The Emergence and Consolidation of Joy, Hope, Gratitude and Confidence in (the Solid Goodness) of the Self Eileen Russell, Ph.D. & Diana Fosha, Ph.D.
Journal of Psychotherapy Integration, 2007 (in press)
Eileen Russell, Ph.D.
Faculty, The AEDP Institute
156 Fifth Avenue, suite 325
New York, NY 10010
Tel: 212 714-5003
Diana Fosha, Ph.D.
Director, The AEDP Institute
80 University Place, 5th floor
New York, NY 10003
Tel: 212 645-8465
Abstract. Positive affects in the context of positive dyadic interactions are fundamental to mental health and the development of the self, and are here considered from within the vantage point of Accelerated Experiential Dynamic Psychotherapy (AEDP), an attachment and emotion model of psychotherapy. We explore three phenomenological/affective/behavioral sets of positive affects –mastery affects, healing affects, and core state--in the context of positive dyadic interactions and understand their adaptive values by referencing the realms of attachment, intersubjectivity and affective neuroscience. We detail an experiential process in which the regulation of painful emotion in the context of a positive dyadic therapeutic relationship naturally culminates in the emergence of positive affects and positive emotional states, which in turn are vehicles for accessing emotional resources and resilience associated with resilient functioning and emotional flourishing. Detailed transcripts from two videotaped sessions are microanalyzed so as to delineate the moment-to-moment phenomenology and dynamics of the AEDP therapeutic process and to document the spontaneous emergence of these positive affective phenomena in a therapeutic context designed to make the most of their therapeutic effectiveness.
“…affect regulation is not just the reduction of affective intensity, the dampening of negative emotion; it also involves an amplification, an intensification of positive emotion, a condition necessary for more complex self-organization. Attachment is not just the re-establishment of security after a dysregulating experience and a stressful negative state; it is also the interactive amplification of positive affects, as in play states” (Schore, 2003, pp. 143-144).
Positive affective interactions and the positive emotions they evoke are the stuff of which a healthy self is built (Damasio, 2003; Keltner & Haidt, 1999; Panksepp, 2001; Schore, 2001; Shiota et al., 2004; Seligman, 2002; Trevarthen, 2001).Yet negative emotions have long had the lion’s share of clinical attention. With treatments focused on the alleviation of suffering and symptoms, the exploration of patients’ strengths, accomplishments, and joys have received short shrift. Viewed as end products of successful therapy, positive emotions have rarely been the objects of process-oriented clinical interest; as a result, a major therapeutic resource has gone untapped. In this paper, we argue that relieving suffering through transforming the negative affects associated with it is essential but not sufficient. To maximize its effectiveness, the therapeutic enterprise must also deal, with equal rigor, with the positive affects associated with experiences of transformation, growth and connection. Thus, the current focus on positive emotions in clinical practice is welcome and overdue.
Work with positive affects has been central to the theory, techniques and practice of AEDP (Accelerated Experiential Dynamic Psychotherapy: Fosha, 2000b; Fosha & Yeung, 2006; Lamagna & Gleiser, in press; Tunnell, in press). In AEDP, therapeutic work with positive affects (a) is part and parcel of day-in, day-out, moment-to-moment psychotherapy; (b) is deemed necessary, in that positive emotions also need to be regulated and experientially processed; and (c) has been shown to make a substantial contribution to improving the individual’s functioning, resilience, relatedness, and joie de vivre.
In this paper, we discuss and illustrate three types of positive affective experiences-- masteryaffects,healing affects (both examples of the transformational affects), and core state-- each of which has the potential to promote the development of different aspects of adaptive self and emotional experience. In Part 1, we briefly describe AEDP, focusing on (a) the role of positive emotions in its metapsychology; (b) its understanding of the separate mechanisms involved in undoing pathology and in healing; and on (c) the three phases of the process involved in working with intense emotional experiences to completion, focusing on somatic markers, invariably positive affects, moment-to-moment marking the process of transformation. In Part 2, we use conceptual and empirical advances in developmental studies, attachment theory and affective neuroscience to formulate our understanding of the role that positive emotions play in optimal development and therapeutic healing. Part 3 will show AEDP in action. We microanalyze therapeutic transactions from two videotaped sessions and illustrate how the three types of positive emotions under consideration here organically emerge from therapeutic work aimed at helping patients process heretofore difficult emotions to completion, working together with a sympathetic, helpful, emotionally engaged other.
AEDP: Theory and Practice
The concepts of the transformational affects and core state were developed in the context of the clinical practice of AEDP. While its technical origins are in the world of the experiential Short-Term Dynamic Psychotherapies (STDPs), AEDP’s attachment- and emotion-based metapsychology, its healing orientation and, interestingly enough, its explicit focus on positive emotions and positive dyadic interaction is precisely what distinguishes AEDP from the other experiential STDPs (e.g., Coughlin Della Selva, 1996; Davanloo, 1990).
Working in an experiential dynamic therapy characterized by an affirming, explicitly empathic, emotionally engaged stance (Tunnel, in press) and focused on the dyadic regulation of intense emotional experiences (Fosha, 2001, 2003) has led to us to a phase-specific phenomenology (Fosha, 2002; Fosha & Young, 2006) and phase-specific interventions. We have identified what we call the transformational affects, a subgroup of positive affective experiences which emerge from and mark different healing transformational moments in the experiential processing of intense and difficult emotions, both negative and positive (Fosha, 2000a, 2005, 2006). We have also developed a set of interventions for working with them: through metatherapeutic processing --a process involving alternating waves of experience and reflection--the positive affective experiences that arise as an integral part of the healing process become the sustained focus of experiential exploration, leading to a cascade of transformations. This cascade in turn culminates in core state, a positive affective state of calm and centeredness in which integration and consolidation of changes takes place, and a coherent self comes to the fore (Fosha, 2000, 2005; Fosha & Yeung, 2006). To our knowledge, AEDP is unique in identifying these experiences, understanding their function, and developing specific technical interventions designed to harness their transformational potential in the service of better therapeutic results.
As an adaptation-based psychotherapy, AEDP takes as its premise two critically important assumptions. The first is that psychopathology reflects a person’s best efforts at adapting to an environment that was a poor match for the person’s emotional and/or self-expression. Thus, even the most self-destructive or disturbed presentations can be seen as manifesting hope, self-preservation and ingenuity. The second assumption, related to the first, is that positive affects are wired-in (a) agents, (b) markers, and (c) sequelae of transformational affective experiences that are healing. From the beginning, the AEDP therapist aims to build a secure attachment with the patient in which heretofore-believed-to-be-too-dangerous emotions can be experienced, deepened, and reflected upon. She does this through (a) an attachment-based therapeutic stance that is explicitly empathic, affirming, mutual, affect-regulating, and emotionally engaged, and (b) experience-rooted techniques that interweave relational, affective and integrative-reflective elements. The secure attachment creates a space in which previously warded off core affects can be accessed, and processed to completion, thus activating the healing and self-righting tendencies within them.
When most patients present for psychotherapy, their “best effort” adaptations, forged in earlier adverse circumstances, have become unwittingly self-destructive in their current life. The triangle of experience captures this phenomenon and what may be driving it. At the bottom
the triangle we find (a) core affects, (b) pathogenic affects, and (c) unbearable emotional states of aloneness (see Figure 1a). Core affects include categorical emotions such as grief, anger, joy, surprise, disgust, and fear, those wired-in complex phenomena identified by Darwin and others (1872/1965) as the “primary” colors of our emotional lives. Core affective experiences are adaptive, and, when processed to completion, invariably yield beneficial consequences for the individual. Pathogenic affects include experiences of fear, shame or intense distress that continue to be warded off. Unbearable states of aloneness include experiences that some patients have described as a “black hole,” i.e., the deep loneliness, despair, helplessness, and emptiness, which compound the original trauma.
Often, in explicitly traumatizing or ill-matched environments, the “stuff” at the bottom of the triangle does not get fully processed to resolution and healed. The experience of these things being touched elicits anxiety, traces of fear, or shame, which we see as “red signal affects.” They alert the person to danger and are sufficiently aversive in and of themselves to trigger the person’s characteristic defenses against emotional and/ or relational experience.
What we just described is the operation of the self-at-worst. However, under conditions that are self-friendly, sympathetic and affect-facilitating, a very different organization of self, the self-at-best, is activated (see Figure 1b). When it is somehow safe to experience and process core affective experience, there is a drop in inhibitory anxiety and there are few, if any, defenses. Instead of being threatening, situations that are potentially affectively charged can elicit interest and curiosity, maybe even glimmers of hope or excitement. The ethos of AEDP is to attempt to work with the self-at-worst from under the aegis of the self-at-best (Fosha, 2000b), and thus evoke the natural spontaneous strategies of resilient individuals (Tugade & Fredrickson, 2004).
In a safe and affect-facilitating environment, the process of working with emotion to completion is characterized by 3 states and 2 state transformations (see Figure 2), culminating in states marked by the positive affects that mark both self-at-best functioning and flourishing (Frederickson & Losada, 2005). Aiming for state transformations, our technical interventions --which due to space limitations, we cannot elaborate-- are determined by where we are and where
Inset Figure 2 here – 3 States and 2 State Transformations
we want to go. State 1 interventions aim to minimize the impact of defenses, alleviate the inhibiting affects of shame and fear, and facilitate the 1st state transformation. State 2 interventions focus on regulating the core affective experiences the patient is now accessing and processing them through to completion. The 2nd state transformation –from State 2 to State 3-- is effected through metatherapeutic processing --or metaprocessing-- of the experience the patient has just completed. The process culminates in core state (State 3), a state of calm and perspective, where affect and cognition come together and meaning is created
The directional flow of AEDP treatment is to always be moving down, as does sand through an hourglass. We move from defenses and inhibiting affects, to core affect and from core affect to core state. We invite the patient to experience the emotions that have been held at bay in the context of a dyadically-coordinated relationship so as to access a connection to self that is authentic and felt in the body. Core affect is the emotional-visceral complex associated with past experiences that have not been fully processed. When processed, the integration of previously warded off feelings, insights and associations leads to core state. Empathy and self-empathy, wisdom, clarity about one’s subjective truth, and generosity are the currency of the realm in core state. Patients talk about feeling open and having a sense of being grounded, solid, in flow, and at ease. They often say, “This feels like the true me.” In touch with one’s core self, which is invariably positive, the patient can now generate a coherent and cohesive autobiographical narrative, a capacity highly correlated with resilience and secure attachment (Main, 1999).
What facilitates the emergence of core state? First, the processing of core affective experiences releases adaptive action tendencies; those release valves that appropriately discharge the long held emotions from the body. For example, a person finally cries over the loss of a loved one whose death was never really mourned. Second, we encounter specific post-affective breakthrough affects such as relief, hope, and feeling lighter or stronger. Third, metatherapeutic processing of the just completed affective experience leads to the transformational affects (see Figure 2), which are another vehicle for the transition from State 2 (core affect) to State 3 (core state). Metaprocessing can lead to a process of mourning-the-self, a painful but liberating experience of self-empathy over what the self has lost either due to the limitations of others and/or to one’s own chronic defensive functioning. It may open one to the experience of affective mastery, the “I did it!” of therapy, which is accompanied by feelings of joy, pride, and confidence. It may be followed by a wave of healing affects: being moved, touched and emotional within the self and feeling love and gratitude toward the other. These often arise as result of having worked through some core emotional process, and the recognition and the therapist's affirmation of having done so.
These concepts will come to life in the transcripts of AEDP clinical work. But before we go to the videotape, so to speak, we wish to explore the foundations of these phenomena in the dyadic interactions of early life and in our phylogenetic past.
The Foundational Importance of Positive Affects and Positive Affective Interactions to the Development of a Secure, Healthy, Joyful and Competent Self.
Positive affective interactions and the positive affects they evoke are foundational to mental health and well being throughout lifespan. As Fredrickson’s broaden-and-build theory of postive emotions predicts, in fact, positive emotions widen the scope of attention, broaden behavioral repertoires, and alter people’s bodies in a positive direction as they are associated with increased immune function, cardiovascular benefits, lower cortisol, and reduced risk of stroke (Fredrickson & Losada, 2005). Furthermore, they “widen the array of thoughts and actions called forth (e.g., play explore), facilitating generativity and behavioral flexibility …[and] broaden [thought action]repertoires….Broadened mindsets carry indirect and long-term adaptive value because broadening builds enduring personal resources, like social connections, coping strategies and environmental knowledge” (Fredrickson & Losada, 2005, p. 679). The salubrious power of positive affect is potentiated by positive dyadic interactions between individuals in relationship of myriad types (Shiota et al., 2004).
In this section, we discuss three distinct positive affective phenomena and their occurrence in both the natural life cycle and in AEDP’s metatherapeutic processing: (1) the zestful pursuit of one’s interests and the exuberant exploration of the world; (2) the deep engagement in the pleasures of intersubjective contact; and (3) the calm and “knowing acceptance” of oneself and of one’s personal truth. In AEDP language, the first two phenomena are the mastery affects (joy and pride) and the healing affects (gratitude toward another and feeling moved); both types of transformational affects. And the third is core state. All three are (i) the result of, (ii) marked and mediated by, and (iii) result in positive affect.
We link these three positive affective phenomena to developmental research (e.g. Trevarthen, 2001; Tronick, 2003), affective neuroscience (e.g., Davidson, 2002; Panksepp, 2001; Porges, 1997), attachment theory (e.g., Schore, 1994, 2003) and research on positive emotion (Dalai Lama & Cutler, 1998; Fredrickson & Losada, 2005; Keltner & Haidt, 1999; Seligman, 2002; Shiota et al., 2004; Tompkins, 1963b; Tugade & Fredrickson, 2004). Particularly relevant to us is the finding that complex positive affects experienced in the aftermath of the processing of intense painful emotion --what we call the transformational affects and core state-- are highly correlated with positive outcome in therapy (Bridges, 2005).
Positive Affects and the Exploration of the World: The Mastery Affects of Joy, Play, Interest-Excitement, and Delight.
“Regulated affective interactions with a familiar, predictable, primary caregiver create not only the sense of safety, but also a positively charged curiosity that fuels the burgeoning self’s exploration of novel socioemotional and physical environments…. This ability is a marker of adaptive infant mental health” (Schore, 2003, p. 144).
We propose that this “positively charged curiosity” is a marker of mental health across the lifespan. For adults, as well as children, the amplification and regulation of these positive states by a caring other is critically important to the self’s ongoing development, the discovery of new capacities, and the healing of old losses and personal deficits.
Allan Schore (1994, 2001, 2003), writing extensively about neuropsychological development and attachment, describes the “practicing” period in infancy. Occuring somewhere between 10 and 16 months, it is characterized by high levels of positive hedonic affect (Schore, 1994). He notes its temporal concordance with the cognitive ability to represent the self, the physical ability to stand and walk, and the maturation of the prefrontal cortex, an area of the brain critically involved in mediating social and emotional behavior.
Caregiver behavior during the practicing phase is overwhelmingly characterized by affection, play, and caregiving. The mother delights in the baby’s discoveries and emergent new capacities and this is fundamental to their amplification and regulation. The child’s behavior is exploratory and assertive, his orientation is toward the world, and the characteristic affective tone is joyful, exuberant and expansive. Such interactions, characterized by playfulness, and delight, have an enormously salutary impact on brain development and new learning, and are critical to the formation of healthy attachment bonds to the caregiver, which, in turn, affect functioning and resilience (Panksepp, 2001; Schore, 1994, 2001, 2003).
We observe a similar “practicing” period for adults in psychotherapy, particularly evident in the process of healing and the nascent discovery of new capacities within the self. In this practicing period, as patient and therapist focus on the experience of healing , the therapist has a unique window of opportunity to amplify positive feelings and positive self states, by mirroring, affirming, valuing, being playful, praising, and, a fortiori, explicitly sharing her own positive feelings. This is especially important for patients who have learned to repress or mitigate positive feelings (as well as negative feelings) about the world and the self. Experiences of joy, pride, and excitement (i.e., the mastery affects) are also often repressed, discouraged, or shamed in less than optimal family environments. Helping patients feel these feelings and share them with another provides them greater access to all emotional states and increases their willingness to expose these states to others with whom they are in relationship. It contributes to the development of their resilience, as having easy access to experiences of interest, eagerness, and excitement – what we call the mastery affects—distinguishes naturally resilient people from those low in the trait (Tugade & Fredrickson, 2004).
Positive Affects and Intersubjective Contact: The Healing Affects of Gratitude, Tenderness, and Feeling Moved.
The healing affects are the second type of transformational affects we examine. They arise especially in interpersonal contexts of pleasure and intimacy where, in addition, there is the unexpected healing of old wounds. These include experiences of feeling moved within the self and of gratitude, love and tenderness toward another. Developmental researcher Colwyn Trevarthen focuses similarly on the positive affects associated with pleasurable intersubjective contact and their importance to mental health. While contributing to the establishment of attachments, intersubjective motives are not subsumed under the rubric of attachment, in that they are not fueled by the need for safety and protection. Instead, they reflect the inborn need for human relatedness in and of itself, as evidenced by the wired in pleasure in response to simply knowing and being known. Trevarthen (2001) posits an inborn “need for joyful dialogic companionship, over and above any need for physical support, affectionate care and protection,” (p. 99-101).
AEDP’s healing affects are transformative precisely because such positive intersubjective meeting was inconsistent or absent in the past (Fosha, 2000a, b; Fosha, 2005; Fosha & Yeung 2006). While phenomenologically and experientially pure (i.e., no anxiety or defense), the healing affects have contrast embedded in them. They arise in response to experiences that disconfirm expectations, i.e., experiences of contact where isolation was before, of kindness when indifference or malice were expected, of being taken seriously rather than being dismissed. What we call the healing affects, along with compassion, awe, and empathy, are being called the quintessentially human affects not only by Trevarthen, but also by Damasio (1999), Emde (1988), Tronick (2003), and others.
In AEDP, reparative experiences are intrasubjective, intersubjective or both. In the former, the focus is to process emotion to completion. In the latter, the goal is to have the therapist and patient connect in such a way that the previously unbearable can be born; that the abyss of aloneness is bridged. Through dyadic regulation, what could not be processed in the past, can finally be processed in the here-and-now. This process simultaneously releases the adaptive action tendencies of the previously repressed emotions and restores intersubjectivity. Shame turns into vitality, fear into excitement, and withdrawal into grateful, tender contact. Isolation undone, the thirst for human contact and engagement can once again motivate behavior. Explicitly processing these newly restored reparative intersubjective moments accesses resources and resilience, and releases the cascade of transformations, eventuating in core state.
Positive Affects and Core State: Calm, Confidence, Knowing Acceptance and Personal Truth
The transformational affects are marked by a sense of movement: something is changing, something new is emerging. In contrast, core state is marked by calm stillness: there is a sense is of having arrived. In this state of calm, there is a sense of personal truth, the capacity to deeply engage the world, and a confidence that one can act on behalf of the self or seek help when the limits of one’s own resources have been reached. Seeking to understand the adaptive origins of core state takes us to affective neuroscience and the importance of the parasympathetic nervous system in affective regulation. We hypothesize that what is happening during the shift from core affective processing to core state is a shift from sympathetic nervous system dominated high arousal states to parasympathetic nervous system low arousal states. Low arousal states are adaptive because, compared to high arousal states, their cardiovascular toll on the body is low, and thus they are energetically conservative.
We are again struck by a parallel between this kind of shift and what Schore (1994) has observed as a more prolonged development in infancy. Following the early practicing period (10-13 mos.), marked by sympathetic excitatory processes of the autonomic nervous system, low-arousal states become more common (around 14 mos.) and may contribute to the growth of parasympathetic cortical structures. This appears to be due, in part, to the caregiver’s increasing behavioral controls in response to the child’s increased physical capacities.
Porges (1997), in his work on the evolution of the autonomic nervous system and its adaptive significance for emotion regulation, sees phenomena and interactions involving the ventral vagal complex (the vagus being the primary nerve of the parasympathetic system) as reflecting the most evolved stage of development. In what he calls the polyvagal theory of emotion, Porges traces the phylogenetic development of emotional responses to threat from the primitive freezing response, to the fight/flight response, to communicative prosocial expressive strategies. The primitive freezing response is mediated by the dorsal vagal complex (primitive parasympathetic) and the high arousal fight/flight emotions are mediated by the sympathetic nervous system. The differentiated affective expressive responses that promote social behavior and communication are mediated by the ventral vagal complex, the most evolutionarily advanced branch of the parasympathetic nervous system:
“The third stage, which is unique to mammals, is characterized by a myelinated vagal system that can rapidly regulate cardiac output to foster engagement and disengagement with the environment. …It is hypothesized that the mammalian vagal system fosters early mother-infant interactions and serves as the substrate for the development of complex social behaviors. In addition, the mammalian vagal system has an inhibitory effect on sympathetic pathways to the heart and thus promotes calm behavior and prosocial behavior” (p. 62). “ ”…[B]y rapidly reengaging the vagal system, mammals can inhibit sympathetic input to the heart and rapidly decrease metabolic output to self-soothe and calm” (p. 68).
Any system that links the heart with breathing, crying, sucking, swallowing, vocalizing and the muscles of facial expression, as does the ventral vagal, seems singularly suited to the task of integrated emotional expression and face-to-face dyadic communication. Behavior mediated by the energy-conserving, low-arousal, reduced cardiac output parasympathetic system maximally allows for the rapid moment-to-moment shifts and fluctuations that attuned communication and attuned sequences of engagement and disengagement require. Highly textured and differentiated expressive emotional communication using face, voice, eyes, tears, and breath in a state of calm, with low expenditure of energy, and maximal contingent responsiveness and variability (all mediated by the ventral vagal) is thus maximally adaptive to survival.
While it is something of a jump to go from phylogenetic development to moment-to-moment emotional regulation of dyadic communication in therapy, the parallels hold. In the state of parasympathetic calm and relaxation that follows in the wake of fully processing high arousal emotions, positive affective phenomena predominate and integration becomes possible. This is borne out in the work of Bridges (2005) who has empirically demonstrated that when the high-arousal intense emotions are processed, there is a sudden drop in the heart rate (signaling the shift to parasympathetic mediation) and a state of peaceful calm ensues in which integration as measured by the Emotional Experiencing Scale (Klein et al., 1969) reaches its highest levels. Furthermore, patients feel good. Their ratings of positive affect experienced in such sessions are correlated with high levels of satisfaction and sense of progress, as well as with high measures of working therapeutic alliance, all of which, in turn are highly linked with positive outcome (Bridges, 2005). In this way, we go from the sympathetic excitement of practicing, mastery, connection and intersubjective meeting, to the attuned parasympathetic calm, curiosity, compassion and meaning-making of core state.
The regulation of high arousal negative states leading to low arousal positive emotional states, marked by low cardiovascular requirements and engagement in meaning making activities, is a strategy that, as Tugade and Fredrickson (2004) rigorously demonstrate, characterizes highly resilient individuals. It is noteworkthy that through AEDP’s method of experientially processing intense emotions to completion and metaprocessing the transformational experience involved in reaching core state, we activate the maximally adaptive organismic strategies. We are nurturing resilience where it was previously compromised. A resilient self can more fully participate in the zestful exploration of the world, the intersubjective companionship of self-other, and the calm in which truth, personal meaning and a core sense of self emerge. In turn, these positive experiences of self and the world strengthen resilience.
AEDP Work with Positive Emotions in Clinical Action: Excerpts from Two Sessions from the Therapy of Responsible Dan
The patient is a 34 year old man whose presenting complaint was extreme anxiety and panic symptoms following his recent engagement. His history was remarkable for the sudden death of his father in an accident when he was 13 years old. His mother never had to work after her husband’s death. While loving, she was not a strong guiding force in his life, refraining from giving him advice, as she did not feel qualified due to her own lack of experience. Two months into treatment, Dan ended his engagement, realizing that he had proposed more out of obligation than desire.