Accelerated experiential dynamic psychotherapy

Accelerated experiential dynamic psychotherapy (AEDP) is an integrative, experiential and attachment-based psychotherapy focused on emotion processing and transformational change.[1][2] AEDP was developed by Diana Fosha in her 2000 book The Transforming Power of Affect: A Model for Accelerated Change,[3] and expanded on in later publications.[4][5]

AEDP is featured by the American Psychological Association in its Systems of Psychotherapy Video Series.[6][7][8]

Overview

The AEDP model originates with Fosha's assertion that a model of therapy must be based upon a theory of what brings about change in psychotherapy. The core constructs and methodologies to promote therapeutic change are informed by contributions from (1)neuroscience on neuroplasticity (that we are wired for growth and seek opportunities do so so),[9] ( 2). from attachment research on the necessity of a secure attachment relationship from which to explore emotional experiences, (3) infant research influencing the clinical applications of attachment theory and of moment-to-moment emotional communication between mothers and infants, (4) from emotion research on the capacity of positive emotion to promote resilience[10] and to repair the effects of negative emotions,[11] and (5) from phenomenological observations that positive change need not be linear and protracted, but can be abrupt and discontinuous, and thereby especially potent.[12][13]

The aim of AEDP therapy is to correct what Fosha believes is at the root of almost all psychopathology;[14] "aloneness in the face of overwhelming emotional experience", that is the trauma endured when a child's need for physiological regulation or emotional soothing is routinely neglected or misread. When left untended, such states are overwhelming to the child's developing nervous system and emotion regulatory capacities. The caregiver's vital role regulating and soothing a child's emotional or physiological dysregulation is central to the development of a secure attachment bond.[15] As dysregulated states cannot be endured in the absence of a soothing caregiver, the child's physiological response is typically to dissociate (the detachment from conscious awareness)[16] or use of other protective strategies (defenses). The developmental trajectory of this repeated trauma is typically evident in the disorders of emotion regulation,[16] dissociative disorders, affect phobia, debilitating shame,[17] and compromised attachment relationships in adulthood.

AEDP methodology is devised to correct the original traumatic conditions by establishing a secure therapeutic relationship from the start.[18] The methodology is in part a sequenced process:[19] it begins with the essential requirement to establish a secure therapeutic relationship[20] through attunement to the patient's emotional states and the skillful assistance in helping the patient regulate difficult emotional states ("dyadic affect regulation"). Once a secure therapeutic relationship is established, the exploration and integration of painful emotion can then proceed.[2][21][22] When painful emotions, once experienced as overwhelming are modulated and then viscerally experienced and processed (e.g., emotions, sensations and cognitions of the experience in concordance and integrated), their adaptive action tendencies[23] (for example, anger provides energy and focus, its adaptive action is toward protecting oneself or others; sadness has an inner directed adaptive action directing compassion toward oneself or others) are enabled. Furthermore, Fosha observed that, when these adaptive action tendencies become the focus of therapeutic attention, an ensuing release of positive emotions, which Fosha terms "transformational affects" (e.g., mastery, “feeling moved,” pride, gratitude toward therapist ) will follow. In short, the goal of AEDP therapy is to facilitate the patient’s capacity to experience and express blocked emotions, their adaptive action tendencies, and the ensuing positive emotions, all of which lead to healing.

Foundational constructs: Transformance and metaprocessing

AEDP theory and methods of change are organized around two foundational constructs, transformance and metaprocessing. Transformance is Fosha's term for the overarching construct for processes underlying positive change in AEDP psychotherapy. Transformance refers to our innate drive for growth, "self righting", and healing, and concomitantly, the predictable sequence of an unfolding healing process. AEDP methodology is devised to activate and facilitate this transformational process. As a foundational construct, transformance naturally lends to AEDP's accentuation of potential and resilience, as opposed to pathology.[14] The transformance construct is culled from research identifying the variables of potent change in psychotherapy. These include, experiences that are viscerally felt as new and emergent,[24] and the experience of amplified positive affect (in the AEDP model, positive need not be happy, but must feel right and true),[25] each occurring within the context of a secure and affect-regulating therapeutic relationship. Psychotherapy research informed by AEDP theory specifically,[26] and experiential models in general, conclude the confluence of the above change variables are necessary for therapeutic change.[4]

Transformance cannot effect psychotherapeutic change without the requisite and crucial act of meta-therapeutic processing, or metaprocessing for short. Metaprocessing is the cornerstone of AEDP methodology. The intent of metaprocessing is to maximize the power of transformance moments by exploring the experience of having the experience[27] as it is happening (for example, the therapist may ask, "what is it like for you to have had this deep emotional experience right now?"), especially in the context of experiences that are therapeutic or positive.[27] Slowing down the emotional experience (somatic, emotional, cognitive) through "moment-to-moment tracking", not only primes its neuroplastic potential,[28] but allows the therapist to help the patient maintain a well-regulated, as opposed to overwhelming, emotional experience (dyadic affect regulation).[29] A second form of relational metaprocessing asks the patient what it was like “to do this with me?” (“dyadic affective reflective process”) which further "undoes the patient’s aloneness", while also strengthening the attachment bond for further emotional work.[22] Empirical studies confirm clinical observations that positive emotions naturally arise following metaprocessing.[20] Positive emotions fortify the patient's healing experience and promote enhanced resilience.[30]

Historical influences and divergences

AEDP as a model of change rests, in part, on postulations from the following influences (1) The emotion theories of [a] Charles Darwin: emotions are innate and each emotion functions for survival purposes.[31] [b] William James: inherent in emotions is the power of emotions to drive quantum change.[12] and [c] Antonio Damasio: emotions underlie our consciousness of 'self.'[32] (2) Humanistic psychology and existential philosophers such as Martin Buber: individuals possess an innate drive toward healing, growth and self-righting. (3) John Bowlby's attachment theory: individuals are biologically driven to form attachment bonds. And, (4) Affective Neuroscience: individuals possess a "neurobiological core self", the agent of the continuity of 'sense of self' throughout development and despite change.[5][33]

Comparison of AEDP to contemporary influences, such as psychoanalysis, intensive short-term dynamic psychotherapy, and experiential-affect focused therapies: AEDP concurs with the traditional psychoanalytic premise that individuals develop psychopathological symptoms and defenses to ward off painful feelings. However, unlike psychoanalysis, AEDP does not adhere to the belief that interpretation of the patient’s symptoms/defenses, along with the patient's cognitive insight into defenses, is the primary agent of change. Instead AEDP focuses on identifying and amplifying the patient’s innate resilience/transformance strivings. In contrast to intensive short-term psychodynamic treatment, in which the therapist directly confronts the patient’s defenses or resistance, the AEDP therapist clears the way for defenses to retreat by cultivating conditions of safety within the therapeutic relationship.[34]

The result of decades of research demonstrating the positive correlation between the therapeutic relationship and positive outcome, along with applications of attachment research findings to psychotherapeutic methodology is a vast shift in most psychotherapies away from the traditionally impersonal stance. AEDP has taken applications of this science further by developing a methodology that is based on the premise that the therapeutic relationship is the driver of change. This includes the therapist use of her own affect, and the judicious use of self-disclosure.[35] The caveat to expressions of genuine care, is that such expressions do not in and of themselves facilitate change. It is the act of metaprocessing the patient's experience of caring interaction with the therapist that potentiates transformance potential/neuroplastic change. AEDP's expansion, beyond bearing witness with empathy, to the explicit expressions of care and the processing of this care distinguishes AEDP from the other experiential and dynamic models of psychotherapy.[36]

Theory of change/model of therapy

Fosha has identified that healing change occurs in identifiable progressive stages, termed “state changes.” State changes mark shifts in the unfolding healing ("transformational") process. States correspond to the patient's progression from emotions that have been defensively blocked from awareness, to the visceral experience of, and the eventual integration of emotions. Emotions drive transformance strivings and underlie the predictable flow of the change process put forth by AEDP. Inherent in the construct of transformance is the foundational premise that once positive change is set in motion, the innate resilience potential drives the momentum through these state changes.

AEDP therapists are trained to identify the somatic markers of state changes, track moment-to-moment shifts within and between each state, and to apply the attendant psychotherapeutic interventions to facilitate movement through the 4 states.

4 States 3 State Transformations
State 1 State 1 is marked by the protective defensives against with pathogenic emotional states (shame, dissociated emotions...). For example, when the patient has learned that the expression of core emotions such as sadness or anger, leads to rejection, shame and self-loathing, emotions will become blocked from awareness and/or expression.[37] In State1 the therapist's focus is on the establishment of a secure therapeutic relationship as a necessary condition to help the patient notice somatic/affective indicators of forbidden affects. At this point, dyadic regulation of patient affect is necessary to modulate exposure to the previously forbidden emotions. Evidence of the patient's resiliency and capacities are highlighted to ensure the patient is sufficiently resourced for the work ahead. Psycho-education is important during this phase to help the patient view symptoms as evidence of resourcefulness toward self-protection and in the service of the preservation of attachment relationships, as opposed to bearing a pathological view of self.[38]
1st State transformation The first state transformation into State 2 is noted by "heralding affects", such as a bodily expression of sadness, or indications, such as curiosity, that the patient is experiencing relationship security. Heralding affects cue the therapist that the patient is ready for exploration of undefended core emotions, with the dyadic regulating therapeutic relationship clearly established.
State 2 State 2 is marked by the patient's immersion in the complete visceral experience of a core emotion, or a complex of emotions. The therapist encourages a visceral experience of emotion, and through dyadic affect regulation, ensures that the patient's new experience of emotion remains tolerable. A core emotional experience will have a pattern of deepening toward affective/somatic/cognitive integration as it prepares the body for action. Each core emotion has a biologically connected adaptive action tendency. For example, fear is crucial for survival and its adaptive action is to run from danger or toward protection; joy has an energizing quality, and an expansive outer directed adaptive action of promoting social interaction.[25] Once an adaptive action is released (either through a self-affirmation, or through an experiential method called portrayal), positive affects follow. Positive affects mark the completion of the natural wave of the emotion.[10][39] Patient's report a sense relief or lightness, what in AEDP are called the breakthrough affects.[14] To consolidate the experience and to propel the patient toward the next stage of transformational change, the AEDP therapists metaprocesses the completed round of core emotion with the patient; i.e., the therapist will ask the patient to reflect on what it was it like to just have had a powerful emotional experience, and equally important, will ask the patient to reflect on what it was like to do so with the therapist.[4]

Patients with complex trauma may present with core affective experiences that are phenomenologically distinct from the core affect described above.[14] These are core affects such as shame, inhibitory emotional experiences that represent freeze states (or fright without solution) of trauma. Therefore, as explained below, interventions are not only state specific, but also specific to the nature of the affects presented, and are in consideration of the patients pattern of attachment, or attachment style.[40]

2 cd State transformation Breakthrough affects and the positive affective consequences of adaptive action tendencies being released are typically experienced in the transition from State 2 to State 3.
State 3 State 3. State 3 is devoted to metaprocessing more fully the accomplishments, and breakthrough affects that emerge at the conclusion of State 2. This metaprocessing evokes its own set of transformational affects and is the focus of State 3.[41] Transformational affects include, the joy of mastering a previously feared emotional experience, the mourning of missed opportunities, the gratitude experienced toward the therapist, and acknowledgement and pride in oneself for the therapeutic accomplishments. Without metaprocessing, the patient simply has an emotional experience that may or may not lead to emotional healing.[20]
3rd State Transformation An ease of receiving affirmation ("receptive affective capacity") characterizes the transformational affects leading to state 4.
State 4 State 4. State 4, a state of calm and integration is characterized by the immersion in the experience of "core state".[42] It involves continued metaprocessing of the positive transformational affects experienced in State 3. This new round of metaprocessing, now of the positive transformational affects, culminates in core state.[43] It is marked by the integration of the insights emerging from the new and deep emotionally felt experiences processed in the previous states. Core state is characterized by the patient reporting a feeling of calm, vitality, a sense of wellbeing, compassion toward self and others, an expanded perspective, and wisdom.[44] It is often described as "transcendent" and "flourishing.[45]” This is a state in which the patient has access to the proposed inherent self - a "neurobiological core self",[5] that through trauma, has been shielded from others, and ultimately oneself. Core self state involves a coherent reorganized self-narrative. The ability to construct a "coherent and cohesive" self-narrative is shown to be highly correlated with secure attachment status in adulthood and with emotional resilience.[46] The positive emotions elicited in States 3 and 4 are associated with, and are the vehicles of, neuroplasticity.

Emotion: The core of pathogenesis and the core of healing

Emotion is a biological, self-organizing and motivational life force. It is the primary source of information about the environment to the self, and about the self to the self, and is also the primary source of communication about the self to others. Clarity of expression, and a capacity for attunement to another's emotions are necessary to effectively interact with the human environment. Because its central organization is biological, emotion gives continuity to our experience of self in spite of the many ways we change throughout development.[47] During infancy, a caregiver's responsiveness to the infant's emotional signaling builds the infant's eventual capacity for self-regulation and the capacity to respond to the emotional cues of other's. The first year marks a critical psychological and neurological developmental phase wherein the right brain, responsible for emotion regulation, emotional attunement toward others, and for “maintaining a coherent, continuous and unified sense of self.,[48]" is actively developing in accordance with the quality of caregiver-infant regulation.[15]

AEDP's approach to treating the adult consequence of sub-optimal right brain development is informed by research that corrective re-organization of the brain can occur in under certain conditions within psychotherapy.[49] Accordingly, AEDP therapeutic interactions aim to activate and remediate those compromised brain structures and functions. Therefore, "right brain-to-right brain" communication; that is, non-verbal somatically-driven communication, i.e., eye contact, facial expressions revealing emotions, features of voice such as prosody) is prioritized. For example, rather than, "what are you thinking right now?" the therapist will say, "what are you feeling as you share this with me?...where do you feel this in your body?" and "what do you see in my 'facial expression' toward you?" Right brain-to-right brain interactions are necessary to activate a patient's visceral experience of the therapist's emotional attunement, thereby facilitating the required secure therapeutic relationship.

In later childhood, failures of attunement toward a child's emotions occur when emotions are routinely denied, ignored, and/or avoided. The child must then inhibit emotional expression in order to preserve the primary attachment bond. Inhibition of emotion invariably leads to a predominance of negative affect.[50] In the worse case scenario, emotions, rather than being a source of information and liveliness, become a source of anxiety, helplessness, guilt, shame, and fear of rejection.

While emotion may be defensively blocked from awareness, inhibited in expression, or dissociated in adaptation to trauma, emotion as a wired-in biologically driven function (with the exception of particular brain injuries or diseases) cannot be eroded or blighted, and therefore, can ultimately be accessed through AEDP methodology. AEDP's metapsychology and methodology is at its core an endeavor to restore this innate function. The goal of AEDP is to free the emotions defensively blocked from expression and/or subjective experience. Once emotional experience and expression are safe, attuned to, and well regulated within the therapeutic relationship, positive emotions naturally follow. The task for the therapist is now to draw attention to the positive affects, encourage a full visceral experience and, unlike work with the painful emotions, to amplify these affects. Positive affects play a central role in healing, because through their release of rewarding neurotransmitters (endorphins, dopamine), they potentiate optimal right brain functioning. The observed outcome is greater freedom of expression, enhanced attunement to the emotions of others,[25] and optimized resiliency.[14]

Empirical studies demonstrate that AEDP's centrality of affective focus, especially as facilitated within the therapeutic relationship, is associated with patient improvement.[26] Furthermore, AEDP is identified as a therapy providing clinical evidence for research findings that the accumulation of positive emotional experiences, will override the impact of negative emotions.[51]

Therapeutic stance: A departure from neutrality

Therapeutic stance refers to the therapist's set of rules and beliefs regarding how the therapist's role in the therapeutic interactions can positively affect/contribute to the patient's progress. The AEDP therapeutic stance is informed by the wealth of studies on infant-caregiver interactions.[50][52] It is within the attachment informed stance that all elements of the AEDP model cohere. The stance and modality rests upon the premise that the brain is wired to seek positive and health-promoting relational interactions.[33]

AEDP utilizes this inherent resilience potential by: (a) targeting emotion,( b) dyadically regulating emotion, (c) tracking the moment-to-moment shifts in emotional experience, and (d) metaprocessing the experience emotion within the therapeutic relationship. While the therapist is working within the right-brain regions wherein attachment and social/emotional skills develop, the metaprocessing of emotional experience engages left brain cognition. Integration of brain regions is thereby activated, allowing new insight and meaning-making of historical experience. Adult attachment studies have found that the ability to create a coherent life narrative is a defining characteristic of secure attachment in adulthood.[53] Secure attachment in adulthood correlates with characteristics of well-being; such as, resiliency, high self-esteem, and satisfying relationships. Psychotherapy research has found that psychotherapies whose methodology optimize both the therapeutic relationship, and the processing of emotional experience, can result in a corrective re-organization of the brain.[54] AEDP is recognized to be one of such therapies[49][55]

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