Meta-therapeutic processes and the affects of transformation: affirmation and the healing affects

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Diana Fosha

Derner Institute for Advanced Psychological Studies, Adelphi University, Garden City, New York. Correspondence should be addressed to the author at 80 University Place, New York, NY 10003.


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Diana Fosha

80 University Place, 5th floor

New York, NY 10003

Tel: 212 645-8465


When successful therapeutic experiences themselves become the focus of therapeutic inquiry and work, it becomes possible to deepen and broaden the treatment’s effectiveness. The systematic exploration of phenomena associated with therapeutic change --through exploring the patient’s experience of having a therapeutic experience-- activates meta-therapeutic processes associated with characteristic affects of transformation. The aim is to raise the consciousness of therapists of all orientations, a fortiori those interested in integration, of the therapeutic potential inherent in the exploration of such non-denominational processes. First, three meta-therapeutic processes -acknowledging mastery, mourning-the-self, and receiving affirmation- and their respective affective markers -joy, emotional pain, and the healing affects- are identified. Then, the focus is on the dynamics of the affirmation process and the phenomenology of the healing affects. Therapeutic benefits of and possible sources of resistance to receiving affirmation -in both patients and therapists- are discussed. In the last part of the paper, a transcript of a clinical vignette illustrates integrative therapeutic work with the response to affirmation and the experience of the healing affects.
KEY WORDS: meta-therapeutic processes; healing affects; receptive affirmation; therapeutic change.


As therapists, bringing about change is our raison d’être. In our different orientations, we conceptualize mutative agents variously, and then, through our interventions, seek to activate them in order to bring change about, thus alleviating suffering and helping our patients lead fuller, richer lives. What I am interested in exploring in this paper is what happens when we achieve our goals, i.e., what happens once the patient has been substantially helped, once significant change for the better has occurred. What happens when patients do experience our empathy and do feel understood? What happens when patients are able to overcome a phobia and (re)gain a sense of freedom in their lives? What happens when, through deep experiencing of previously unbearable affects, patients are able to achieve mastery and work-through traumatic pasts? What happens when --through treatment-- depressions lift, anxieties are mastered, personality restrictions are overthrown, symptoms disappear, maladaptive patterns are replaced by adaptive ones, and previously feared situations become opportunities for demonstrating mastery? What is usually the endpoint of the therapeutic road is the starting point of this investigation. This is the beginning of a new phase where meta-therapeutic processes and the affects of transformation that are their markers can come into operation, providing an opportunity to deepen and broaden the treatment’s effectiveness.

In considering meta-therapeutic processes at what is often taken to be the end of the therapeutic road, I am also, of course, putting forward a particular view of what constitutes an essential therapeutic process that I have elaborated elsewhere (Fosha, 1995, 2000; Fosha & Osiason, 1996; Fosha & Slowiaczek, 1997). Suffice it to say here that this view of therapeutic change, like many integrative experiential therapies (see Gold, 1996, Chapter 6), places the experience of affect in the context of an emotional relationship at the center of its understanding of psychic development and therapeutic process; it does so within a development-informed psychodynamic conceptual framework. This article concludes with a brief overview of this psychotherapeutic approach, Accelerated Experiential/Dynamic Psychotherapy, in the context of presenting an illustrative vignette with a moment-to-moment analysis of the clinical material from a therapy session.

Regardless of the therapist’s model, in any therapy that is going well, the patient (and the therapist too, it is important to add) experiences a sense of accomplishment. Successful therapeutic experiences --be they in the moment or the cumulative results of a course of treatment-- provide the opportunity for the next round of therapeutic work. The focus shifts to the patient’s experience of having a therapeutic experience, thus the name meta-therapeutic processes. These processes themselves are associated with characteristic affects, which I have called the affects of transformation, as they are the markers for processes of therapeutic change. Acknowledging mastery, mourning-the-self and receiving affirmation are the three major meta-therapeutic processes.

  • In the process of acknowledging mastery, the patient is in contact with his success in overcoming obstacles that stood in his way before. This a fortiori applies to patients’ active and successful efforts at change (Bohart & Tallman, 1999a; 1999b; Gold, 1994, 1996; Hubble, Duncan, & Miller, 1999). The affective markers most common to mastery and its acknowledgment are the categorical emotion of joy and the feelings of exuberance, pride and happiness (Kissen, 1995; Perls, 1969; Tomkins, 1962).

  • In the process of mourning-the-self, the therapeutic experience activates the patient's awareness of what he didn't have, what he lost and what he missed. Similar to the work of mourning (Freud, 1917; Lindemann, 1944; Volkan, 1981), the work of mourning-the-self involves facing and working-through the impact of the painful reality that resulted in the patient's psychic suffering. The affective marker associated with the process of mourning-the-self involves the experience of emotional pain, which is a grief whose object is the self (Fosha, 2000).

  • The process of receiving affirmation is the other side of the coin of the mourning process. It involves fully acknowledging, feeling and working-through the emotional reverberations of therapeutic experiences, i.e., those experiences that led to the alleviation of the patient's suffering and to engendering his nascent and growing sense of well-being. The affective markers associated with being the recipient of affirmation are the healing affects, of which there are two main types: (a) feeling moved, touched or strongly “emotional” within oneself; and (b) feeling gratitude, love, tenderness and appreciation toward the affirming other.

Alternating Waves of Experiential and Reflective Work

The essence of making use of the meta-therapeutic processes lies in the experiential processing, patient and therapist together, of the patient’s reaction to changing and to having been helped in a useful and meaningful way. Patient and therapist together become involved in tracing the affective contours of their successful collaboration. The exploration involves alternating waves of experiential (Greenberg & Safran, 1987; Greenberg, Rice & Elliott, 1993) and reflective (Fonagy et al., 1995) work, in a manner akin to good public speakers who are advised to “tell them what you're going to do, do it, and then tell them what you've done.” What’s involved here is (a) facilitating a therapeutic experience, (b) naming and acknowledging it as such, and then (c) exploring the patient’s experience of the therapeutic experience. In ordinary language, what is being suggested is feeling and talking about feeling, and feeling what it’s like to talk about feeling, and so on. This way, it is not only that the patient has been successful and has been helped; he also deeply knows that he has been able to have a success and that he has been helped, which contributes to self-efficacy and capacity to trust. The patient also has access to how he experiences that success and help and to what they mean to him. The process of change itself is thereby identified and marked for the patient as a coherent experience and thus becomes an accessible part of his affective-cognitive-behavioral repertoire. Experience, reflection and meaning-construction --all in a relational context-- are all integral aspects of meta-therapeutic processing.

Therapeutic Opportunities Residing in the Therapeutic Exploration of the Meta-Therapeutic Processes.

How is the focus on the meta-therapeutic processes and their associated affects of transformation clinically useful? Why draw attention to them? There are several reasons:

First, by explicitly elaborating the meta-therapeutic experiences, rather than allowing them to operate silently, we give our patients the opportunity to process, and thus learn about, the nature of experiences that are helpful to them, experiences where they have already been successful. This furthers the transfer of therapeutic learning to experiences outside of treatment; these processes then become something patients can reflect on. As the work of Fonagy et al. (1995) and Main (1995) has powerfully demonstrated, the capacity to reflect on one’s own experience, as well as on that of others, is powerfully related to resilience and psychic health.

Second, the acknowledgment of and focus on the impact of positive therapeutic experiences gives rise to specific clinical phenomena that themselves have enormous therapeutic potential as they tap the psyche's natural healing forces. This dual process is reflected in the two meanings of healing affects: they are markers for processes that are healing, and, they are affects which are healing in and of themselves. Experientially focusing on them leads to ushering in a state transformation where deeper resources are accessed, which include some of the following:

  • general awakening of the adaptive action tendencies released by the full experiencing core affects (Darwin, 1872; Frijda, 1986; Greenberg & Safran, 1987; Lazarus, 1991; McCullough Vaillant, 1997; Safran & Segal, 1990);

  • increased confidence and self-esteem;

  • access to states of well-being, calm, ease and relaxation

  • access to ‘true self’ states and experiences of aliveness, liveliness and authenticity (Ferenczi, 1931, 1933; Gendlin, 1991; Perls, 1969; Winnicott, 1949, 1960);

  • deepened capacity for intimacy and closeness (Davanloo, 1990)

  • true insight, i.e., deep knowing and clarity about the nature of one’s needs, difficulties, as well as a felt sense of one’s resources in being able to overcome them (Greenberg, Rice & Elliott, 1993)

  • increased empathy and self-empathy (Alpert, 1992; Jordan, 1991; Kohut, 1984; McCullough Vaillant, 1997).

Third and finally, having -and acknowledging having-positive affective experiences with the therapist help patients recover memories of positive relationships, vital to their psychic survival, but often forgotten or dismissed as unimportant. For example, work with a patient had focused on her deep grief and anger about her father's failure to understand, nurture and appreciate her (i.e., the process of mourning-the-self). In the course of doing the work, the patient was deeply moved by what she experienced as my loving interest in her, an experience she was encouraged to explore and articulate. Her experience with the therapist de-repressed long-forgotten memories of her father when he had been both very loving and very proud of her. She remembered a nickname he had had for her, which she had not thought of in years, and she remembered how proud she had been of his interest in her writing when, at the age of 6, she had declared herself an 'authoress.' The recovery of these positive memories allowed us to better understand her dynamics. She had had her father's love up until she lost it irrevocably and inexplicably during the latency years (the loss appeared related to the birth of another child, who became father’s favorite, as well as to the patient’s turning nine, the exact age at which her father had lost his father). While the loss of her father’s love and subsequent starkness of her relationship with both parents shaped her adult personality and concerns, the recovery of early memories of her father's love solidified her core sense of herself as good and worthy of love and understanding. It also shed light on the origins of her incapacitating fears of loss, which had inhibited her growth and development. These consolidating memories of a good past relational experience might never have been recovered without the meta-therapeutic focus on present relational experience.

The working-through of the meta-therapeutic processes and their accompanying affects of transformation is a major source of healing and one which, to my knowledge, has not been fully acknowledged in any other major therapeutic approach. This work can be seen as building on several strands characteristic of integrative therapy work. These include, but are by no means not limited to, work that recognizes the importance and therapeutic effectiveness of :

  • the patient as active healer (Bohart & Tallman, 1999a; 1999b), agent of change (Hubble, Duncan and Miller, 1999), and psychotherapy integrationist (Gold, 1994, 1996), thus emphasizing the importance of the recognition of mastery experiences through being attuned to and fostering “the clients’ perception of the relationship between their own efforts and the occurrence of change” through therapists’ drawing attention to and showing interest in the “client’s role in changes that occur during treatment” (Hubble, Duncan and Miller, 1999, p. 411);

  • affirming and valuing of the patient (e.g., Rice & Greenberg, 1991; Rogers, 1961; Wachtel, 1993);

  • being change- and strength-focused, rather than pathology-focused (e.g., Fosha, 2000; Gold & Wachtel, 1993; Greenberg, Rice, & Elliott, 1993; Hubble, Duncan and Miller, 1999; Rogers, 1961; Wachtel, 1977, 1993);

  • relational process factors in psychotherapy, for example, to only select a few, empathic attunement (Greenberg, Rice & Elliott, 1993; Stern, 1985), corrective emotional experiences (Alexander & French, 1946), disconfirmation of pathogenic beliefs (Reeve, Inck & Safran, 1993; Weiss & Sampson, 1986); repair of therapeutic ruptures (Safran & Muran, 1996; Safran, Muran, , & Samstag, 1994; Safran & Segal, 1990)

The experiential and reflective exploration under consideration here occur after these types of successful therapeutic experiences -be they patient-focused, therapist-focused or process-focused- have made their impact; possibly, the dyadic, mutual exploration of meta-transformational processes is a beginning of a methodology for exploring the mechanism of “magic” so gracefully evoked by Gold (1996, p 213-216).


In this section, first the concept of the true other as a counterpart to the concept of the true self will be introduced; then the process of receiving affirmation will be explored in detail, and the phenomenology of the healing affects described.

On the Concept of the ‘True Other’, the Relational Counterpart of the ‘True Self’

Winnicott's (1960) ‘true self,’ aside from its extraordinary importance as a construct for both patients and therapists, captures a certain essential quality of experience that is rarely encountered in pure form; nevertheless, it does exist experientially at those times we call peak moments. An experience-near construct, it is deeply meaningful for the experiencing self.

The ‘true other’ is the relational counterpart of the ‘true self.’ Like the notion of the 'true self,' the notion of the 'true other' describes a subjective experience: on those occasions when one person can respond to another in just the right way, that person becomes experienced for that moment as a ‘true other’. The action of the other is "true" to what is emotionally necessary in the situation, necessary being defined in the terms of the experiencing individual. The sense of the ‘true other’ has experiential validity, and it is important to both conceptually identify it and validate the individual's experience of it. It is related to Bollas’ (1987) concept of the “transformational object.”

For the most part, optimal functioning is characterized by the 'true-enough' self, a mixture of ‘true self’ stuff with some defenses, conscious (i.e., socially necessary) or unconscious (i.e., psychically necessary) thrown in. However, there are moments of experience and self realization when we have pure ‘true self’ experiences. These have been described as peak experiences, being in the zone, being in a state of flow , etc. Similarly, in relational optimal case scenarios of the responsiveness of the other, we have that other wonderful Winnicottian construct, the good-enough m/other. In the relational realm as well, there are peak moments throughout the life cycle when a particular other responds to one's self in such a way as to provide exactly what is needed, even when there was no awareness of the need prior to its fulfillment. These are peak relational moments. The phenomenon refers to an essential responsiveness, to a deep way of being known and understood, seen or helped, which is meaningful, attuned, appreciative and enlivening.

Therapeutically, it is not something to strive for, for it can only be genuinely spontaneous. But it is extremely important to be aware of and recognize the patient’s experience of the other as a ‘true other’, for the therapeutic potential residing in such experiences is enormous. By being with a ‘true other,’ the individual can more readily evoke and experientially connect with his authentic ‘true self.’

It is important to localize the ‘true other’ experience in the experiential moment and not mistake it for a claim of the perfection of the other or any other thing that smacks of idealization. The ‘true other,’ as I am using it here, has nothing to do with idealization; it has to do with responsiveness to need. It captures an experientially-accurate, in-the-moment assessment, given the impact of the other on the self at that given moment in the particular emotional predicament. It is real, actual, deeply felt, unmistakable. Idealization, which by definition implies distortion, would enter the picture only if the patient then went on to assume that ‘trueness’ is an invariant feature of the other, i.e., assumed the other to be in her everyday life an always-and-across-the-board true other, rather than a human being with frailties, faults, etc. Like its counterpart, ‘true self’ experiencing, ‘true other’ experiencing takes place in a state of deep affective contact. Unlike idealization, it is contingent, not rigidly fixed.

A wonderful example of how the sense of the ‘true other’ captures an experientially accurate assessment that bears no relation to idealization occurs in the movie Scent of a Woman. Colonel Frank Slade, played by Al Pacino, could not be a more frayed and contaminated individual. Narcissistic, arrogant, alcoholic and abusive, his blindness, isolation and alienation are the tragic consequences of a life-long severe character disorder. Charlie Simms, the other lead character played by Chris O’Donnell, is a young prep school boy with an endearing mixture of innocence and integrity. Through the vicissitudes of plot, a bond grows between the two, though Charlie has no illusions about Slade. There is a moment when Charlie faces a situation with a potentially disastrous consequences. It is at this precise moment that Slade comes forward for Charlie, and does so very effectively. Deeply understanding what Charlie needs, he provides it: he is there, he is effective when it counts and completely counteracts Charlie’s excruciating and poignant aloneness. At that moment, a lifetime of narcissistic pathology notwithstanding, Colonel Frank Slade is a ‘true other’ for Charlie Simms.

Now we are ready to consider the reception of affirmation. This meta-therapeutic process captures the experience of core affect of a ‘true self’ in relationship with a ‘true other’ (Fosha, 2000).

The Process of Receiving Affirmation and the Healing Affects: Having and the Processing of Good-Enough (and Then Some) Emotional Reality

In experiences that are deemed healing or therapeutic, suffering is relieved and well-being is brought about. While healing or therapeutic experiences by no means occur only within the confines of spaces formally deemed to be therapeutic, it is hoped that they more reliably occur within such spaces, which, after all, are designed to provide them. When they do occur within the therapeutic setting, it is crucial that they are recognized and that the most is made of their therapeutic potential.

Less familiar than the mourning process, the process of receiving affirmation can be a major pathway of therapeutic resolution. In contradistinction to the process of mourning-the-self, it involves processing the positive emotional consequences of ‘having’ (as opposed to ‘not having’. The process of receiving affirmation is activated by and involves the experience of having an important aspect of one’s self affirmed, recognized, understood and appreciated. The affirmation can apply to a deep recognition of one’s achievements or of one’s transformation; or it can inform and underlie the other’s actions toward the self.

Change for the much better is an essential aspect intrinsic to the affirmation process. A deep transformation occurs within the self as a consequence of being with another --a fortiori with a ‘true other-- rather than alone; of being seen, loved, understood, empathized with, affirmed; of being able to do that which was too frightening to do before; of being in touch with the aspects of emotional experience that were previously feared to be beyond bearing; and so on. As a result, one is closer to one's true, essential self, the self one has always known oneself to be. As one patient put it: “thank you for giving me back the self I never had.”

Being the recipient of deep affirmation elicits a highly specific affective reaction which has two aspects: feeling moved, touched, and strongly “emotional”, on one hand, and feeling love, gratitude, and tenderness, on the other. There exists no single word in the English language for this emotion, yet it has all the features of a categorical emotion (Damasio, 1994; Lazarus, 1991): a specific phenomenology (with presumably a distinct physiological profile), specific dynamics, a state transformation taking place and adaptive action tendencies being released upon its being experienced. Being a marker for therapeutic experiences, the label of healing affects seems apt. Its crucial elements are captured in the well-known hymn "Amazing Grace":

“Amazin’ Grace

How sweet the sound

That saved a wretch like me

I once was lost, but now I’m found

Was blind, but now I see”

The healing affects arise specifically in response to the alleviation of emotional suffering, to being seen or responded to just as one has always wished, as well as to one's recognition of oneself as --in that moment-- expressive, authentic and true to oneself. The healing affects register a change in oneself --"I was blind, but now I see"-- a strongly welcomed one. This change is either witnessed and understood by the other, and/or actually reflects the impact of the other upon the self.

The two types of healing affects differentiate two reactions that arise in response to feeling affirmed: Feeling ‘moved,’ ‘emotional,’ or ‘touched’ appear intimately linked with the recognition of transformation of the self toward greater authenticity; feelings of love, gratitude, appreciation, and tenderness specifically arise toward the affirming other. Darwin (1872) discusses the various aspects of what I call the healing affects, in a chapter titled "Joy, High Spirits, Love, Tender Feelings, Devotion."

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