the frontal cortex The midline structures of the neurobiological core self-have a bidirectional connection to and with ➢ insula ➢ anterior cingulate ➢ right hemisphere

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SOME QUALITIES OF THE NEUROBIOLOGICAL CORE SELF The self’s activities are guided by self-related values, i.e., the values selectively accorded to environmental stimuli reflecting their salience to self – and those values being both unique to the individual and emergent. ➢ coherence, organization ➢ drive, direction ➢ self-related values: the values selectively accorded to environmental stimuli reflecting their salience to self; unique to the individual and emergent ➢ sense of identity ➢ agency, initiative ➢ ownership of experience ➢ behavioral coherence ➢ viewing the world through the lens of self-related values ➢ felt sense of “I” ➢ guided by recognition processes

TAGS OF THE NEUROBIOLOGICAL CORE SELF

➢ the tag of coherence ➢ the tag of seeking ➢ the tag of recognition, and its marker: the click of recognition ➢ the tag of aliveness, vitality, energy

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The SEEKING SYSTEM in SRP (Panksepp, Northoff)

The SEEKING system is “the active explorer inside the brain” (Panksepp, 2009, p. 9)

“This appetitive motivational system energizes the many engagements with the world as individuals seek goods from the environment as well as meaning from everyday occurrences of life. … [It is] a system that energizes our intentions in actions.” (Panksepp, 2009, p. 9) ➢ motivational system, reward system: dopamine mediated ➢ cued by the felt sense of recognition ➢ direction, drive ➢ fuel for life: “neural energy,” vitality ➢ pleasurable DOPAMINE, Fuel of the Seeking System Dopamine is the fuel of the self’s seeking. Like oxytocin, dopamine flows in conditions of low stress and threat (MacDonald, 2012, personal communication). In facilitating environments, i.e., in transformance-based conditions, the seeking system of the neurobiological core self can come to the fore and epigenetically unfold. However, in affectively thwarting environments, where stress/threat are high, not regulated and thus cannot be rapidly metabolized (Schore, 2009), the combo of oxytocin and dopamine is supplanted by the 2 neurotransmitters of stress management.

The Link with NEUROPLASTICITY (Doidge, Siegel) “The qualities of pleasure and reward are essential features for processes that support neuroplasticity (Doidge, 2007; Siegel, 2010): pursuits that are rewarding and pleasurable become recursive appetitive processes, where more begets more and thus the brain changes (Fosha, 2009a, 2009b; Fredrickson, 2001,2009; Ghent, 2002). Vitality and energy are the affective/somatic markers of such processes. Manifestations of seeking, in conjunction with the self-related valuation of stimuli, are to be found in experiences of agency, initiative, enthusiasm, and drive” (Fosha, in press, p. 8).

Manifesting neuroplasticity in clinical action transformance, positive affect, motivation / drive and energy are organically aligned (Fosha, 2010)

2 While dopamine and cortisol (the HPA axis) are inversely related, oxytocin and dopamine are congruent and positively correlated (MacDonald, 2012, personal communication).

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NEUROPLASTICITY

"The brain ... is not an inanimate vessel that we fill; rather it is more like a living creature with an appetite, one that can grow and change itself with proper nourishment and exercise" (Doidge, 2007, p. 47).

“The power to direct our attention has the power to shape the brain’s firing patterns, as well as the power to shape the architecture of the brain itself” (Siegel, 2010).

"Many tastes we think ‘natural' are acquired through learning and become 'second nature’ to us. We are unable to distinguish our ’second nature ‘from our ’original nature ‘because our neuroplastic brains, once rewired, develop a new nature, every bit as biological as our original" (Doidge, 2007, p. 102).

Neuroplasticity – capacity for creating new neural connections and growing new neurons in response to experience. Experience = Neural Firing, which in turn leads to the production of proteins that enable new connections to be made among neurons

Conditions that promote neuroplasticity ➢ focused attention (activates the nucleus basalis, which secretes acetylcholine, which strengthens synaptic connections) ➢ emotional arousal: need to work at the edge: safe but not too safe ➢ novelty (also stimulates growth of new neurons) ➢ repetition, practice of new experiences, skills ➢ motivation: when an organism is motivated to learn (drive to explore), the brain responds plastically ➢ pleasure/reward dopamine and acetylcholine consolidate the changes just made – manifested in positive affect and positive affective markers ➢ the necessity of dopamine and other neuromodulatory systems for lasting neural plasticity: the role of motivational brain systems in memory formation and later behavior, particularly adaptive long-term memory formation appropriate to therapeutic change ➢ dopamine: specific neurophysiological states, (i.e., anticipated reward, accompanied by activation of dopaminergic regions of midbrain together with the nucleus accumbens and hippocampus, low levels of anxiety and physiological arousal, surprise, and mnemonic encoding shifts from temporal lobe cortex to hippocampus) predict adaptive long-term memory formation appropriate to therapeutic change.

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On Dissociation: The Dark Gets Left Out (excerpts from Fosha (2013): A heaven in a wild flower. Psychoanalytic Inquiry, 33.)

In neurobiological language, dissociation represents the top down, cortical inhibition, manifested in the overmodulation of limbic function, such that there is a decreased connectivity with emotional (e.g., amygdala-mediated and right-brain mediated) and somatic (e.g., insula- mediated) experience (Bluhm et al, 2009; Lanius et al, 2006, 2010, 2011). In dynamic and affective language, the dissociation is maintained by defensive exclusion, (Bowlby’s 1980 term): whatever threatens the integrity of the self and/or of the primary attachment relationship, becomes defensively excluded.

“The dissociative subtype of PTSD is described as a form of emotion dysregulation that involves emotional overmodulation mediated by midline prefrontal inhibition of the … limbic regions” (Lanius et al, 2010, emphases mine, p. 640).

Faced with trauma based stimuli, the PTSD subjects in question, i.e., 30% of Lanius’s PTSD sample, had a purely dissociative response, i.e., with no evidence of hyperarousal. It “predominantly involved subjective states of depersonalization and derealization with no significant concomitant increase in heart rate” (Lanius et. al., 2006; emphasis added, p. 718). Noteworthy are distinguishing characteristics in the connectivity of the default network of dissociative patients. The default network links the brain structures that are active when the individual is at rest; Compared to normal subjects, there is a decrease in the connectivity of the default network of dissociative patients with emotional and somatic channels (i.e., the right hemisphere, insula, amygdala and hippocampus, all brain structures involved in affect regulation and affectively based communication); and there is an increased connectivity with cognitive channels.

That top down control is significantly heightened for those relying on dissociation exclusively as a strategy of control at the expense of access to the biologically salient information residing in the emotions, called “the ancestral tools of survival” by Panksepp (2009) and the “beacons of truth” by Grotstein (2004).

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The Relational Antecedents of Dissociation

(excerpts from Fosha (2013): A heaven in a wild flower. Psychoanalytic Inquiry, 33.)

“In contrast to a more discrete traumatic event, the child’s fear of remaining unseen and unheard by his caregiver, resulting in unmet needs, is worked into the fabric of identity from a very early age.” (Dutra et al., 2009a, p. 91).

➢ Errors of Omission lead to Dissociation: Contributors to dissociation and dissociative manifestations at age 19 are neither “big T trauma” nor parental hostility, but rather the “quieter” (Lyons-Ruth, 2003) caregiving failures: emotional unresponsiveness, flatness of affect, and psychological unavailability in childhood. The only aspect of abuse which appears to correlate with dissociation is verbal abuse (Dutra et al., 2009; Teicher et al., 2006), which is a caregiver attack on the self of the young child.

➢ Thou Shalt Not Know: There is no pain, there is no distress. Dissociation can be construed “as a way of mentally accommodating to intense social pressures not to acknowledge pain and distress within a set of caregiving relationships that are vital for survival. The attachment relational context imbues both the caregiving transactions and their internalized mental representations with the intense emotional valences characteristic of defensive responses. This valence does not come simply from an intrapsychic need not to know, but also from a relational communication not to speak.” (Dutra et al., 2009a, p. 88)

➢ No soothing, no comfort. “In particular, the early lack of a caregiver to whom one can communicate one’s distress and discomfort and elicit a soothing response appears to heighten the risk for dissociation later in life” (Lyons-Ruth, 2003, p. 885). A parent-child affective dialogue that repeatedly signals the parent’s reluctance or refusal to respond to infant fear or distress shapes the child’s corresponding mental organization.

Sans Caregiving, Dissociate: Default Strategy for Regulating Fear Arousal. “[P]arental affective unresponsiveness can be conceptualized from a psychobiological viewpoint as a form of ‘hidden trauma’ specific to infancy - trauma that has the potential to hyperactivate the infant’s responses to stressors over time. Such heightened vulnerability to stressors, in combination with an implicit injunction from very early in life not to bring one’s fear and distress to the caregiver for comfort and soothing, may then shape the ‘choice’ of dissociation as one of the few available means for achieving a modicum of relief from fearful arousal.” (Lyons-Ruth, 2003, p. 887).

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EMOTION: Being Enthusiastic About the Night

The delectable creatures of the night “but he would have us remember most of all to be enthusiastic over the night, …. because it needs our love. With large sad eyes its delectable creatures look up and beg us dumbly to ask them to follow: they are exiles who long for the future” (From W. H. Auden, In Memory of Sigmund Freud)

ALCHEMY: The Transformational Process in AEDP

From Survival to Thrival, from the Energy-Depletion Emotions of Suffering to the Energy-Enriching Emotions of Transformation How do we counterbalance the evolutionary tilt toward the negative and give our brains, bodies, and sociocultural systems the energy-enriching benefits of the positive emotions? And how do we do so clinically, when the entry point into our work is negative emotions associated with the depletion and demoralization of trauma and emotional suffering? Craig (2002, 2009, 2010), exploring the role of the insula in the energy management aspect of affect regulation, asks the same question: “How do we bring energy enriching emotions into the system?” (2005, p. 570)

➢ Transformance Detection ➢ Metaprocessing of transformational experience and the positive transformational affects associated with it. ➢ Undoing Aloneness: Dyadic affect regulation ➢ Dyadic Embodied Mindfulness: GEM-to-GEM tracking of fluctuations in affective experience ➢ Intersubjective Relatedness, Attachment Based Stance: states of safety, engagement, connection, resonance, support, synchrony ➢ Experiential Work with the Transformational Process o Processing emotional experience (to an affective shift from a negative affective valence to a positive affective valence ➢ Metaprocessing of transformational experience and the positive transformational affects associated with it.

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USING RECOGNITION TO WORK WITH DISSOCIATION

“Under conditions of stress that evoke fear and shame, dissociation tears the psyche. Yet at a figuratively deeper level, below the dissociation, if you will, an integrated self is pulsing, has always pulsed and will always be pulsing. It is evident in the coherence, organization and integration that is there even when it is not felt. It is not that the experience of being split/fragmented is not valid: it is. Nor is it that dissociation does not affect the organization and function of the brain: it does. It is just that the core self as neurobiological organizer is always there, functioning integratively even when it is somewhat compromised, as it is in dissociation. And it is this fundamentally integrative function that is a huge resource in the treatment of dissociation. Channeling transformance, we access this resource through working with the qualities of the neurobiological core self and the unguarded moments of core self living. The method of moment-to-moment tracking, dyadic mindfulness, and experiential exploration applied to the tags and GEMs of the core self is optimized in an environment of kindness, facilitation and dyadic help. Previous work focused on entraining transformational processes (Fosha, 2003; Fosha et al., 2009; Gleiser et al., 2008), working to heal dissociation --in the time honored fashion of depth treatments-- from the inside out. In the case below, emergent processes revealed a different path: the use of recognition, here initially the therapist’s recognition of the patient’s self, to heal dissociation from the outside in. By focusing on the manifestations of the integrative aspects of the neurobiological core self, we aim to grow the individual’s capacity to tolerate (i.e., the equipment to deal with) increasing amounts of aliveness. Internal conditions thus get created in which previously dissociated emotion and other areas of dissociated experience can come online and be processed. Once processed, experiences can more readily be integrated into self. The resources residing within them can also come online. Over time, resilience grows, dissociative barriers thin out, and the flow of communication, i.e., information and energy, vitality and truth, proceeds as increasingly access to the felt core self, the felt sense of “I” gets progressively restored “(Fosha, in press, pp. 26-27).

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AEDP Safety, Experience, Affirmation, Integration

1. Establish Safety & Undo Aloneness ➢ empathy, affirmation, validation, valuing ➢ engagement, presence, authenticity ➢ active use of the therapist’s affect ➢ readiness to help ➢ willingness to bear and share painful emotion ➢ delight and pleasure in the patient

2. Facilitate and Process Emotional Experience ➢ work moment-to-moment, tracking affect and relatedness ➢ dyadic affect regulation of intense emotional states ➢ counteract the patient’s aloneness ➢ work to minimize defensive exclusion ➢ alleviate inhibiting impact of pathogenic fear and shame ➢ facilitate and process core affective experiences involving emotion, relatedness, the body, the self and transformation ➢ work to completion, until adaptive action tendencies released

3. Affirm Transformation and Process Transformational Affects ➢ affirm and process the experience of § the transformation of the self

§ being transformed with the help of another, i.e., feeling seen, understood, and helped by another § transformation itself ➢ affirm and process the experience of the healing affects § feeling moved and emotional within the self § feeling gratitude and love toward the other

4. Promote and Foster Reflection and Integration

➢ elaborate core state and foster the construction of a coherent and cohesive autobiographical narrative ➢ the sense of existing in the heart and mind of the other ➢ the development of self-compassion and compassion for others

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COMPREHENSIVE (tho not complete) AEDP REFERENCES

DVDs Fosha, D. (2006). Accelerated Experiential Dynamic Psychotherapy with Diana Fosha Ph.D. Systems of Psychotherapy APA Video Series # 4310759. www.apa.org/ videos/4310759.html Fosha, D. (2013). Accelerated Experiential Dynamic Psychotherapy (AEDP) with a Male Client. with Diana Fosha Ph.D. Series II - Specific Treatments for Specific Populations APA Video Series http://www.apa.org/pubs/videos/4310906.aspx Fosha, D. (2016, in press) A Live AEDP Supervision Session with Diana Fosha Ph.D: Essentials of Accelerated Experiential Dynamic Psychotherapy (AEDP) Supervision. APA Video Series Lamagna, J. (2015). Making good use of suffering: Intra-relational AEDP work with overwhelming emotional experience.

BOOKS on AEDP Fosha, D. (2000). The transforming power of affect: A model for accelerated change. New York: Basic Books. Fosha, D., Siegel, D. J., & Solomon, M. F. (Eds.), (2009). The healing power of emotion: Affective neuroscience, development & clinical practice. New York: Norton. Frederick, R. (2009). Living like you mean it: Use the wisdom and power of your emotions to get the life you really want. San Francisco, CA: Jossey-Bass. Prenn, N. & Fosha, D. (in preparation). Essentials of AEDP supervision. Washington DC: APA. Russell, E. M. (2015). Restoring resilience: Discovering your clients’ capacity for healing. New York: Norton.

AEDP in the Press Hendel, H. J. (2015). It’s Not Always Depression New York Times, March 10, 2015. Hendel, H. J. (2015). The Healing Power of Hugs. New York Times, September 1, 2015. Retrieved from http://opinionator.blogs.nytimes.com/2015/09/01/the- healing-power- of-hugs/?_r=1

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BOOK CHAPTERS and JOURNAL ARTICLES Fosha, D. (2002). The activation of affective change processes in AEDP (Accelerated Experiential-Dynamic Psychotherapy). In J. J. Magnavita (Ed.). Comprehensive handbook of psychotherapy. Vol. 1: Psychodynamic and object relations psychotherapies, pp. 309-344. New York: John Wiley & Sons. Fosha, D. (2003). Dyadic regulation and experiential work with emotion and relatedness in trauma and disordered attachment. In M. F. Solomon & D. J. Siegel (Eds.). Healing trauma: Attachment, trauma, the brain and the mind, pp. 221-281. New York: Norton. Fosha, D. (2004). “Nothing that feels bad is ever the last step:” The role of positive emotions in experiential work with difficult emotional experiences. Special issue on Emotion, L. Greenberg (Ed.). Clinical Psychology and Psychotherapy, 11, 30-43. Fosha, D. (2005). Emotion, true self, true other, core state: toward a clinical theory of affective change process. Psychoanalytic Review, 92 (4), 513-552. Fosha, D. (2006). Quantum transformation in trauma and treatment: Traversing the crisis of healing change. Journal of Clinical Psychology/In Session, 62(5), 569- 583. Fosha, D. (2008). Recognition, vitality, passion. And love. Constructivism in the Human Sciences, 12 , 57-77. Fosha, D. (2008). Transformance, recognition of self by self, and effective action. In K. J. Schneider, (Ed.) Existential-integrative psychotherapy: Guideposts to the core of practice, pp. 290-320. New York: Routledge. Fosha D. (2009). Emotion and recognition at work: Energy, vitality, pleasure, truth, desire & the emergent phenomenology of transformational experience. In D. Fosha, D. J. Siegel & M. F. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development, clinical practice (pp. 172-203). New York: Norton. Also reprinted in the Neuropsychotherapist, (2013), 2. www.theneuropsychotherapist.com Fosha, D. (2009). Healing attachment trauma with attachment (…and then some!). In M. Kerman (Ed.), Clinical pearls of wisdom: 21 leading therapists offer their key insights (pp. 43-56). New York: Norton. Fosha, D. (2009). Positive affects and the transformation of suffering into flourishing. W. C. Bushell, E. L. Olivo, & N. D. Theise (Eds.) Longevity, regeneration, and optimal health: Integrating Eastern and Western perspectives (pp. 252-261). New York: Annals of the New York Academy of Sciences.

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Fosha, D. (2013). Speculations on emergence: Working the edge of transformational experience and neuroplasticity. International Neuropsychotherapy Magazine, 2013, 1 (1), 120-121. also in The Neuropsychotherapist, Issue I, www.theneuropsychotherapist.com. Fosha, D. (2013). A heaven in a wild flower: Self, dissociation, and treatment in the context of the neurobiological core self. Psychoanalytic Inquiry, 33, 496-523. Fosha, D. (2013). Turbocharging the affects of healing and redressing the evolutionary tilt. In D. J. Siegel & Marion F. Solomon (Eds). Healing moments in psychotherapy. Chapter 8 (pp. 129-168). New York: Norton. Fosha, D., Paivio, S. C., Gleiser, K. & Ford, J. (2009). Experiential and emotion- focused therapy. In C. Courtois & J. D. Ford (Eds.), Complex Traumatic Stress Disorders: An Evidence-Based Clinician's Guide. Chapter 14, pp. 286-311. New York: Guilford Press. Fosha, D. & Yeung, D. (2006). AEDP exemplifies the seamless integration of emotional transformation and dyadic relatedness at work. In G. Stricker & J. Gold (Eds.), A casebook of integrative psychotherapy (pp. 165-184). Washington DC: APA Press. Gleiser, K., Ford, J. D., & Fosha, D. (2008). Exposure and experiential therapies for complex posttraumatic stress disorder. Psychotherapy: Theory, Research, Practice, Training, 45 (3), 340-360. Grotstein, J. (2002) . The transforming power of affect: A book review. (Division 39) pp.23-25. Hanakawa, Y. (2011). Receiving loving gratitude: How a therapist’s mindful embrace of a patient’s gratitude facilitates transformance. Transformance: The AEDP Journal, 2 (1). www.transformancejournal.com Harrison, R. L., & Westwood, M. J. (2009). Preventing vicarious traumatization of mental health therapists: Identifying protective practices. Psychotherapy: Theory, Research, Practice, Training, 46 (2), 203-219. Hill, R. & Dahlitz, M. (2013). What’s hot in neuroscience for psychotherapy. Transformance: The AEDP Journal, volume 3. www.transformancejournal.com Lamagna, J. & Gleiser, K. (2007). Building a secure internal attachment: An intra- relational approach to ego strengthening and emotional processing with chronically traumatized clients. Journal of Trauma and Dissociation 8 (1), 25-52. Lamagna, J. (2011). Of the self, by the self, and for the self: An intra-relational perspective on intra-psychic attunement and psychological change. Journal of Psychotherapy Integration, 21 (3), 280-307. Lamagna, J. (2016) Making good use of suffering: Intra-relational work with pathogenic affects. Transformance: The AEDP Journal. www.transformancejournal.com -

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Lipton, B. (2015). Introduction to The Couples issue. Transformance: The AEDP Journal, 6 (1). www.transformancejournal.com Lipton, B. & Fosha, D. (2011). Attachment as a transformative process in AEDP: Operationalizing the intersection of attachment theory and affective neuroscience. Journal of Psychotherapy Integration, 21 (3), 253-279. Pando-Mars, K. (2011) Building attachment bonds in AEDP in the wake of neglect and abandonment: Through the lens and practice of AEDP, attachment and polyvagal theory. Transformance: The AEDP Journal, 1 (2). www.transformancejournal.com Prenn, N. (2009). I second that emotion! On self-disclosure and its metaprocessing. In A. Bloomgarden & R. B. Menutti, (Eds.), Psychotherapist revealed: Therapists speak about self-disclosure in psychotherapy. Chapter 6, pp. 85-99. New York: Routledge. Prenn, N. (2010). How to set transformance into action: The AEDP protocol. Transformance: The AEDP Journal, 1 (1). www.transformancejournal.com Prenn, N. (2011). Mind the gap: AEDP interventions translating attachment theory into clinical practice. Journal of Psychotherapy Integration, 21 (3), 308-329. Russell, E. & Fosha, D. (2008). Transformational affects and core state in AEDP: The emergence and consolidation of joy, hope, gratitude and confidence in the (solid goodness of the) self. Journal of Psychotherapy Integration. 18 (2), 167-190. Snyder, M. (2013). Leaning into love: The radical shift. Transformance: The AEDP Journal, volume 3. www.transformancejournal.com Tunnell, G. (2006). An affirmational approach to treating gay male couples. Group, 30 (2), 133-151. Tunnell, G. (2011). An attachment perspective on the first interview. In C. Silverstein (Ed.), The Initial Psychotherapy Interview: A Gay Man Seeks Treatment. New York: Elsevier Insight Books. Recipient of 2011 Distinguished Book Award from American Psychological Association, Division 44. Tunnell, G. (2012). Gay male couple therapy: An attachment model. In J. J. Bigner & J. L. Wetchler (Eds.), Handbook of LGBT-affirmative couple and family Therapy. London: Routledge. Welling, H. (2012). Transformative emotional sequence: Towards a common principle of change. Journal of Psychotherapy Integration, 22 (2), 109-136. Yeung, D., & Fosha, D. (2015). Accelerated Experiential Dynamic Psychotherapy. In The Sage Encyclopedia of Theory in Counseling and Psychotherapy. New York: Sage Publications.

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AEDP RESEARCH: Publications Faerstein, I. & Levenson, H (2015). Validation of a fidelity scale for accelerated- experiential dynamic psychotherapy." Journal of Psychotherapy Integration Iwakabe S. & Conceicao, N. (2015) Metatherapeutic processing as a change- based therapeutic immediacy task: Building a initial process model using a modified task- analytic research strategy. Journal of Psychotherapy Integration. http://dx.doi.org/ 10.1037/int0000016 Harmon, K. L. & Lambert, M. J. (2012). The case of “Grace:” A commentary. Commentary on “Combining expressive writing with an affect- and attachment- focused psychotherapeutic approach in the treatment of a single-incident trauma survivor: The case of "Grace." Pragmatic Case Studies in Psychotherapy, 8 (2), 123-138. http://pcsp.libraries.rutgers.edu Johansson, R., Bjorklund, M., Hornborg, C., Karlsson, S., Hesser, H., Ljótsson, B., Rousseau, A., Frederick, R. J., & Andersson G. (2013). Affect-focused psychodynamic treatment for depression and anxiety through the Internet: a randomized controlled trial. PeerJ 1:e102.http://dx.doi.org/10.7717/peerj.102 Johansson, R., Frederick, R. J., & Andersson G. (2013). Using the Internet to provide psychodynamic psychotherapy. Psychodynamic Psychiatry. Dec; 41(4):513-40. doi: 10.1521/pdps.2013.41.4.513. Johansson, R., Hesser, H., Ljótsson, B., Frederick, R. J., & Andersson G. (2012). Transdiagnostic, affect-focused, psychodynamic, guided self-help for depression and anxiety through the Internet: Study protocol for a randomized controlled trial. BMJ Open. Dec 19;2(6). pii: e002167. doi: 10.1136/bmjopen-2012-002167. Print 2012. http://www.ncbi.nlm.nih.gov/pubmed/23257775 Messer, S. B. (2012). Assimilative and theoretical integration in the treatment of a trauma survivor. Commentary on “Combining expressive writing with an affect- and attachment-focused psychotherapeutic approach in the treatment of a single- incident trauma survivor: The case of "Grace." Pragmatic Case Studies in Psychotherapy, 8 (2), 113-117. http://pcsp.libraries.rutgers.edu Pass, E. R. (2012). Combining expressive writing with an affect- and attachment- focused psychotherapeutic approach in the treatment of a single-incident trauma survivor: The case of "Grace." Pragmatic Case Studies in Psychotherapy, 8 (2), 60-112. http://pcsp.libraries.rutgers.edu

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AEDP RESEARCH: Dissertations Faerstein, I. (2014) "Validation of a Fidelity Scale for Accelerated-Experiential Dynamic Psychotherapy." Doctoral Dissertation. Wright Institute, Berkeley, CA. Lee, A. (2015). Building a Process-Model for Metaprocessing: Exploration of a key change event in Accelerated Experiential Dynamic Psychotherapy (AEDP). Doctoral Dissertation. Wright Institute, Berkeley, CA Piliero, S. (2004). Patients reflect upon their affect-focused, experiential psychotherapy: A retrospective study. Doctoral Dissertation. Adelphi University Schoettle, E. (2009). A qualitative study of the therapist's experience practicing Accelerated Experiential Dynamic Psychotherapy(AEDP): An exploration of the dyadic process from the clinician's perspective. Doctoral Dissertation. Wright Institute, Berkeley, CA.

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