This is a course in therapeutic technique, and at the same time a seminar in theory of technique. I invite members to consider, as healers, what works best for your own patients and clients. Ideally, by the end of the course, you will have distilled an idea of what makes certain avenues of technique interesting to you, and others irrelevant or boring.
Our springboard is the work of Diana Fosha, PhD, particularly in her The Transforming Power of Affect (Basic 2000) and several of her other papers (see bibliography). Essentially, her work addresses the issue of healing affects as activated in the dyadic therapeutic relationship.
Fosha builds on the foundation of Short-Term Dynamic Psychotherapy (all variations of which derive from the ground-breaking work of H. Davanloo, M.D.). Fosha emphasizes that the patient gets better through a process of affective mastery attained in the working through of attachment disturbances. Fear motivates restriction and constriction. Therapy offers a chance to alter the relative balance of fear and security, and affirms the process of growth/transformation of the self.
Technically, anxiety management is facilitated through application of a schema known as The Triangle of Conflict, mastery of which underpins all the S-TDPs. We will spend some time throughout this course on the technical applications of the triangle of conflict. [This course is explicitly NOT a course in the Davanloo techniques.]
In emphasizing core affective states, Fosha makes several important points:
1. Experience has a physical signature. Disembodied utterances [from a patient] never reflect core affective states.
2. Core states build from, but are different from, the core emotions [=categorical emotions] such as anger, joy, sadness, surprise, and disgust.
3. Core state is manifest by effortless focus and concentration. It reflects the selfs holding environment Note the embedded assumption that core states require prior exposure in a healthyactual and phantasytwo person holding environment.
Video tape I./discussion Adjustment Disorder
Session #2 April 15th, 2002
Because it is the necessary context for all therapeutic work on affects, the theme of relatedness and attachment run through Foshas work. Alonenessunwanted and unwilled alonenessin the face of overwhelming emotional experience is a key factor in the development/ intensification of psychopathology. Positive affects mark and make attachment, closeness and connection.
She emphasizes certain clinical lessons drawn from infant observation studies between mothers and babies:
1. Reparative tendencies are mutual as mother and baby attempt to restore contact Healthy infants seem to be in sync with mother no more than 30% of the time. There is a constant oscillation between attunement, disruption, and repair [reparation] in the moment-to-moment coordination of affective states.
2. The principal difference between the optimal and pathological dyad is how disruptions and negative affects are handled.
Therapy is thus necessarily a process that is achieved by the clinical couple, from which springs further emotional competence.
Roughly, there are three aspects to the achievement of affect mastery by the patient in the therapeutic dyad:
Undoing the restrictive/constrictive forces of fear (anxiety) and shame (self-constriction, the inhibition of core state and an expansive pride-filled self).
A process of mourning the costs (to the self) of (prior) self-constriction. In therapy the self is supported in a special form of intimate relationship (one which reflects and encourages self reflection) while tolerating experiences of emotional pain. Attending to visceral and deeply felt emotions, pressures a spontaneous de-repression of painful experiences. And, of course, the resultant healing induces new capacities to tolerate emotional pain and to develop empathy for the self.
Therapy entails a process of transformation of the self (the opposite of mourning, yet never without being preceded by mourning/grief-filled states) as a consequences having been touched by a true other [the prototypical self-less self-object].
1. The patient then, feels emotion, moved, touched (affect)
2. The patient feels gratitude (relationship component)
3. The patient develops a capacity for love and tenderness (mutuality/intimacy).
Integrating the attachment and emotional issues, Fosha contrasts the Affects of Coordination (the healing affects) to the Affects of Disruption.
The affects of coordination
1. Vitality affects [the alive self]
2. Relational affects [the we affects; resonance]
3. Affective resonance results when the self registers both the effect of the other on the self and the self on the other
4. Result in receptive experiences- feeling helped, being taken care of.
The affects of disruption
1. The categorical emotions of anger, sadness, disgust
2. To be out of contact is distressing. Feeling angry or sad leads to even bigger emotional loops and threat of lost control.
3. Transient disturbance in parent/therapist dyad [e.g. baby pulls mothers hair who momentarily gets angry]
4. In optimal dyads, disruption motivates reparative efforts
5. In pathological dyads, disruption leads to disconnection, aloness, and failure to metabolize disruption.
The goal of therapy is to establish mutual coordination [the alliance] aiming toward increased capacity for relatedness, and increased capacity to regulate emotion. Therapy must undo defenses against affect, relatedness and receptiveness. This requires
1. Moment to moment attunement
2. Use of the therapists affect
3. Promotion of patients visceral experience.
Video tape 2/ discussion [tentatatively, depression]
Session #3 April 22, 2002
Patricia Coughlin Della Selva on working the triangle of conflict from, I-STDP Theory and Technique pp 6-19.
Videotape/discussion (tentatively, working with anxiety/somatization)
Session #4 April 29, 2002
Working with the resistance to feeling
Discharge through tantrums and
Videotape/ Discussion (tentatively, explosive discharge)
Supplementary reading/ References
Bowlby, J. (1982). Attachment and loss: Vol. 1. Attachment (2d ed.). New York: Basic Books.
Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York : Basic Books.
Darwin, C. (1872/1965). The expression of emotion in man and animals. Chicago: University of Chicago Press.
Davanloo, H. (1990). Unlocking the unconscious: Selected papers of Habib Davanloo. New York: Wiley.
Della Selva, P, (1996), Intensive Short-Term Dynamic Psychotherapy: Theory and Technique, Wiley
Fonagy, P.(2000) Attachment & Borderline Personality Disorder, JAPA 48:4, 1129-1146
Fosha, D. (2000a). The transforming power of affect: A model of accelerated change. New York: Basic Books.
Fosha, D. (2000b). Meta-therapeutic processes and the affects of transformation: Affirmation and the healing affects. Journal of Psychotherapy Integration, 10, 71-97.
Hesse E,& Main, M (2000), Disorganized Infant, Child & Adult Attachment, JAPA 48:4, 1097-1128
Insel, T. and Young R. (2001). The neurobiology of attachment. Nature Reviews Neuroscience 2: 129-36
Jones,J.M. (1995). Affects as process. Hillsdale, NJ: The Analytic Press
McCullough, L (2001), Desensitization of Affect Phobias in Short-Term Dynamic Psychotherapy, in Short-Term Therapy for Long-term Change, Solomon, Neborsky, McCullough et al, eds. Norton
Main M, (2000), The Organized categories of Infant, Child & Adult Attachment, JAPA 48:4, 1055-1096
Pally, R. (2001) The Mind-Brain Relationship. London: Karnac Press.
Tomkins, S.S. (1962). Affect, imagery, and consciousness: Vol 1. The positive affects.New York: Springer.
Tomkins, S.S. (1962). Affect, imagery, and consciousness: Vol 2. The negative affects. New York: Springer.