Trauma & Attachment Therapy

Trauma Treatment Handbook: Protocols Across the Spectrum

My copy of the new book arrived today. Here is what Diana Fosha says about it:

"This is a thorough, accessible, and very practical book, filled with resources and sound ideas, filtered through the intelligence and experience of a savvy, compassionate, down-to-earth, and very experienced clinician. It is like a travel guide to the land of trauma and trauma treatment: if you are new to it, it will orient you to all there is to do and see; if you're a frequent traveler, it is a worthwhile reminder of all that is out there, above and beyond the familiar places you always visit. Once could ask for a better guide. I highly recommend it."

I explain trauma, complex trauma, dissociation and how to assess them and prepare for treatment, and all the kinds of treatment that I know about from the main-stream to the obscure. I talk about working with military, sexually-abused, and relationally traumatized people, and how to take care of yourself while doing the work.

 Some of my heroes comment on it. Dan Siegel wrote the introduction, despite my lack of research. Diana Fosha, Stephen Porges, Kathy Steele, and Onno van der Hart wrote very nice blurbs on the back. I'm humbled by their support.

This is the first book written completely by me. I'm amazed to be responsible for synthesizing so many people's therapies in one book. The design is great, and the photos, by Doug Plummer (my beloved) are gorgeous.

Positive Affect

Happiness, Joy, Giggles, Aha!s,Shared Humor. What place does positive affect have in therapy? In my opinion, a big one. Delving deep and bringin to consciousness avoided trauma responses, anxiety, anger, hatred, and shame are important elements of any therapy. First you find them, then you process them in some way, so that the client is neither run by their defenses against these affects, or by the affects themselves. But where do go from there? Stephen Gilligan says it's Life's job to make every human being experience every feeling that any human being could feel, and that it's each human's job to allow those feelings to flow through, unimpeded. (workshop, 1996). That includes the positive affects.

When I do EMDR, good feelings often spontaneously arise as the client clears the traumatic experience. When a client says, "I just feel so much relief, now!", the therapist says, "Go with that!" and processes it, like any other experience. The "Installation Phase" of the Standard Protocol, includes bringing the client's positive cognition "in" while applying bilateral stimulation. I often boost that with a direction to "bring that into every cell of your body." In David Grand's Brainspotting, you might have the client visualize a color that goes with the positive affect, and watch it grow as you clear the other not-so-fun affects and experiences.

In AEDP, Diana Fosha's technique, you might ask, "What was it like to share that happy moment with me and to know that we both were feeling it at the same time?" (acknowledging intersubjectivity) This "nails in" the experience to both the reasoning/verbal left brain  and the emotional right brain, while it enhances the affect. In AEDP, therapists share their internal good feelings about the experience of the client. "I'm deeply touched that. . ."  "I got a warm feeling right here when you said . . ."

Most of us use positive affect spontaneously. We smile at the client in the waiting room and exchange how nice it is to see each other. We laugh at the ironies of life, together. We celebrate victories. I'm quite fond of handshakes or high fives when a client reports success from their week. "The nightmares are gone." "I finally stood up to my coworker." "I really felt out from under it this week."

Sometimes a client who has made great progress will report anxiety upon feeling better. Some folks, with truly horrible trauma, may experience terror or nasty introjected abuse, upon "feeling better". On further exploration, you will often find that

• They don't have much experience of positive affect and lack much right brain wiring for its regulation. (In which case you need to bring more and more experience of it into the room and let them coregulate it, with you. "Bring that in, breathe deeply, ground yourself. What's that like."Do it a lot.)
• They weren't mirrored in it as kids. (See above, also a lot.)
• They were punished by an anxious parent who couldn't tolerate high spirits. (Clear it!)
• They live with someone who because of their own childhood issues, can't tolerate joy or giggles in their partner. (Clear it and teach differentiation.)

There is a difference between real joy and joking or fake happiness as a defense. I have an aquaintance from an alcoholic family who is happy, happy, happy. Underneath she's pretty angry and terrified. Those feelings leak out sometimes. She's been in therapy for about a year and is starting to get congruent, and much easier for me to be around.

When I have a client who is charming me with defensive "unreal" "positive" affect, I might say, "Stop for a moment. Scan your body now, and notice what sensations are there. Is there something underneath this story? What's the feeling?" It's always there. With someone else, I might say, "I usually feel connected to you, and I don't now. Is there something inside that you're not connecting with?" When they burst into tears, it's hard not to say, "Bingo!"

From the minute I see the clients in the waiting room, until they walk out of my door, I'm ready to share in whatever authentic affect they experience. I'm always on the lookout for the "good stuff". Always wanting to enhance it and bring it to consciousness. If they have no capacity, we spend many sessions building it. If it's scary, we clear the fear. With some people, we collaboratively use humor to regulate otherwise intolerable traumatic incidents.  Client: "It completely sucked! My childhood was a horror movie!" Me (in snotty adolescant voice) "Well, yeah!"  The client laughs, and dives back into the horror show for more processing, crying as he goes through it, and connecting with me, throughout.

When I work with couples, I'm on the alert for signs of collaborative joking, giggles, shared smiles. If there isn't any, I know that they're in trouble. I ask about it. "When did the laughter go away?" That usually brings jointly shared authentic sadness into the room, a place of connection. And a place to start from.

Diana Fosha's "Transforming Power of Affect"

The Tranforming Power of Affect (Basic Behavioral Science, 2000) is the best therapy book I've read in many years. It is a readable, comprehensive, and creative survey of attachment research and how to apply it to your adult clients. Diana Fosha comes from the Short Term Dynamic Therapy lineage of Davanloo and Malan, and adds to it attachment-informed use of self to help propel clients forward. I have no training in STDP and just a little in AEDP, Fosha's Accelerated Experiential-Dynamic Psychotherapy. The book gave me tools I can use.

The book group liked it. Most of us found the prose a bit dense, but understandable. All of us said that our work had already changed from the reading. We agreed that her therapeutic lens included attachment awareness, affect awareness, and the therapist's own relational experience with the client. Her techniques were many, and way cool. We are now all finishing our sessions with, "What was that like to do this piece of work together?" We are either feeling validated for how we already use ourselves in the sessions, or doing more of it. This therapy puts the space between the client and the clinician in the center of awareness and process.

What does Fosha do that I like: She uses her self. She uses the body. She teaches attunement. She teaches several new ways to make sense of the client's material/behavior. She keeps clients in their experience. She is collaborative with her clients. She's real. Her therapy is backed-up with research and it is (informed) intuition. Her descriptions of human interactions are exquisite. And her asides in describing interactions with patients can be quite funny.

I do think that Fosha uses process awareness as a kind of dual attention. I like that, it works. AEDP processes relational trauma, pretty well. I think EMDR is more efficient for many kinds of trauma. (I know that Fosha is trained in EMDR and uses it on occasion, though it's not mentioned in the book.) There is no overt mention of dissociation, though she discusses the phenomenon as defense and "disorganized attachment." Her techniques have caused some of my most dissociative clients to "disappear". I think AEDP can help keep other, less dissociated folks in the room.

I'd like to be able to explain the techniques, but, they are so nuanced, that I fear to put broad, unexplored, descriptions on this blog. Read the book. Six good therapists in Seattle think you should. If you have seen Fosha speak at conferences and were unimpressed, read the book anyway. She's one of the few people who writes better than she talks. If you are going to take Fosha's 5-day AEDP immersion class, read the book first, you'll get more out of the class. The videos in the class are worth the price of admission. I think if you simply watched the videos, you'd become a better therapist, though you might not know why. It's good stuff.