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.

UCLA Trauma Conference Synthesis

I escaped the conference yesterday, and am typing in the dark this morning beside my snoring husband. I can’t see my notes, so let me tell you my impression of the conference:

Trauma impacts the right hemisphere of the brain. Helpful trauma therapy targets the right brain. Left brain cognitions and interpretations don’t have much impact on the right brain. (So said Alan Schore in 500 quotes, yesterday.)

How do we, as therapists, help traumatized people heal? We use our attuned relationship with them to keep them present and socially engaged. If they are socially engaged, now, they’re in a meyelenated ventral vagal state and can’t go dorsal/shut down /immobilized or too ventral/ mobilized/ hypervigilant. Connect. Attune. Not just with your words: "I hear you say that you’re scared." Attune with your body. "I feel your fear in the room." Then help your clients locate that sensation. "Where is it in your body?" Then stay connected with them as they mindfully explore what it’s like to be scared, while connected to you, and tracing the affect through their body. If you’re Pat Ogden, you will have your clients try out the movement that they didn’t get to do when the bad thing happened. (I have a movement tx background and incorporate this in what I do.) If you’re Diana Fosha, you’ll use the power of your connection and your brilliant countertransferential language to do hold the clients in your therapeutic embrace while they move through the trauma. (I use her language all the time – in the moment self-disclosure as containment and dual attention, cool stuff.) If you’re Francine Shapiro, you will make sure that client have a deep, attuned connection with you, while bringing cognitions, affect, and sensations into consciousness, applying periodic eye movements, and deeply connecting during the breaks between, while the clients watch their minds clear the trauma. If you’re Dan Siegel, you’ll teach your clients mindfulness, so that they can get fully present, so that they can socially engage, be present with the trauma, and let it move through with whatever techniques you use. If you’re Bessel van der Kolk, you might do any of the above, and you’ll send them to Yoga class, to become re-embodied.

What are the threads that run through this varied work?

1. Presence. Getting into the here and now experience of body, affect, and thought. That includes clients being inside the Window of Tolerance: not overstimulated, not immobilized (dorsal vagal), not over-mobilized (unmeyelenated ventral vagal). Present and capable of connection so that the work can move through them.

2. Dual Attention: In EMDR, it’s the bilateral stimulation. In Yoga and in Ogden’s work it’s the attention to bodily experience. In Fosha and good relational analytic work it’s the relationship that keeps one mind on the present and the other on the traumatic past.

3. Affect while in relationship: In all of this work, clients have affective experiences while "held" inside the window of tolerance and a therapeutic relationship. It’s not that the affect is "discharged", though it might be. It’s that it is felt; not avoided; witnessed; survived; and transformed into a memory, no longer a developmental catastrophe.

4. Relationship with self and the other: Tolerance for one’s own affect and history. Capacity for relating to others.

You have just read the thesis of my next book, Trauma Therapies. I already had it, and was validated and heartened by what I heard, every moment. The next wave of therapy is Right Brain, Mindful, Affective, Embodied, and Relational.

The husband is up and it's time to go. I'm on vacation for the rest of the week. Imagine me bird and scenery-watching on the California coast, self-regulating with no set schedule. I want to see a Condor, this time.

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.