RH: How does this help the client?
FOSHA: Let’s say a client’s depression lifts, or she resolves some piece of her trauma history, or her anxiety diminishes, or she feels understood in a new way. Usually, we proceed in therapy as if that’s a good thing, which it certainly is, but we now need to move on to focus on the next issue. In AEDP, rather than being an endpoint, that experience of change is treated as an entry point into the next round of processing.The therapist might say, “So, what’s it like for you to feel strong and clear? What’s it like for you to have your depression lift? What’s it like for you to feel vitality in your body?” This kind of metatherapeutic processing explores what’s therapeutic about the patient’s therapeutic experience and is a way of applying mindfulness to the actual experience of change. “Dyadic mindfulness” refers to mindfulness of both patient and therapist applied to their co-constructed interaction, which can also support healthy intimacy and closeness in the patient’s other relationships.
RH: Can you describe AEDP’s concept of transformance?
FOSHA: People often come into therapy traumatized, depressed, nervous wrecks; their relationships are in shambles, and their work is falling apart. They’re usually starting off with us in a terrible place, and it’s easy to focus on pathology. But at the same time, if you look closely, there are always glimmers of health, strength, and resilience, which is what we focus on in AEDP. That’s the idea of transformance—inside every individual, there’s a force that strives for healing and growth and self-repair. That force manifests in the motivation toward vitality, authenticity, and genuine contact, even in the face of trauma. It should never be overlooked, as it’s a huge ally in fostering therapeutic change from the get-go and throughout the therapy process.
RH: Even in our pain, there’s something in us reaching out.
FOSHA: Yes. Too often, therapists tend to ignore patients’ striving for growth and healing. The people who ask us for help are listening to that drive. Otherwise, they wouldn’t pick up that phone to make the appointment with the belief that something can change.
RH: I’m intrigued by this quote from your book: “Assumptions about the fragility of patients are often rationalizations for ineffective technique.” Can you explain?
FOSHA: I was initially trained in a psychoanalytic model in which the nondirective stance ruled. There was so much concern about the patient’s fragility or about doing damage with a premature interpretation or intervention that treatment often became unnecessarily prolonged. I believe our patients are often much more resilient than we might think, and we shouldn’t proceed on untested assumptions about their fragility.
I teach that the main unit of intervention isn’t what the therapist says or does, but rather what the therapist says or does and the patient’s response to it. If the patient’s response indicates fragility, then we work with that, based on the evidence we’ve just obtained; if the patient’s response gives us a green light, we proceed. That’s why the moment-to-moment tracking of experience is such a crucial part of AEDP.
RH: Let’s say a man comes to therapy and says he’s felt numb since his divorce a year ago. What would be some initial thoughts from an AEDP perspective?
FOSHA: Again, no thoughts! I have a colleague who jokes that you don’t have to be very smart to do AEDP because you don’t have to know anything! It’s true. You don’t have to be clever. But, of course, it’s not that I don’t have any thoughts—I may have 10 million. It’s that my thoughts don’t matter, since there’s so much going on inside the patient at any given moment. The right brain, the limbic system, and the autonomic nervous system all have minds of their own, so to speak. My interest is in how my patient’s experience is organized, and my job is to create conditions that’ll allow that unique organization of experience to reveal itself.
RH: So what might you say to this numbed patient?
FOSHA: I’d ask him to tell me about a specific, concrete example of a moment from his divorce or something that sticks out in his mind, and then explore with him what it feels like to tell me about this experience, what he feels in his body, and what he notices. From there, we could see where this exploration of his internal experience takes us and what it may have to do with the divorce or his numbness. As an AEDP therapist, I’m always on a mission of discovery with the patient, and we’re both finding things out for the first time. That process of discovery is so much more interesting than any hypotheses I might have.
RH: Your description of therapy reminds me of Irv Yalom’s idea of the therapist as a fellow traveler.
FOSHA: In a way. My phrase is “undoing aloneness”—the notion that the dyadic regulation of emotion is fundamental to the experience of good therapy. As therapists, we need to play different roles at different phases of the process. Sometimes you’re there as a companion and, at other times, a facilitator—all are aspects of “undoing aloneness.”
So much of what gets called psychopathology is just being overwhelmed by big emotions and feeling terribly alone in the world. There’s something about being together with someone who’s going to share it with you and lend a helping hand that can change the situation in a profound way.
Ryan Howes, Ph.D., is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs “In Therapy” for Psychology Today. Contact: rhowes@mind spring.com; website: www.ryanhowes.net. Tell us what you think about this article by e-mail at firstname.lastname@example.org, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine section.