“Draft:Accelerated experiential dynamic psychotherapy”的意思、由来-开放百科全书

Accelerated experiential dynamic psychotherapy (AEDP)is a form of psychotherapy that is primarily used to treat adults suffering the effects of childhood attachment trauma and abuse^[1]. AEDP is designed to activate the mind's innate drive toward healing by providing a healing emotional experience for the patient^[2]. The AEDP therapist creates a collaborative and especially affirming therapeutic relationship, providing a safe, supportive environment to help patients both access and successfully process difficult emotions which previously felt overwhelming.

The first publication on AEDP was Diana Fosha's book, The Transforming Power of Affect, published in 2000^[3] . Since then, the AEDP model has been expanded on in later publications by both Fosha and her colleagues.^[4]^[5]^[5]^[7].

AEDP is recognized as an effective treatment for complex post-traumatic stress disorder.^[6]^[7], and attachment disturbances in adults^[8]^[9]. AEDP is featured by the American Psychological Association in its psychotherapy training DVD Systems of Psychotherapy Series,^[10]^[11]..and Psychotherapy Supervision Series^[12]

Overview

AEDP proposes a theory of how emotional experiences in psychotherapy bring about positive change^[15]. Its core concepts are informed by contributions from the following sources^[13]:

1. Neuroscience research findings on neuroplasticity throughout the life cycle, showing that human beings are wired for growth and tend to actively seek growth opportunities^[17], informs AEDP’s concept of transformance, the wired-in motivation of the mind to heal and repair itself^[18]^[5].

2. Attachment theory, with its emphasis on the importance of the formation of a secure relationship between infant and caregiver to the child’s successful social and emotional development, informs (i) AEDP’s emphasis on the importance of co-creating safety and connection in the therapeutic relationship as a prerequisite for subsequent work with difficult emotions, and (ii) AEDP’s intentionally positive therapeutic stance of explicit empathy, affirmation, and emotional engagement.

3. Emotion theory and research has contributed the understanding of emotions as hard wired by eons of evolution into the brain, nervous system, and body, providing the primary channel of adaptation-enhancing self-to-self and self-to-others communication. Closely informed by emotion theory, AEDP therapy seeks to reconnect the person to unprocessed emotions that have been blocked due to trauma, and with therapist guidance, enable these emotions to be fully experienced and processed, aiming to recover each core emotion’s vital ability to inform and empower healthy, adaptive action^[14].

4. Developmental research into dyadic affect regulation, which has led to an understanding of the nature of the moment-to-moment emotional communication between mothers and infants, and the application of the insights of this work in AEDP's moment-to-moment work by which therapists seek to help their adult clients process difficult emotions in therapy^[15] .

5. Research into “broaden-and-build emotions^[22]”, the capacity of positive emotions to promote psychological resilience , well being, and flourishing, and to repair the physiologically stressful effects of negative emotions, is translated into AEDP’s focus on working systematically with the positive emotions that emerge when traumatic experiences are resolved.

6. Observations by Fosha and other psychologists that the process of positive change in therapy need not be linear, gradual and protracted, but can also be abrupt and discontinuous, and thereby especially potent^[23]^[24]^[18]

AEDP aims to correct what Fosha believes is at the root of almost all psychopathology: "the individual's unwilled and unwanted aloneness in the face of overwhelming emotional experiences," especially when those painful experiences involve one's caregivers in early life. Such traumatic states, and the negative emotions associated with them, are overwhelming to the child's developing brain and stressful to the nervous system, and undermine development of the capacity to regulate emotion.^[16]^[20] ~~^[7]~~

The caregiver's vital role regulating and soothing a child's emotional or physiological dysregulation is central to the development of a secure attachment bond.^[21] As dysregulated states cannot be endured in the absence of a soothing caregiver, the child's response is typically to dissociate (the detachment from conscious awareness) or use other protective strategies, such as various psychological defense mechanisms reference].While protective in the short-run, long-term reliance on dissociation and other psychological defense mechanisms can take a toll on an individual's social and emotional functioning, diminishing their resilience and compromising their wellbeing.

This emotional trauma typically results in the development of disorders of emotion regulation:^[22] dissociative disorders, affect phobia, debilitating shame,^[23] and compromised attachment relationships in adulthood.

Given that AEDP understands psychopathology as resulting from the individual’s aloneness in the face of overwhelming emotional experiences, undoing aloneness and the dyadic regulation and processing of emotional experiences, previously too overwhelming for the individual to deal with alone, are its overarching therapeutic aims. Always informed by an orientation toward identifying the manifestations of the capacity for healing within each individual, known in AEDP as transformance,AEDP seeks to engender new experiences of feeling understood, of recognizing and expressing emotional truths that previously have gone unacknowledged, and of integrating positive affective experiences linked to healthy action tendencies and resources. From the beginning and through the entire course of the therapy, the AEDP therapist seeks to facilitate corrective emotional experiences reference ] in which the client feels safe enough to allow core aspects of the self—previously shielded by defenses—to come to the fore to be met, helped and responded to, and to be reintegrated into his or her full emotional repertoire.

AEDP is a sequenced process.^[24] It begins with the essential requirement to establish a secure, affirmative, supportive and emotionally engaged therapeutic relationship^[25] through creating an empathic bond with the client, and then using that bond to help the client regulate difficult emotional states.^[26]

Once a secure therapeutic relationship is established, emotional processing, the exploration and integration of more painful emotions, can then be engaged.^[6][27][28] First, through the process of dyadic affect regulation, painful, overwhelming emotions are reduced to manageable intensity; then, with support and guidance from the therapist, the client is helped to experience and process emotions that were previously too painful to bear, but can now be dealt with.

Putting into clinical action concepts from emotion theory, AEDP proposes that this kind of integrated core emotional experience will activate a particular emotion's corresponding adaptive action tendency^[30].

The core emotions, such as anger, fear, grief, and joy, are expressive of a particular need to take adaptive actions: to protect, seek safety, come to acceptance of loss, or exuberantly connect and explore, respectively. These biologically hard-wired adaptive action tendencies provide clarity about what positive actions need to be taken, and if taken, lead to resilience, the capacity to recover quickly from difficulties, and to valuable feelings of well-being.

As a result, the individual's innate self-healing resources, previously hidden and offline beneath the defenses, can come to the fore, enhance the client’s capacity to adapt to their environment, and improve emotional and social functioning.

Fosha has observed that, when each emotion's adaptive action tendencies are brought to the client’s awareness and focused on, an ensuing release of positive emotions may follow, which AEDP terms transformational affects, such as mastery, "feeling moved", pride, joy, and gratitude.^[31]

At this point, AEDP introduces the technique of metatherapeutic processing, which is a methodology for working systematically with these transformational affects, the positive emotions associated with ‘change for the better’. The term "metatherapeutic processing" was created to describe the therapeutic activity that aims for the exploration and integration of the emotions associated with what is therapeutic, or healing, about therapy.

When, in the context of a secure, emotionally engaged therapeutic relationship, the emotional processingof negative emotions is followed by the metatherapeutic processingof positive emotions, the result is often a state of calm and flow, that Fosha calls "core state," in which therapeutic changes are consolidated.

Core state is characterized by the natural emergence of the same qualities of mind—well-being, compassion, self-compassion, wisdom, generosity, clarity—that mindfulness and contemplative practices seek to bring forth, providing an internal experience of coherence and a sense of completion.

In core state, a newly cohesive experience of self may be fostered. This experience of the self, featuring a balanced presence of emotions and thoughts, rooted in an awareness of the body and its sensations, is necessary for the sense of an integrated self to be developed.^[8][29]

Origins of the therapeutic model

AEDP is based upon a theory of what brings about change in psychotherapy, a theory that is informed by contributions from:

Theory of psychopathology

AEDP aims to correct what Fosha believes is at the root of almost all psychopathology: "aloneness in the face of overwhelming emotional experiences" that are traumatic, especially when those experiences involve one's caregiver. Traumatic states are overwhelming to the child's developing nervous system and undermine the development of emotion regulation capacities.^[22] The caregiver's vital role regulating and soothing a child's emotional or physiological dysregulation is central to the development of a secure attachment bond.^[23] As dysregulated states cannot be endured in the absence of a soothing caregiver, the child's physiological response is typically to dissociate (the detachment from conscious awareness)^[24] or use of other protective strategies (defenses). The developmental trajectory of this repeated trauma is typically evident in the disorders of emotion regulation,^[24] dissociative disorders, affect phobia, debilitating shame,^[25] and compromised attachment relationships in adulthood.

Application in therapy

AEDP is in part a sequenced process.^[26] It begins with the essential requirement to establish a secure therapeutic relationship^[27] through helping the client regulate difficult emotional states.^[28] Once a secure therapeutic relationship is established, the exploration and integration of painful emotion can then proceed.^[9]^[29]^[30] When painful emotions, once experienced as overwhelming, are modulated and then viscerally experienced and processed, a cohesive experience of self may be fostered. The concordance of emotions, cognition and physiology is necessary for a sense of an integrated self.^[7]^[31] AEDP theory posits that an integrated core emotional experience will activate the emotion's corresponding adaptive action tendency^[32] (for example, anger provides energy and focus, its adaptive action is toward protecting oneself or others; sadness has an inner directed adaptive action directing compassion toward oneself or others). Fosha observed that, when these adaptive action tendencies become the focus of therapeutic attention, an ensuing release of positive emotions, which Fosha terms transformational affects (such as mastery, "feeling moved", pride, gratitude) may follow.^[33]

Historical influences and contemporary divergences

Historical influences

Comparison of AEDP to contemporary psychotherapies

AEDP concurs with the traditional psychoanalytic premise that individuals develop psychopathological symptoms and defenses to ward off painful feelings.^[38]However, unlike psychoanalysis, AEDP does not presume that interpretation of the client's symptoms/defenses, along with the client's cognitive insight into defenses, is the primary agent of change. Instead AEDP focuses on identifying and amplifying the client's innate psychological resilience.

In contrast to intensive short-term dynamic psychotherapy, in which the therapist directly confronts the client's defenses or resistance, the AEDP therapist focuses on clearing the way for indirect reduction of defenses by cultivating conditions of safety within the therapeutic relationship.^[39]

Building on previous research demonstrating positive effects of a good therapeutic relationship on therapy outcome,^[40] AEDP emphasizes the therapeutic relationship as the driver of change. This includes the therapist's use of her own emotion, and her judicious use of self-disclosure.^[41] However, AEDP posits that expressions of genuine care do not by themselves facilitate change; rather it is the meta-therapeutic processing of the emotional effects of the relationship, as it is happening, that augment the change process.^[28] AEDP theorists claim that this emphasis on the therapist's expressions of care combined with meta-therapeutic processing of the client's experience of care is what distinguishes AEDP from other experiential and emotion-focused models of psychotherapy.^[28]^[42]^[43]

Key concepts

Transformance

Transformance is Fosha's umbrella term for the psychological processes underlying positive change. Transformance refers to each person's innate drive for growth, "self righting", and healing, and to the predictable sequence of an unfolding change process that AEDP aims to activate and facilitate (see {{section link||Map of the change process}} below). The term is derived from AEDP's treatment approach that focuses upon a patient's potential and resilience, as opposed to psychopathology.^[6] The most important aspects of transformance include experiences that are viscerally felt as new and emergent^[44] and the experience of amplified positive affect.^[64] In the AEDP model, "positive" refers to an experience that need not be "happy", but must feel right and true.^[45]{{rp|179}}

Meta-therapeutic processing

Meta-therapeutic processing, the cornerstone of AEDP methodology,^[28] involves reflecting upon experience, specifically upon a positive experience, as it is happening, within a therapeutic relationship.^[28] The intent is to maximize the experience of change, or transformation, by exploring the experience of having the experience^[46] as it is happening. For example, the therapist may ask, "What is it like for you to have had this deep emotional experience right now?"

According to AEDP theory, slowing down the emotional experience through moment-to-moment tracking allows the therapist to help the client maintain a well-regulated, as opposed to overwhelming, emotional experience (dyadic affect regulation).^[47] A second form of relational meta-therapeutic processing (dyadic affective reflective process) asks the client "What was it like to do this with me?",^[48] which further undoes the client's aloneness, while also strengthening the therapeutic relationship for further emotional work.^[30] Empirical studies confirm clinical observations that positive emotions tend to naturally arise following meta-therapeutic processing.^[28] Positive emotions facilitate the client's transformance and promote enhanced psychological resilience.^[49]^[50]

When doing meta-therapeutic processing, therapists emphasize "right-brain-to-right-brain" communication—that is, nonverbal communication including eye contact, facial expressions, features of voice such as emotional prosody, and other emotional expressions—between therapist and client. For example, rather than, "What are you thinking right now?" the therapist will say, "What are you feeling as you share this with me?", "Where do you feel this in your body?", and "What do you see in my 'facial expression' toward you?" This "right-brain-to-right-brain" communication aims to engage brain activity involved in secure attachment responses and behaviors.^[46]

Meta-therapeutic processing, which psychiatrist and psychoanalyst James Grotstein recognized as a technical innovation by Diana Fosha,^[38] was later incorporated into focusing-oriented therapy,^[51] a method of psychotherapy originally developed by Eugene Gendlin, whose ideas also influenced Fosha's development of AEDP.^[3]{{rp|146,173}}

Emotion

The ultimate aim of AEDP therapy is to enable free and safe access to one's emotions. The centrality of vitalized, regulated, and accessible emotion, unrestrained in expression cannot be overstated. Emotion is the primary source of information about the environment to the self, and about the self to the self, and is also the primary source of communication about the self to others. Clarity of expression of emotions, and a capacity for attunement to another's emotions, is necessary for social well-being and is essential in order to experience one's emotional life as coherent, adaptive and resilient.

Facilitating the transformational process of a full cycle of emotional processing, whether in a moment during a session, or within a larger period of growth (see {{section link||Map of the change process}} below), is what characterizes a typical AEDP therapy session.^[52]

Empirical studies demonstrate that AEDP's focus on emotions within the therapeutic relationship is associated with client improvement.^[50] AEDP has contributed to clinical and empirical evidence that the accumulation of positive emotional experiences can override negative emotions.^[53]

Map of the change process

Fosha posits that healing change occurs in progressive stages, termed "state changes", identifiable to the therapist by a patient's emotional and somatic shifts.^[54]{{rp|254–256}} States correspond to the client's progression from emotions that have been defensively blocked from awareness, to the visceral experience of the emotions, to the eventual integration of emotions. AEDP therapists are trained to identify the signs of state changes, track moment-to-moment shifts within and between each state, and to apply interventions to facilitate movement through four states and three state transformations, described below.^[45]{{rp|184}}

State 1

State 1 is marked by the protective defensives against with pathogenic emotional states such as shame or dissociated emotions. For example, when the client has learned that the expression of core emotions such as sadness or anger, leads to rejection, shame and self-loathing, emotions will become blocked from awareness and/or expression.^[3]{{rp|128}} At this point, dyadic regulation of the client's affect is necessary to modulate exposure to the previously forbidden emotions. Evidence of the client's resiliency and capacities are highlighted to ensure the client is sufficiently resourced for the work ahead. Psycho-education is important during this phase to help the client view symptoms as evidence of resourcefulness toward self-protection and in the service of the preservation of attachment relationships, as opposed to bearing a pathological view of self.^[55]

First state transformation

The first state transformation into State 2 is noted by heralding affects, such as a bodily expression of sadness, or indications, such as curiosity, that the client is experiencing relationship security. Heralding affects cue the therapist that the client is ready for exploration of undefended core emotions, within the dyadic regulating therapeutic relationship.

State 2

State 2 is marked by the client's immersion in the complete visceral experience of a core emotion, or a complex of emotions. The therapist encourages a visceral experience of emotion, and through dyadic affect regulation, ensures that the client's new experience of emotion remains tolerable. A core emotional experience will have a pattern of deepening toward affective/somatic/cognitive integration as it prepares the body for action. Each core emotion has a biologically connected adaptive action tendency. For example, fear is crucial for survival and its adaptive action is to run from danger or toward protection; joy has an energizing quality, and an expansive outer directed adaptive action of promoting social interaction.^[56] Once an adaptive action is released (either through a self-affirmation, or through an experiential method called portrayal), positive affects follow. Positive affects mark the completion of the natural wave of the emotion.^[18]^[57] Clients may report a sense relief and lightness, which in AEDP are called the breakthrough affects.^[6] To consolidate the experience and to propel the client toward the next stage of transformational change, the AEDP therapists metaprocesses the completed round of core emotion with the client; i.e., the therapist will ask the client to reflect on what it was it like to just have had a powerful emotional experience, and equally important, will ask the client to reflect on what it was like to do so with the therapist.^[45]

Clients with complex trauma may present with core affective experiences that are phenomenologically distinct from the core affect described above.^[6] These are core affects such as shame, inhibitory emotional experiences that represent freeze states (or fright without solution) of trauma. Therefore, as explained below, interventions are not only state specific, but also specific to the nature of the affects presented, and are in consideration of the client's pattern of attachment, or attachment style.^[58]

Second state transformation

Breakthrough affects and the positive affective consequences of adaptive action tendencies being released are typically experienced in the transition from State 2 to State 3.

State 3

State 3 is devoted to the meta-therapeutic processing of (1) what has just occurred in the progression from State 1 defense to the experience of core affect in State 2, and (2) the positive emotions that emerge from this experience as it is facilitated by the therapist. This meta-therapeutic processing evokes its own set of transformational affects and is the focus of State 3.^[59] Transformational affects of State 4 include mastery affects (pride, joy), healing affects (gratitude, feeling moved), tremulous affects associated with the somatic experience of a change process as it is occurring.^[60] Without meta-therapeutic processing, the client simply has an emotional experience that may or may not lead to emotional healing.^[28]

Third state transformation

State 3 transformation into state 4 involves the experience of releasing the inhibitions a patient may have in receiving affirmation (receptive affective capacity). The ability to internalize the positive affirmation, and to allow self-affirmation, characterizes the transformational affects leading to State 4.

State 4

State 4 involves the immersion in the experience of core state.^[61] It involves continued meta-therapeutic processing of the positive transformational affects experienced in State 3.^[62] Core state is characterized by the client reporting a feeling of calm, vitality, a sense of wellbeing, compassion toward self and others, an expanded perspective, and wisdom.^[63] Core self state involves a coherent reorganized self-narrative. The ability to construct a "coherent and cohesive" self-narrative is shown to be highly correlated with secure attachment status in adulthood and with emotional resilience.^[64] The re-organzied self-narrative is evidence to the therapist that a corrective emotional experience has occurred.

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