Building Attachment Bonds in the Wake of Neglect and Abandonment - 11th August 2021 View online at https://aedpinstitute.org Building Attachment Bonds in the Wake of Neglect and Abandonment Through the lens and practice of AEDP, Attachment and Polyvagal Theory By Karen Pando-Mars This paper will illustrate the process of building attachment bonds in the context of the transformational journey of one patient by examining segments of four sessions over the course of a two-month period of psychotherapy. As the bond between patient and therapist develops, so develops the patient’s capacity to engage in the healing of her early attachment trauma and to reorganize her relationship with her self. This case study provides a window into the powerful impact of the AEDP therapist stance, which is positive, helpful, and goes beyond mirroring with empathic responsiveness that truly assists patients in getting what is needed to foster a secure sense of self. Polyvagal theory offers a neuroscience perspective to help us understand which neurological circuits get activated during trauma and how therapists can engage with patients to establish the kind of safety and regulation of affective experience that facilitates transformational process. The breeze at dawn has secrets to tell you. Don’t go back to sleep. You must ask for what you really want. Don’t go back to sleep.People are going back and forth across the doorsill Where the two worlds touch. The door is round and open. Don’t go back to sleep. – Rumi The above poem keenly recognizes processes that occurred in the patient I am going to present in this article, for whom getting sleepy at inopportune times became a significant marker heralding this phase of our work together. I will point out occasions in which the AEDP therapist’s stance informed by attachment theory and my use of self as therapist, impact the patient’s developing sense of self. The work progresses through emergent state transformations (Fosha, 2000, 2006, Fosha & Yeung, 2006) that are identified by AEDP’s articulation of the phenomena of the healing journey (Fosha, 2000, 2002, 2004, 2006, 2008, 2009) providing valuable orientation and direction. Polyvagal Theory (Porges, 2009) provides a perspective from which to understand how this patient’s nervous system was activated when early attachment trauma occurred. We Page 1 Building Attachment Bonds in the Wake of Neglect and Abandonment - 11th August 2021 View online at https://aedpinstitute.org can infer that those early neural pathways became fixed into specific defenses over time. It also provides a way to understand more about how our relationship, therapist to patient, draws upon “the social engagement system” (Porges 2009) to strengthen the experience of safety and build the capacity for connection. Just as the secure attachment with a therapist isn’t the sine qua non of therapy (Fosha, 2006), so this connection isn’t the be all and end all of treatment. What emerges through this patient’s deepened trust in listening to her body in the presence of a caring and responsive “other” (Fosha, 2000) is a willingness to pick up the unexpected and explore its meaning. This moves and truly elicits the healing potential of this therapeutic encounter in a powerful and intimate way and touches a wound that is simultaneously very personal while also profoundly universal. POLYVAGAL THEORY IN A NUTSHELL Polyvagal theory is based on the study of the evolution of the nervous system, (Porges, 2009) and expands the theory of the autonomic nervous system from having two branches — the sympathetic and parasympathetic — to having three neurological circuits. These circuits are hierarchically organized in how we react to our environment, meaning that one system can override the other, usually from the newest system back to the oldest. We engage these circuits as part of a process Porges calls neuroception: a non-conscious process that appraises threat and seeks safety. Central to Polyvagal theory is that most of parasympathetic innervation, which goes to the viscera and comes from the vagus nerve. There are two vagal systems, an old one and a new one. The newest circuit, the ventral vagal complex, goes to the heart and lungs. It is myelinated and connects to cranial nerves which affect and are affected by facial expressions and vocalizations and is activated through a feeling of safety. In this state, we can read faces and pick up social cues. It is most readily accessed with eye contact, gaze, voice tone, pace and prosody of speech. When AEDP therapists are meeting our patients, right-brain-to right-brain, and inviting them to slow down and become more present to moment–to-moment experience, we are likely in this circuit, which Porges refers to as the social engagement system. Being in this system gives rise to the self-at-best: having access to the depths of our emotional and relational experiences. The middle, or second oldest circuit is the sympathetic/adrenal part of the autonomic nervous system, which is activated when we perceive ourselves to be in a state of danger. In fear, we are mobilized to take action via the fight or fight response. When this circuit is activated without fear, play can initiate mobilization, which I believe may have positive implications for use in a therapeutic situation (i.e. when a patient is slipping into an area of sleepy torpor.) The oldest circuit, the dorsal vagal complex, is unmyelinated, goes to the gut, and is activated in the case of something life threatening. In fear, it produces a state of immobilization in which a person shuts down, dissociates, loses contact with the capacity to act or think coherently and feels nauseous and weakened with a sense of heaviness and exhaustion. In AEDP terms, I think of this as a time when a person is their self-at- worst, meaning they are at the mercy of a paralyzing fear, without access to their emotional experiences and capacity for relating to another. Page 2 Building Attachment Bonds in the Wake of Neglect and Abandonment - 11th August 2021 View online at https://aedpinstitute.org AEDP THERAPIST STANCE AEDP (Accelerated Experiential Dynamic Psychotherapy) draws upon attachment theory in its understanding that how a patient meets experience is usually characterized by how they were met by caregivers in critical periods of their early development (Stern, 1985; Siegel, 2007). There are three different behavioral systems associated with attachment. The first, the attachment behavioral system, has protection as its primary function, i.e. running to an older, stronger, wise Other in moments of danger. The second, the care giving or parental behavioral system, is primarily facilitative: a warm smile and tender look to a nervous child reassures and soothes. The third, the exploratory system, has as its primary function to seek, roam and learn about the environment (Bowlby, 1988). The stance of the AEDP therapist is in part founded on this theory. The therapist offers proximity and contact to our patients with an attuned sensitivity to their response. This contact has as one of its primary objectives “to establish safety and undo aloneness” (Fosha, 2000) and, with our companionship, provides our patients a springboard from which to explore their environment, internally and externally, for the purpose of healing what has been wounded, finding what was lost and expanding their capacity for living well. The therapist stance is affirming, positive, and helpful (Fosha, 2000, 2001; Fosha & Lipton, 2010; Prenn, 2010). In this paper, I am going to focus on elements of this therapist stance that address my patient’s needs by “going beyond mirroring” to helping (Fosha, 2000, 2010; Frederick, 2010) and beyond attunement to empathic responsiveness, which refers to the therapist being “moved outside of oneself in a compassionate gesture…to help, to offer something or simple to be a consciously comforting presence” (Russell, work in progress). I want to propose that the lengths to which we must go in order to truly help must be defined by what occurs in the therapeutic dyad itself. By noticing the impact of an intervention, the therapist can study what assists patients to move, with attuned accompaniment, toward that which is disturbing rather than away from it. For it is how we call upon ourselves in our relationship with our patients that has the capacity “to shift the motivational vector from moving away (fear activating shrinking or constriction) to moving toward (curiosity activating openness and expansiveness” (Fosha, 2006). This relationship capacity is most influenced by the therapist’s affective competence (Fosha, 2000) and willingness to show up no matter what. AEDP also posits that, as the relationship between the therapist and patient deepens, they can enter coordinated relational states (Fosha, 2000) which are exemplified by the hum of the dyad that is moving along (The Boston Change Group, in Russell, work in progress). One way to picture this is imagining a mother and infant who are enjoying each other’s presence, feeling vital and alive through the ins and outs of simply being with each other, cooing and gurgling, smiling and looking away, looking back and smiling together again. Sometimes in the therapy process, we are being with our patients in ways that are not necessarily moving into deeper categorical emotions, yet the sense of being with each other feels alive and vital, fuels our bonding and as such lays the groundwork for further unfolding to occur. Page 3 Building Attachment Bonds in the Wake of Neglect and Abandonment - 11th August 2021 View online at https://aedpinstitute.org In the case of neglect and early abandonment there is often a particular quality of absence that comes into the treatment room: an emptiness of contact with self that is at once palpable, yet vague, as it makes itself known through gaps in connectedness rather than flow.