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The effectiveness of accelerated experiential dynamic psychotherapy (AEDP) in private practice settings: A transdiagnostic study conducted within the context of a practice-research network

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  • The AEDP Institute

Abstract

Accelerated experiential dynamic psychotherapy (AEDP) is an integrative model of psychotherapy that brings together relational and experiential work, with the aim of not only alleviating suffering but also bringing about flourishing. The present study took place within a developing AEDP practice research network and examined outcomes for 62 self-referred adults treated using a 16-session format of AEDP treatment. Participants completed self-report measures before and following treatment. Measures assessed a variety of psychological problems, subjective distress, as well as aspects of positive psychological functioning. Treatment occurred in naturalistic independent practice outpatient settings in the United States, Canada, Israel, Japan, and Sweden. Large effect sizes (d > 0.80) were obtained for clinical problems and subjective distress. The majority of patients evidenced clinically reliable change according to Jacobson, Roberts, Berns, and McGlinchey's (1999) criteria. Effectiveness was further examined by dividing the sample into a clinical group with pervasive and severe problems and a subclinical group with fewer problems and mild severity. Within the clinical group, total and global scores on all measures improved significantly following treatment. Effect sizes were d > 1.00 for all scales. The subclinical group also demonstrated significant improvements, with effect sizes ranging from d = 0.46 to d = 2.07. These results provide initial empirical support for the effectiveness of AEDP as a model of therapy that can effect meaningful and significant improvements across a range of psychological symptoms. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
Psychotherapy
The Effectiveness of Accelerated Experiential Dynamic
Psychotherapy (AEDP) in Private Practice Settings: A
Transdiagnostic Study Conducted Within the Context of a
Practice-Research Network
Shigeru Iwakabe, Jennifer Edlin, Diana Fosha, Heather Gretton, Andrew J. Joseph, Sarah E. Nunnink,
Kaori Nakamura, and Nathan C. Thoma
Online First Publication, September 24, 2020. http://dx.doi.org/10.1037/pst0000344
CITATION
Iwakabe, S., Edlin, J., Fosha, D., Gretton, H., Joseph, A. J., Nunnink, S. E., Nakamura, K., & Thoma, N.
C. (2020, September 24). The Effectiveness of Accelerated Experiential Dynamic Psychotherapy
(AEDP) in Private Practice Settings: A Transdiagnostic Study Conducted Within the Context of a
Practice-Research Network. Psychotherapy. Advance online publication.
http://dx.doi.org/10.1037/pst0000344
The Effectiveness of Accelerated Experiential Dynamic Psychotherapy
(AEDP) in Private Practice Settings: A Transdiagnostic Study Conducted
Within the Context of a Practice-Research Network
Shigeru Iwakabe
Ochanomizu University
Jennifer Edlin, Diana Fosha, Heather Gretton
Andrew J. Joseph, and Sarah E. Nunnink
The Accelerated Experiential Dynamic Psychotherapy Institute,
New York, New York
Kaori Nakamura
Ochanomizu University
Nathan C. Thoma
Weill Cornell Medical College
Accelerated experiential dynamic psychotherapy (AEDP) is an integrative model of psychotherapy that
brings together relational and experiential work, with the aim of not only alleviating suffering but also
bringing about flourishing. The present study took place within a developing AEDP practice research
network and examined outcomes for 62 self-referred adults treated using a 16-session format of AEDP
treatment. Participants completed self-report measures before and following treatment. Measures as-
sessed a variety of psychological problems, subjective distress, as well as aspects of positive psycho-
logical functioning. Treatment occurred in naturalistic independent practice outpatient settings in the
United States, Canada, Israel, Japan, and Sweden. Large effect sizes (d0.80) were obtained for clinical
problems and subjective distress. The majority of patients evidenced clinically reliable change according
to Jacobson, Roberts, Berns, and McGlinchey’s (1999) criteria. Effectiveness was further examined by
dividing the sample into a clinical group with pervasive and severe problems and a subclinical group with
fewer problems and mild severity. Within the clinical group, total and global scores on all measures
improved significantly following treatment. Effect sizes were d1.00 for all scales. The subclinical
group also demonstrated significant improvements, with effect sizes ranging from d0.46 to d2.07.
These results provide initial empirical support for the effectiveness of AEDP as a model of therapy that
can effect meaningful and significant improvements across a range of psychological symptoms.
Clinical Impact Statement
Question: This study examines the effectiveness of accelerated experiential dynamic psychotherapy
(AEDP), a transdiagnostic treatment for psychological problems and positive psychological func-
tioning in independent practice settings. Clinical researchers and practitioners partnered in the
development of an AEDP practice research network (PRN) model. Findings: Findings support the
use of AEDP for a range of presenting problems and symptoms. Meaning: Results support the
clinical application of AEDP across a variety of psychological problems and functionings and
ongoing research using a PRN model. Next Steps: Future research will continue AEDP PRN
initiatives and partnerships in independent practice settings and will investigate maintenance of
therapeutic gains over a 6- and 12-month follow-up period.
Keywords: treatment outcome, emotion, transdiagnostic, accelerated experiential dynamic psychotherapy
(AEDP), practice research network
XShigeru Iwakabe, Department of Human Sciences, Core Research
Faculty, Ochanomizu University; XJennifer Edlin, XDiana Fosha,
Heather Gretton, XAndrew J. Joseph, and Sarah E. Nunnink, The Ac-
celerated Experiential Dynamic Psychotherapy Institute, New York, New
York; Kaori Nakamura, Department of Human Developmental Sciences,
Graduate School of Humanities and Sciences, Ochanomizu University;
Nathan C. Thoma, Department of Psychiatry, Weill Cornell Medical Col-
lege.
The authors wish to thank all of the patients and therapists who
participated in the study, the AEDP faculty members who consulted on
each treatment, and the researcher-clinician liaisons, all of whom con-
tributed to the strength and capacity of our PRN and without whom this
study would not have been possible. This work was supported in part by
2016 –2019 Grants-in-Aid for Scientific Research, Japan Society for the
Promotion of Science (Grant 16K04347) to Shigeru Iwakabe.
We have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to
Shigeru Iwakabe, Department of Human Sciences, Core Research Fac-
ulty, Ochanomizu University, Otsuka2-1-1, Bunkyoku, Tokyo 112-
8610, Japan. E-mail: iwakabe.shigeru@ocha.ac.jp
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Psychotherapy
© 2020 American Psychological Association 2020, Vol. 2, No. 999, 000
ISSN: 0033-3204 http://dx.doi.org/10.1037/pst0000344
1
Accelerated experiential dynamic psychotherapy (AEDP) is an
integrative model of psychotherapy that brings together relational
work, experiential techniques, and a focus on experientially work-
ing with the in-session experience of positive change (see meta-
therapeutic processing in the following text), with the aim of not
only alleviating suffering but also enhancing functioning and
bringing about positive flourishing (Fosha, 2000, 2017a; Fosha &
Thoma, 2020; Russell, 2015). Drawing upon research in attach-
ment, affective neuroscience, emotion theory, and positive psy-
chology, AEDP navigates the complex interactions between pos-
itive and negative emotions toward psychological growth and
adaptation (Fosha, Thoma, & Yeung, 2019). It has been clinically
developed and elaborated over the past 2 decades and has come to
be practiced by a growing number of practitioners worldwide, with
therapists on six continents, including therapists and patients doing
AEDP therapy in Arabic, Cantonese, Danish, English, Farsi,
French, German, Greek, Hebrew, Italian, Japanese, Korean, Man-
darin, Norwegian, Portuguese (as spoken in both Portugal and
Brazil), Romanian, Spanish, Swedish, and Turkish. The AEDP
Institute has trainings across the world offering experiential
courses in AEDP principles and techniques and also has a formal-
ized program for therapists wishing to be certified in AEDP and
also a formalized program for certification as AEDP supervisors.
AEDP is transdiagnostic in its focus: The model targets a set of
central psychopathological processes that are believed to underlie
a variety of diagnoses and symptoms, such as depression, anxiety,
and various maladaptive behaviors (Sauer-Zavala et al., 2017).
These psychopathological processes center on early life attach-
ment trauma and consequent disrupted capacity for emotional
processing, including the avoidance of adaptive emotion (Fosha,
2003). AEDP reframes psychopathology as arising from the indi-
vidual’s unwilled and unwanted aloneness in the face of intense
emotions, which then become too overwhelming to be regulated
and processed and necessitate reliance on defenses, which are
strategies instituted to avert overwhelming emotional experience.
Symptoms represent the maladaptive consequences of inflexible
defenses instituted to manage unbearable emotions in the absence
of effective dyadic affect regulation by primary attachment figures.
Accordingly, disorders such as depression, anxiety, and interper-
sonal problems are manifestations of common underlying difficul-
ties in attachment, emotional regulation, and emotional processing
and reflect reliance on emotional avoidance. Avoidance of adap-
tive emotion is seen as a key psychopathological process in other
transdiagnostic treatments, such as the unified protocol for the
transdiagnostic treatment of emotional disorders (Barlow et al.,
2011). However, rather than rely primarily on structured, skills-
based behavioral and cognitive strategies, which can be viewed as
a top-down approach to working with emotion, AEDP, with its
emphasis on moment-to-moment tracking and fostering of emer-
gent emotional phenomena, works bottom up. This parallels other
experiential and somatically focused therapies, such as emotion-
focused therapy (Greenberg, 2015) and somatic experiencing (SE:
Levine, 2008). AEDP adds to the experiential tradition a substan-
tial focus on in-session relational work by explicitly focusing on
processing the therapy relationship to rewire the internal working
model, work through defenses, create emotional safety, and ulti-
mately foster greater relational capacity.
In this way, AEDP is an experiential therapy that also remains
rooted in developmentally informed relational psychoanalysis and
short-term psychodynamic psychotherapies from which the ap-
proach originated (Fosha, 2000). However, AEDP differs from
more traditional models of psychodynamic psychotherapy that
emphasize the importance of transference interpretations to bring
about insight into the ways in which the past intrudes upon the
present (Levy & Scala, 2012). Instead, the focus on the therapy
relationship in AEDP is aimed at creating and calling attention to
here-and-now corrective relational experiences, thus using the
therapy relationship less as a source of insight and more as a
wellspring of healing new experience (Fosha, 2017b; Lipton &
Fosha, 2011). Explicitly affirming and celebrating what is right
and good about the patient rather than what is wrong is central to
the practice of AEDP, as is authentic relating through therapist
self-disclosure of immediate feelings instead of a more neutral
stance for uncovering unconscious material.
In addition, unlike traditional psychoanalytic models (Gabbard,
Litowitz, & Williams., 2012), AEDP does not seek to explore early
life events to uncover conflicted emotions. Rather, AEDP takes a
different approach: an experiential focus on deepening present-
tense affect can automatically link to early experience, unlocking
memories, child-based ego states, as well as a welling up of
emotion that was disallowed at the time. Allowing and accepting
the previously disallowed emotion becomes a healing experience,
alleviating symptoms such as anxiety and hopelessness while also
reducing the need for inflexible defenses and maladaptive coping
strategies that avoid emotional experience. AEDP’s aim is to help
patients become better able to experience their emotions and reap
their adaptive benefits.
AEDP further differs from other models of psychotherapy in
that it does not end its therapeutic process once emotions are
processed to their adaptive completion. There has been a growing
interest in the field of psychotherapy to focus on more than
reducing psychopathology and symptoms and to actively foster
positive emotion, positive experiences, and what Keyes (2002) has
called “flourishing” (see e.g., the recent special issue in this
journal, Volume 57, Issue 3). AEDP and additional approaches
such as acceptance and commitment therapy (ACT) can be con-
sidered fellow travelers in sharing the aim of moving beyond mere
symptom reduction and helping patients move actively toward
more meaningful living (Hayes, Strosahl, & Wilson, 2012). AEDP
shares an interest with ACT in helping patients cultivate their
personal values to bring greater clarity on how to live more
meaningfully. However rather than dialogic examinations of val-
ues (Luoma, Hayes, & Walser, 2007), AEDP uses a technique
called metatherapeutic processing to work with incipient positive
emotion within session by focusing upon experiences of therapeu-
tic change that have just taken place (Fosha, 2009; Fosha &
Thoma, 2020). In AEDP, the experience of change is itself con-
sidered to be a mechanism of change. Emotions such as pride, joy,
serenity, delight, gratitude, and compassion for self and others
frequently arise as patients notice and savor their here-and-now
experience of healing (Iwakabe & Conceição, 2016). These posi-
tive emotions, called “transformational affects” in AEDP, bring
with them clarity in values and priorities as well as the motivation
to pursue meaningful actions. These positive emotions can them-
selves become the object of further metatherapeutic processing,
forming an upward spiral that broadens patients’ mindset, in-
creases resilience, and builds their inner resources and capacities
(Fosha & Thoma, 2020; also cf. Fredrickson, 2013; Iwakabe &
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2IWAKABE ET AL.
Conceição, 2016). The bottom-up, experiential technique of meta-
therapeutic processing (or sometimes simply “metaprocessing” for
short in the AEDP literature) is also what distinguishes AEDP’s
work with positive emotion from positive psychology and positive
psychotherapy, which mainly use top-down, structured induction
exercises to bring about positive emotion (Seligman, Rashid, &
Parks, 2006). For clinical examples of AEDP, including transcript
material demonstrating the use of metaprocessing, see the case
studies in Fosha (2004, 2009) and Fosha & Thoma (2020).
Thus, AEDP is an integrative psychotherapy that brings together
many principles and elements of interest to the field in a unique
way. It has also generated considerable enthusiasm among its
growing base of practitioners worldwide. However, empirical in-
vestigations of AEDP have only just begun. Several systematic
case studies have been conducted (Gonzalez, 2018; Markin, Mc-
Carthy, Fuhrmann, Yeung, & Gleiser, 2018). Qualitative research
has used task analysis to describe the stages of metaprocessing and
the way metaprocessing can be used to broaden and build positive
emotion within session (Iwakabe & Conceição, 2016). A random-
ized controlled trial of an Internet-based psychotherapy for anxiety
and depression based on AEDP principles showed moderate-to-
large effects (Johansson et al., 2013) and a similar Internet-based
trial targeting social anxiety disorder showed large effects (Johans-
son et al., 2017). However, a direct test of the efficacy or effec-
tiveness of AEDP had as yet not been conducted. The present
study was aimed at testing the effectiveness of AEDP.
Bridging Practice and Research
We decided that testing outcomes within the natural environ-
ment of independent practice settings was an ecologically valid
approach to assessing AEDP treatment within the context in which
it was developed and is currently practiced. To do so, we devel-
oped a practice research network (PRN; Castonguay, Barkham,
Lutz, & McAleavy, 2013). Setting up a PRN was also a way to
establish an enduring connection between practice and research
among AEDP therapists and a culture of researcher–practitioner
partnership (Castonguay et al., 2013). We sought to assess the
effectiveness of AEDP within a transdiagnostic research context,
working with patients who self-referred with a wide variety of
problems and symptom profiles rather than restricting our assess-
ment to pure-form DSM diagnoses, which some have argued are
not as generalizable to real-world practice (Westen, Novotny, &
Thompson-Brenner, 2004). Because of the transdiagnostic nature
of this study, we used outcome measures that tapped a wide range
of psychological problem areas, including depression, anxiety,
emotional avoidance, emotional dysregulation, and interpersonal
problems along with positive indicators of mental health including
self-compassion and self-esteem that were relevant to assessing the
effectiveness of AEDP in a comprehensive manner (Barkham,
Lutz, Lambert, & Saxon, 2017; Cuijpers, 2019).
We hypothesized, first, that AEDP is an effective model of
treatment, achieving clinically significant improvement on pa-
tients’ general psychological symptoms, depression, and subjec-
tive distress with a large effect size. Second, we hypothesized that
experiential avoidance will improve, that is, lessen, at a similar
magnitude, as enhancing patients’ emotional functioning through
helping them become increasingly able to experience their adap-
tive emotions is one of the key components of AEDP. We pre-
dicted that interpersonal relationships, though not a primary focus
of AEDP treatment, would be improved as a result of AEDP’s
positive affirming therapeutic relationship and explicit relational
work. Furthermore, positive psychological functioning such as
self-compassion and a sense of well-being will improve to a
similar extent with AEDP’s emphasis on enhancing positivity via
metatherapeutic processing in addition to alleviating psychological
distress. In sum, we hypothesized that a large effect size will be
obtained for all outcome scales.
For feasibility as well as greater comparability with outcome
studies of other psychotherapy models, we modified the treatment
duration to be standardized at 16 sessions. In practice, AEDP
treatment duration is determined by collaboration between thera-
pist and patient, and can range from very short-term to longer term
work. However, the AEDP model needed relatively little modifi-
cation to fit the time-limited format due to the AEDP ethos of
“healing from the get-go” (Fosha, 2017a). That is, AEDP applies
the same principles and techniques throughout the treatment, in-
cluding from the first moments of the first session, relying on
therapist responsiveness to the patient’s needs and emotional ca-
pacities at any given time, seeking to maximize the possibilities of
positive change at each moment, calibrating the work to the
patient’s present-tense level of functioning. The work focuses on
enhancing glimmers of positive affect, facilitating deep emotional
experiencing, dyadically regulating dysregulated emotions, or
working through entrenched defenses that protect more vulnerable
parts of the self, depending on what emerges from the patient. For
clinical examples of working with patients of varying degrees of
difficulty, see the studies by Vigoda Gonzalez (2018) for work
with a patient with major depression, Fried (2018) for work with
a psychotic patient, and Piliero (2020) for work with a patient with
complex posttraumatic stress disorder (PTSD). The main way in
which the treatment was modified to fit the fixed number of
sessions offered for the purposes of this study centered on inte-
grating Mann’s (1973) principle of calling attention to the finite-
ness of the treatment from the start of treatment and maintaining
awareness of this finiteness throughout, making this awareness an
integral and active part of the treatment (Harrison, 2020).
Method
Patients
The AEDP PRN is an ongoing research program. For this study,
we used the initial data, gathered between June 2016 and Novem-
ber 2019. Patients were 62 (20 men and 42 women) self-referred
adults who completed the 16-session AEDP treatment in indepen-
dent practice settings. Demographic information is shown in Table
1. The patients ranged in age from 22 to 72 years (M36.8, SD
13.52). Prospective patients contacted AEDP therapists in inde-
pendent practice requesting services for common psychological
difficulties, such as depression, anxiety, and interpersonal difficul-
ties. Individuals involved in another treatment, or who started or
withdrew from medication within 3 months of participation in the
study, were excluded to control for confounding effects. Addi-
tional exclusion criteria included the following: (a) active suicid-
ality; (b) addiction and substance abuse; (c) psychosis and severe
impulse disorders; (d) prior dissociative identity disorder (DID),
bipolar disorder, or moderate to severe autism spectrum diagnosis;
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3
EFFECTIVENESS OF AEDP IN PRIVATE PRACTICE SETTINGS
and (e) a current crisis situation requiring immediate crisis inter-
vention (e.g., intimate partner violence). Severe impulse disorders
were excluded because of the strong possibility that such problems
would be better addressed by a behaviorally oriented treatment and
the possibility that strong emotions experienced in sessions may be
acted out. Moderate-to-severe autism spectrum diagnosis was ex-
cluded due to uncertainty whether such persons, who are often
highly concrete and emotionally constricted, would make good use
of this emotionally focused treatment. DID, and bipolar disorder
were excluded due to concerns that short-term treatment would not
be sufficient for such diagnoses and ethical concerns led us to refer
such patient to longer term treatment. Inclusion criteria included a
level of distress as measured by the Target Complaint (Battle,
Imber, Hoehn-Saric, Nash, & Frank, 1966) score, for the main
presenting issue, of at least 6 or 7 (very much) on a 15-point Likert
scale. One year into the research project, we decided to also screen
out those patients who had two or less problems that reached 1 SD
of elevation from the normal population mean on a total of 16
clinical scales. The decision was made to make the reduced-fee
therapy available for those who needed it most and also to further
ensure that we were testing the model on those with clinical levels
of problems. Those who did not meet our criteria were given
referrals to other appropriate professionals. All therapy sessions
were conducted in English. All patients and therapists were fluent
in English, though in some cases, English was not their first
language.
Measures
In keeping with recent calls for comprehensive examination of
therapeutic outcome (Barkham et al., 2017; Cuijpers, 2019), we
included measures that were associated with four different out-
come targets: a subjective measure of distress and change; mea-
sures of psychological symptoms (e.g., Beck Depression Inventory
[BDI], Symptom Assessment-45 [SA-45]), measures of positive
mental health, and measures of subjective well-being, as well as
secondary measures associated with the change mechanisms of
AEDP.
Subjective measure of distress. Target Complaints (TC; Bat-
tle et al., 1966) is used to assess main problems and the level of
associated subjective distress as experienced by patients. They were
asked to write down three issues they would like to see change as a
result of therapy. They were then asked to rate each of the three
problems on a 12-point distress scale (ranging from 1 [not at
all]to12[couldn’t be worse]) in terms of how distressing the
problem. The TC was administered pretreatment. Posttreatment,
the same three complaints initially identified were given and
patients rated the current intensity of distress of each of the
three problems. Battle et al. (1966) reported good test–retest
reliability as well as high correlations of the TC with other
outcome measures.
Measures of psychological symptoms. BDI (Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961) is a self-report measure of
depression, widely used in psychotherapy outcome research. The
BDI is shown to be highly correlated with other self-reported
measures of depression as well as clinicians’ ratings of depression.
The coefficient alpha in the present sample was .91.
SA-45 (Davison et al., 1997) is a shorter version of the Symp-
tom Checklist-90 (Derogatis, Rickels, & Rock, 1976) a widely
used measure of different symptoms. The SA-45 consists of 10
symptom indexes: nine 5-item scales assessing each of the same
Table 1
Patient Characteristics at Pretreatment Baseline
N(%)
Variable Total Clinical Subclinical
N62 39 23
Gender
Female 42 (67.74%) 26 (66.67%) 16 (69.57%)
Male 20 (32.26%) 13 (33.33%) 7 (30.43%)
Age M(SD/range) 36.81 (11.87/22–72) 34.49 (9.64/22–65) 40.74 (14.31/22–72)
Self-identified ethnic or cultural background
White 45 (72.58%) 25 (64.10%) 20 (86.96%)
BIPOC 14 (22.58%) 12 (30.77%) 2 (8.70%)
No response 3 (4.84%) 2 (5.13%) 1 (4.35%)
Highest level of education
Primary school completed 1 (1.61%) 0 (0.00%) 1 (4.35%)
Secondary/high school completed 7 (11.29%) 5 (12.82%) 2 (8.70%)
College/university completed 33 (53.23%) 23 (58.97%) 10 (43.48%)
Postgraduate degree 21 (33.87%) 11 (28.21%) 10 (43.48%)
Primary work status
Employed 52 (83.87%) 32(82.05%) 20 (86.96%)
Student 7 (11.29%) 5 (12.82%) 2 (8.70%)
Homemaker 2 (3.23%) 2 (5.13%) 0 (0.00%)
Unemployed 1 (1.61%) 0 (0.00%) 1 (4.35%)
Marital status
Married/common law 27 (43.55%) 15 (38.46%) 12 (52.17%)
Single 28 (45.16%) 20 (51.28%) 8 (34.78%)
Divorced or separated 4 (6.45%) 3 (7.69%) 1 (4.35%)
Other 3 (4.84%) 1 (2.56%) 2 (8.70%)
Note. BIPOC Black, Indigenous, and People of Color includes people who self-identified as Lantinx, Black, Asian, Middle Eastern, Israeli, or
multiracial.
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4IWAKABE ET AL.
symptom domains as the Symptom Checklist-90 and a Global
Severity Index, calculated by summing the scores of nine sub-
scales. For the present sample, coefficient alpha for Global Sever-
ity Index (GSI) was .94, and for subscales, it ranged between .63
(Psychoticism) and .95 (Depression).
Inventory of Interpersonal Problems-32 (IIP-32; Barkham,
Hardy, & Startup, 1996), a 32-item measure, assesses the severity
of problems in interpersonal functioning (Horowitz, Rosenberg,
Baer, Ureño, & Villaseñor, 1988). All items are answered using a
5-point scale, ranging from 0 to 4. The original IIP includes 127
items tapping into eight dimensions of interpersonal functioning.
The shorter version was developed to allow for greater conve-
nience in administration in clinical practice and research. Barkham
et al. (1996) concluded that hardly any of the psychometric prop-
erties of this short version were inferior to a full 127-item scale.
The coefficient alpha in the present sample in this scale was .91.
Automatic Thought Questionnaire (ATQ; Hollon & Kendall,
1980), a 30-item instrument, measures the frequency of automatic
negative statements about the self. The five subscales include the
following: Demoralization, Self-Criticism, Brooding, Amotiva-
tion, and Interpersonal Disappointment. The ATQ demonstrates
excellent internal consistency with a coefficient alpha of .97. In
this sample, we used a full-scale score with a coefficient alpha of
.97.
Difficulties in Emotion Regulation Scale (DERS; Gratz & Ro-
emer, 2004), a 41-item self-report measure, was designed to assess
clinically relevant difficulties in emotion regulation. It is rated on
a 5-point Likert scale. The four subscales include the following:
awareness and understanding of emotions, acceptance of emotions,
the ability to engage in goal-directed behavior when experiencing
negative emotions, and access to emotion regulation strategies. In
the present sample, the full-scale coefficient alpha was .95.
Acceptance and Action Questionnaire (AAQ-II; Hayes et al.,
2004), a nine-item self-report scale, measures experiential avoid-
ance, a tendency to avoid unwanted internal experiences. It is
significantly related to the tendency to suppress emotionally rele-
vant thoughts and feelings. Items are rated on a 7-point Likert
scale. The coefficient alpha in the present sample was .90.
Measures of positive mental health. Rosenberg Self-Esteem
Scale (RSES; Rosenberg, 1965), a 10-item scale, is one of the most
widely used scales for measuring global self-esteem. Items include
both positive and negative feelings about the self and are answered
using a 4-point Likert scale. The coefficient alpha for the present
sample was .91.
Self-Compassion Scale (SCS; Neff, 2003) consists of 26 items
that measure the ability to hold one’s suffering within a sense of
warmth, connection, and concern in situations of a perceived
difficulty. Items are rated on a 5-point Likert-type scale. The six
subscales are Self-Kindness, Common Humanity, Mindfulness,
Over-Identification, Isolation, and Self-Judgment. The coefficient
alpha for the full scale was .91 in the present sample.
Measure of well-being. Mental Health Continuum–Short
Form (MHC-SF: Keyes, 1998) consists of 15 items that each
measure dimensions of subjective sense of psychological wellbe-
ing. Items are rated on a 7-point Likert scale. The scale was used
to measure the psychological wellness of patients by categorizing
into three levels: languishing, moderately mentally healthy, and
flourishing. The coefficient alpha in the present sample was .92.
Treatment
Therapists. Thirty-five therapists participated in this study
(Table 2). All therapists but one (who was a psychiatrist) held a
minimum of master’s or doctoral level degree in clinical or coun-
seling psychology or social work. All participating therapists re-
ceived extensive prior training in AEDP. A majority of therapists
(n29, 82.86%) were trained at a certified level or higher, which
entails 120 to 200 hr of seminar-based training that includes
didactics, extensive session video analysis, experiential practice,
plus extensive (a minimum of 40 hr) individual supervision of
video-taped sessions. Six therapists (17.14%) who received an
intermediate level of training but who were not certified were
invited to participate based on the recommendation of supervisors
who had viewed the therapists’ previous clinical work and judged
it to demonstrate substantial mastery of AEDP skills. Among the
35 therapists, 18 therapists had one case, whereas 17 had multiple
cases: Of those 17, 10 therapists had two cases, four therapists had
three cases, and three therapists had four cases.
All study therapists participated in a 2-hr online-training session
outlining AEDP interventions according to the modified 16-
session treatment protocol. In addition, therapists received two
individual supervision sessions with a faculty member of the
AEDP Institute for each case in the study they treated. There was
also a weekly drop-in supervision group coled by two AEDP
Institute faculty members that participating therapists were encour-
aged to attend as often as possible. All therapy sessions were
videotaped. Both individual and group supervision were based on
direct viewing of segments of videotaped sessions. Supervisors
Table 2
Therapist Characteristics at Pretreatment Baseline
Variable N(%)
Gender
Female 26 (74.29%)
Male 9 (25.71%)
Age M(SD) 55.97 (9.06/35–70)
Experience M(SD/range) 20.83 (11.14/1–44)
AEDP experience M(SD/range) 4.54 (4.85/0–15)
AEDP
Faculty member 10 (28.57%)
Supervisor 9 (25.71%)
Certified therapist 10 (28.57%)
Recommended as study therapist
by AEDP supervisor
6 (17.14%)
Ethnicity
White 31 (88.57%)
BIPOC 4 (11.43%)
Degree
PhD/PsyD 12 (34.29%)
MSW 12 (34.29%)
MA/MFT 8 (22.86%)
Other 3 (8.57%)
Number of patients
One patient 18 (51.43%)
Two patients 10 (28.57%)
Three patients 4 (11.43%)
Four patients 3 (8.57%)
Note. AEDP accelerated experiential dynamic psychotherapy;
BIPOC Black, Indigenous, and People of Color includes people who
self-identified as Lantinx, Black, Asian, Middle Eastern, Israeli, or multi-
racial.
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5
EFFECTIVENESS OF AEDP IN PRIVATE PRACTICE SETTINGS
viewing the video segments closely monitored interventions in
accordance with AEDP principles.
Intervention protocol. AEDP treatment in this study con-
sisted of sixteen 1-hr sessions. According to AEDP principles and
training, therapists were instructed to use the AEDP framework
actively and to work to optimize the therapeutic relationship to
provide safety, “undo aloneness” and facilitate patients’ emotional
processing according to AEDP’s four-state model of change
(Fosha, 2009, 2018). Therapist intervention strategies included the
following (Fosha, 2000; Prenn & Fosha, 2017): (a) focusing on
and working with glimmers of healing from the get-go, (b) restruc-
turing strategies to work with patient defenses against emotional
experiencing, (c) dyadic affect regulation and other relational
strategies aimed at building relational capacities, (d) experiential-
affective strategies to work with patient painful emotions, and (e)
metatherapeutic processing strategies to work with and enhance
the emerging positive affective experiences. To navigate which of
the five strategies to focus on at any given moment, the therapists
used the four-state map that articulates the phenomenology of the
transformational process as a road map to guide moment-to-
moment decision making for interventions within the AEDP ther-
apeutic process (Fosha, 2017a, 2018; Fosha et al., 2019). Although
AEDP therapists usually do not determine the number of sessions
prior to the beginning of treatment, we decided to limit the number
of sessions to 16, which is a typical length of therapy in many
outcome studies for depression and other anxiety disorders.
Procedure
Prospective patients were self-referred individuals. Participating
therapists explained the nature of the study and invited prospective
patients to visit a website that provided detailed information about
the study. Subsequently, if they were interested, prospective pa-
tients were asked to fill out the pretreatment questionnaires on the
website. Patients who met the inclusion/exclusion criteria were
invited to participate in the study. All those who were invited to
participate did so. When it was ascertained that the prospective
patients understood their role in the study, a written informed
consent was reviewed by the patient and signed. Patients received
a significant fee reduction to offset the additional time required to
participate in the study protocol, such as filling out assessments
and postsession forms. Institutional review board approval from
Shigeru Iwakabe’s institutional affiliation (Ochanomizu Univer-
sity, Japan) was obtained before conducting the study and also
when any changes were made in the procedures.
Within a week of the completion of the 16 sessions, patients
were asked to fill out the posttreatment questionnaires and
measures. All patients, except two, attended 16 sessions. Two
patients were given three extra sessions because their treatment
was disrupted by life events. The decision to add three sessions
followed a discussion between the therapist and their patient
and the therapist’s consultation with the research team. It was
determined that three extra sessions were necessary to fulfill
clinical and ethical responsibilities. Analyses were conducted to
control for this variation in treatment length to ensure that
inclusion of these patients did not significantly impact the
outcome findings.
Results
Sixty-nine patients started the treatment, and 62 completed the
treatment. Seven patients dropped out of the study (Sessions 2 to
12). The dropout rate in this study (10.15%) is lower than the
average rate (20%) reported in a recent meta-analysis (Swift,
Greenberg, Tompkins, & Parkin, 2017). The patients who dropped
out were contacted to ask about their reasons for discontinuation
and to assess potential distress and risks. Reasons for dropout
included the patient’s feeling that the treatment did not directly
address their needs and therapist-patient mismatch in terms of
style. The six therapists of those dropout cases (one therapist had
two dropout cases) had significantly less experience in AEDP
(average years of AEDP experience for therapists with study
dropouts 1.17 SD 1.33) than other therapists (3.65, SD
3.24; F5.123, p.05), though their overall clinical experience
did not differ significantly, F.006, p.94.
Table 3 presents the pre- and posttreatment means and standard
deviations and pre–post Cohen’s d. Large effect sizes were ob-
tained for most scales: TC, SA-45, BDI, ATQ, SCS, and AAQ-II.
For IIP-32, RSES, and DERS, the effect sizes approached a large
effect size (d.74). Therefore, our hypotheses about the effec-
tiveness of AEDP and effect sizes were mostly supported.
Target complaints had missing data because patients listed tar-
get complaints at the end of treatment that did not match the target
complaints they had listed at pretreatment. Out of a total of 62
patients, there were 27 (43.5%) patients whose first target com-
plaint did not match at pre- and posttreatment, 34 (54.8%) whose
second target complaint did not match, and 37 (59.6%) whose third
target complaint did not match.
Table 4 provides the proportions of patients who reached reli-
able change posttreatment according to the updated criteria of
Jacobson et al. (1999): patients who moved into a functional
distribution, patients who achieved clinically significant change
(patients who achieved both reliable change and movement into a
functional range), and patients who significantly deteriorated. In
our calculations, we used cutoff b, which is achieved when the
level of functioning falls within 2 SD from the normal population.
We adopted this cutoff as our sample included some patients
whose pretreatment scores were not elevated into a clinical range.
A series of paired ttests were conducted using the Holm-
Bonferroni correction, setting the initial Type I error rate at .005.
The reliable change was calculated using Speer’s (1992) method
that controls the effect of regression toward the mean by the use of
test-rest reliability instead of Cronbach’s for its estimation. We
used this more stringent method as our study did not have a control
group. The proportion of the patients who achieved the reliable
change criterion varied from scale to scale: The highest proportion
of patients with reliable change achieved was found with GSI
(74.2%), whereas on the IIP-32 it was 19.4% of patients. On most
other scales around 50% of patients achieved reliable change. The
majority of patients achieved the cutoff for movement into a
functional distribution. The proportion of patients who achieved
both reliable change and movement into a functional distribution
exceeds 50% with the exception of IIP-32. The lower proportion of
patients achieving clinically significant change on the IIP-32 is
partly owing to the low test–retest reliability of this scale (r.78).
Deterioration was observed on all scales except on SA-45,
with between one to five individuals on each scale: AAQ-II
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6IWAKABE ET AL.
(n5), DERS (n4), ATQ, IIP, and RSES (n2), and BDI
and SFS (n1). There were two patients who showed deteri-
oration on three scales and one patient on two scales. All of
these patients also showed significant improvements on other
scales; therefore, their outcome presented a mixed picture. In
sum, these results indicate that AEDP was generally highly
effective in reducing a variety of psychological symptoms as
well as patients’ subjective sense of distress, and also effective
in producing an increase in positive indexes of psychological
functioning, with a small number of patients showing some
deterioration on some outcome scales (while still improving on
others).
Finally, with MHC-SF, we conducted a Pearson chi-square
using three categories of wellbeing by pre- and posttreatment. The
result showed the significant change from pretreatment to post-
treatment with an increase in the number of patients who moved
out of the Languishing category and moved into the Flourishing
category at posttreatment (
2
9.81, p.007). The number of
Table 3
Pretreatment Baseline, Posttreatment Outcome, Improvement (Paired t Test), and Effect Sizes (Cohen’s d) for All Outcome Measures
for All Patients
Pre–Post
Pop Pre Post ttest
Measure MSDNMSDMSD TpES
TC1 35 8.23 1.50 5.83 2.58 4.148 .000
1.60
TC2 28 7.89 1.81 6.00 3.21 3.085 .005 1.04
TC3 25 7.36 1.75 5.36 2.25 3.333 .003
1.14
GSI .95 60.30
a
18.00 62 48.98 24.08 24.15 17.66 10.195 .000
1.03
BDI .91 7.28
b
6.89 62 17.94 8.45 8.06 6.28 9.095 .000
1.17
ATQ .97 48.57
c
10.89 62 70.55 24.16 50.08 19.51 8.185 .000
0.85
IIP-32 .91 50.00
d
10.00 62 59.34 9.02 52.44 9.11 6.305 .000
0.77
RSES .90 22.62
e
5.80 62 16.29 5.02 19.98 5.14 6.565 .000
0.74
DERS .95 77.99
f
20.72 62 94.39 23.05 77.35 21.20 6.361 .000
0.74
SCS .95 18.25
g
3.75 62 15.51 3.96 19.34 4.70 7.653 .000
0.97
AAQ-II .90 17.34
h
4.37 57 30.51 6.66 22.46 8.01 8.054 .000
1.21
MHC-SF .92 38 31.11 12.04 43.53 12.41 6.316 .000
1.03
Note. Pop population mean; TC target complaints; GSI Global Severity Index of Symptom Assessment-45; BDI Beck Depression Inventory;
ATQ Automatic Thoughts Questionnaire; IIP-32 Inventory of Interpersonal Problems-32; RSES Rosenberg Self-Esteem Scale; DERS
Difficulties in Emotion Regulation Scale; SCS Self-Compassion Scale; AAQ-II Acceptance and Action Questionnaire-II; MHC-SF Mental Health
Continuum–Short Form. ES Cohen’s d.
a
Extracted from Strategic Advantages, Inc. (2000).
b
Extracted from Beck, Steer, and Carbin (1988).
c
Extracted from Hollon & Kendall (1980).
d
Ex-
tracted from Horowitz, Alden, Wiggins, and Pincus (2000).
e
Extracted from Sinclair et al. (2010).
f
Extracted from Gratz & Roemer (2004).
g
Ex-
tracted from Neff (2003).
h
Extracted from Bond et al. (2011).
p.0042.
Table 4
Proportions of Patients Who Reached Reliable Change (Jacobson et al., 1999)
Pop Pre–Post
Measure Test–Retest MSD RC MIFD CSC DF
GSI .82
a
60.30 18.00 74.2% 100.0% 74.2% 0.0%
BDI .90
b
7.28 6.89 67.7% 95.2% 62.9% 1.6%
ATQ .71
c
48.57 10.89 51.6% 87.1% 50.0% 3.2%
IIP-32 .78
d
50.00 10.00 19.4% 95.2% 19.4% 3.2%
RSES .87
e
22.62 5.80 40.3% 95.2% 40.3% 3.2%
DERS .88
f
77.99 20.72 51.6% 95.2% 50.0% 6.5%
SCS .93
g
18.25 3.75 62.9% 96.8% 62.9% 1.6%
AAQ-II .81
h
17.34 4.37 56.1% 73.7% 49.1% 8.8%
Note. Pop population mean; GSI Global Severity Index of Symptom Assessment-45; BDI Beck Depression Inventory; ATQ Automatic
Thoughts Questionnaire; IIP-32 Inventory of Interpersonal Problems-32; RSES Rosenberg Self-Esteem Scale; DERS Difficulties in Emotion
Regulation Scale; SCS Self-Compassion Scale; AAQ-II Acceptance and Action Questionnaire-II; RC the proportion of patients who achieved
reliable change according to Speer’s method (1992), controlling the effect of regression toward the mean; MIFD movement into a functional distribution:
the proportion of patients who achieved the level of functioning that fell within the range of the normal population, where range was defined as beginning
at 2 SDs below the mean for the normal population; in other words, those who achieved cutoff point baccording to Jacobson et al. (1999); CSC clinically
significant change: the proportion of patients who achieved both RC and MIFD; DF deteriorated in functioning: patients who exceeded reliable change
index in the negative direction.
a
Extracted from Strategic Advantage, Inc. (2000).
b
Extracted from Lightfoot & Oliver (1985).
c
Extracted from Charles, Bouvard, Mollard, and
Cottraux (1989).
d
Extracted from Horowitz et al. (2000).
e
Extracted from Torrey, Mueser, McHugo, and Drake (2000).
f
Extracted from Gratz &
Roemer (2004).
g
Extracted from Neff (2003).
h
Extracted from Bond et al. (2011).
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7
EFFECTIVENESS OF AEDP IN PRIVATE PRACTICE SETTINGS
patients who were initially Languishing decreased from 9 at pre-
treatment to 2 at posttreatment, whereas the number of patients
who were Flourishing increased from 3 at pretreatment to 15 at
posttreatment.
In examining the initial results, we noted a bimodal distribution
in pretreatment patient profiles, with one group of patients with
numerous elevated pretreatment symptom scales and another
group of patients with only a few elevated pretreatment symptom
scales. To adequately distinguish these two important profiles
(Cuijpers et al., 2014; Fava & Mangelli, 2001), we report the
results for the whole sample (as discussed earlier) as well as results
of a post hoc analysis separating the sample into clinical and
subclinical groups (discussed later). This allowed us to examine
the effects of AEDP on these two profiles separately.
In defining the clinical and subclinical groups, we used 16
outcome indices: seven different outcome scales (described earlier
except MHC-SF, which was added later in the study) and nine of
the 10 subscales of the SA-45. (The Psychoticism subscale was
excluded owing to a lower internal consistency in our sample, with
Cronbach’s ␣⫽.63.) Patients with elevated scores on four or more
of these 16 indices were defined as the clinical group, where
elevation was defined as one standard deviation or more from the
normal population mean. Patients who had three or fewer elevated
scores across the 16 indices were defined as the subclinical group.
Similar symptom severity grouping procedures can be seen in the
study by Barkham, Shapiro, Hardy, and Rees (1999).
Demographic characteristics and pretreatment scores for the
clinical and subclinical groups are shown in Table 2. Thirty-nine
patients met the criteria for the clinical group with a mean number
of 8.0 (SD 2.8) elevated indices with a range between 4 and 16.
Twenty-three patients met the criteria for the subclinical group
with a mean number of 1.6 (SD 1.1) elevated indices with a
range between 0 and 3. There were no significant differences in
demographic characteristics between the clinical and subclinical
groups.
Table 5 presents the pre- and posttreatment means and standard
deviations and pre–post Cohen’s dvalues. As seen in Table 5, at
pretreatment, patients in the clinical group had significantly higher
mean scores than patients in the subclinical group on all outcome
scales except on the target complaints. Patients from both groups
scored similarly on all three target complaints, showing similarity
between the groups in intensity of ratings of subjective distress.
Similarly, at posttreatment GSI, ATQ, IIP-32, RSES, DERS, and
AAQ-II scores were all significantly higher in the clinical group
than the subclinical group, whereas BDI and SCS were not sig-
nificantly different in the two groups, but highly improved in both.
The BDI pretreatment average for the clinical group (BDI: M
21.95; SD 7.38) was in the moderately depressed range (BDI
19 –29), while the subclinical group (BDI: M11.13; SD 5.16)
was, on average, in the mildly depressed range (BDI 10 –18). In
the clinical group, each of the pretreatment mean scores on the
ATQ, BDI, IIP-32, RSES, DERS, SCS, and AAQ-II fell outside 1
SD from the population means.
The Holme–Bonferonni correction was used to control for mul-
tiple comparisons, setting the initial Type I error rate at .005. The
clinical group had achieved large effect sizes over d1.00 on all
scales. The subclinical group had a large effect size d.80 on the
first TC, SA-45, BDI, and AAQ-II. For IIP-32, RSER, DERS, and
SCS, moderate to large effect sizes were obtained (d
0.46 –0.69).
Table 6 presents the proportion of patients in the clinical group
who, at posttreatment, reached a level of reliable change according
to Jacobson et al.’s (1999) classification. In the clinical group,
82.1% of patients reached reliable change (Speer, 1992) on SA-45
and 79.5% on the BDI. For most scales, approximately 50% of
patients were classified as achieving reliable change. According to
Jacobson et al.’s (1999) classification, for BDI, the proportion of
those who moved into a functional distribution was 92.3% and the
proportion of those who achieved clinically significant change was
71.8%.
Table 5
Pretreatment Baseline, Posttreatment Outcome, Improvement (ANOVA), and Effect Sizes (Cohen’s d) for All Outcome Measures for
Clinical and Subclinical Groups
Pre Post Pre–Post
Clinical Subclinical t-test Clinical Subclinical t-test ANOVA ES
Measure N M SD N M SD t p M SD M SD t p FpClinical Subclinical
TC1 21 8.33 1.74 14 8.07 1.07 0.55 .586 5.81 2.66 5.86 2.57 0.05 .958 15.65 .000
1.45 2.07
TC2 16 8.25 1.84 12 7.42 1.73 1.22 .235 5.81 3.29 6.25 3.22 0.35 .728 8.47 .007 1.32 0.67
TC3 14 7.43 1.87 11 7.27 1.68 0.22 .831 5.07 2.53 5.73 1.90 0.72 .482 10.18 .004
1.26 0.92
GSI 39 61.67 20.79 23 27.48 9.61 8.80 .000
29.41 19.01 15.22 10.40 3.80 .000
103.24 .000
1.55 1.28
BDI 39 21.95 7.38 23 11.13 5.16 6.18 .000
9.33 6.53 5.91 5.30 2.13 .037 75.36 .000
1.71 1.01
ATQ 39 82.90 21.75 23 49.61 8.53 8.51 .000
55.46 22.46 40.96 6.78 3.75 .000
60.96 .000
1.26 1.01
IIP-32 39 63.46 7.58 23 52.35 6.73 5.81 .000
55.21 9.34 47.74 6.52 3.69 .000
33.10 .000
1.09 0.69
RSES 39 13.85 3.33 23 20.43 4.70 6.45 .000
18.44 5.00 22.61 4.32 3.33 .001
35.69 .000
1.38 0.46
DERS 39 105.79 18.57 23 75.04 15.97 6.62 .000
84.92 20.79 64.52 15.01 4.11 .000
33.46 .000
1.12 0.66
SCS 39 13.89 2.86 23 18.24 4.10 4.49 .000
18.33 4.52 21.04 4.59 2.27 .027 50.05 .000
1.55 0.68
AAQ-II 39 32.95 5.29 18 25.22 6.34 4.81 .000
24.18 8.28 17.90 6.44 3.01 .004
50.50 .000
1.66 1.15
MHC-SF 31 28.84 11.11 7 41.14 11.51 2.63 .012 41.77 11.71 51.29 13.33 1.90 .066 20.30 .000
1.16 0.88
Note. TC target complaints; GSI Global Severity Index of Symptom Assessment-45; BDI Beck Depression Inventory; ATQ Automatic
Thoughts Questionnaire; IIP-32 Inventory of Interpersonal Problems-32; RSES Rosenberg Self-Esteem Scale; DERS Difficulties in Emotion
Regulation Scale; SCS Self-Compassion Scale; AAQ-II Acceptance and Action Questionnaire-II; MHC-SF Mental Health Continuum–Short Form;
ES Cohen’s d; ANOVA analysis of variance.
p.0042.
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8IWAKABE ET AL.
In the subclinical group, although each participant exceeded 1
SD from the population mean on at least one symptom scale, on
average as a group these patients started less than 1 SD from the
population mean score across the measures. Therefore, there was
less room for improvement for these patients in the subclinical
group. Nonetheless, over 60% of patients in this group made
clinically significant change on GSI and SCS, and about 50% on
BDI and SCS. About 30% to 40% of patients achieved clinically
significant change on ATQ and DERS.
We also looked at what Jacobson et al. (1999) define as dete-
rioration within the clinical and subclinical groups. Deterioration
more frequently occurred in the clinical group, with about 10% of
patients showing deterioration on DERS and AAQ-II. Three pa-
tients from the subclinical group showed significant deterioration
on a total of three scales.
A series of analyses of variance were conducted to examine the
interaction between groups. On all outcome scales, patients in the
clinical group improved significantly more than those in the sub-
clinical group (Table 5).
Finally, for MHC-SF, patients moved toward flourishing in both
clinical and subclinical groups. For the clinical group, Pearson
2
showed that there was a significant relationship between the pre–
post scores and three categories of well-being (
2
9.814 df 2,
p.007). For the subclinical group, Fisher’s exact test showed a
nearly significant result (
2
4.667 df 1, p.051). There were
more patients who were classified as flourishing in both groups at
the end of treatment than there were at the beginning of treatment.
Discussion
The present study is the first large-scale investigation of the
effectiveness of AEDP using a 16-session treatment format in the
independent practice settings where AEDP is most frequently
practiced. It is based on the AEDP PRN that has come to form an
infrastructure of research in the AEDP community of clinicians.
The present study used a naturalistic sample consisting of adults
who sought psychotherapy from private practitioners. To capture
the effect of AEDP comprehensively, the current study employed
an array of robust measures of psychological symptoms widely
used in other psychotherapy outcome studies. In our primary
analysis, the 62 patients improved significantly on a number of
outcome measures, with large effect sizes at posttreatment. Only
three patients deteriorated on one or more of the outcome mea-
sures. Furthermore, even these patients also achieved reliable
positive change on other outcome scales. In sum, the initial attempt
to build a PRN and to demonstrate the effectiveness of AEDP in
independent practice settings successfully achieved its goals.
In addition to demonstrating the effectiveness of AEDP, our
study contributes to the emerging field of PRN research by show-
ing that a PRN that centers on a specific theoretical orientation and
model of treatment can be effectively implemented. Our PRN is
built within the community of AEDP therapists who share not only
a therapeutic method but also the worldview underlying the theory
and practice of AEDP. We were able to increase the interest of
clinicians in research and in integrating research more seamlessly
in their everyday practice. Individual communications from ther-
apists indicated enthusiasm for contributing to the research project
as well as for the benefits of increased intertherapist engagement
(Edlin, Fosha, & Iwakabe, 2020). Using online individual and
group supervision, clinicians who were geographically dispersed
across different continents were able to participate in the study and
connect with one another. In addition to offering a way of partic-
ipating in research, this also helped undo the isolation of private
practitioners, as participant therapists indicated. This dual function
can both enrich therapists’ professional development and also
provide a way to monitor effectiveness in the era of evidence-
based practice. In sum, with many approaches establishing their
own community of therapists, our PRN can serve as a model to
instill a research infrastructure into a community of therapists of a
particular theoretical orientation.
Cuijpers (2019) listed five targets of psychotherapy outcome
research that need to be examined to comprehensively assess the
effectiveness of any psychotherapy: symptom reduction, patient-
defined targets and outcomes, quality of life, intermediate out-
comes or mediators and working mechanisms, negative outcomes,
Table 6
Proportions of Participants Who Reached Reliable Change (Jacobson et al., 1999) for Clinical and Subclinical Groups
Clinical (N39) Subclinical (N23)
Outcome scale RC (%) MIF (%) CSC (%) DF (%) RC (%) MIFD (%) CSC (%) DF (%)
GSI 82.1 100.0 82.1 0.0 60.9 100.0 60.9 0.0
BDI 79.5 92.3 71.8 0.0 47.8 100.0 47.8 4.3
ATQ 64.1 79.5 61.5 5.1 30.4 100.0 30.4 0.0
IIP-32 23.1 92.3 23.1 5.1 13.0 100.0 13.0 0.0
RSES 48.7 92.3 48.7 2.6 26.1 100.0 26.1 4.3
DERS 59.0 92.3 56.4 10.3 39.1 100.0 39.1 0.0
SCS 61.5 94.9 61.5 2.6 65.2 100.0 65.2 0.0
AAQ-II 59.0 64.1 48.7 10.3 50.0 94.4 50.0 5.6
Note. GSI Global Severity Index of Symptom Assessment-45; BDI Beck Depression Inventory; ATQ Automatic Thoughts Questionnaire;
IIP-32 Inventory of Interpersonal Problems-32; RSES Rosenberg Self-Esteem Scale; DERS Difficulties in Emotion Regulation Scale; SCS
Self-Compassion Scale; AAQ-II Acceptance and Action Questionnaire-II; RC reliable change: The proportion of patients who achieved reliable
change according to Speer’s (1992) method controlling the effect of regression toward the mean; MIFD movement into a functional distribution: The
proportion of patients who achieved the level of functioning that fell within the range of the normal population, where range was defined as beginning at
2SDs below the mean for the normal population; in other words, those who achieved cutoff point baccording to Jacobson et al. (1999); CSC clinically
significant change: The proportion of patients who achieved both RC and MIFD; DF deteriorated in functioning: patients who exceeded reliable change
index in the negative direction. For AAQ-II, Nfor subclinical group was 18.
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9
EFFECTIVENESS OF AEDP IN PRIVATE PRACTICE SETTINGS
and economic outcomes. In this study, we covered the first four of
these five areas, and in all four, we had favorable results according
to important outcome indexes such as effect size and the reliable
change index.
The effect sizes of improvement on depression, experiential
avoidance, as well as psychological symptoms were similar to
those obtained in outcome studies on major approaches such as
psychodynamic psychotherapy (Shedler, 2010), cognitive–
behavioral therapy (Butler, Chapman, Forman, & Beck, 2006;
Hans & Hiller, 2013), ACT (A-Tjak et al., 2015) and experiential
therapies (Elliott, Greenberg, & Lietaer, 2004), as well as transdi-
agnostic approaches on affective disorders (Newby, McKinnon,
Kuyken, Gilbody, & Dalgleish, 2015). Although a direct compar-
ison cannot be made because of the differences in focus, sampling,
and other treatment parameters, AEDP in a 16-session format is
effective and worth continuing to examine in a more controlled
experimental design as well as for more specific clinical popula-
tions. Currently, most research-supported treatments for depres-
sion and anxiety disorders are cognitive– behavioral in orientation
(e.g., https://www.div12.org/treatments/). However, there are a
substantial number of patients who drop out from cognitive–
behavioral therapy and may seek different therapy approaches
(Hans & Hiller, 2013). In addition, a greater variety of effective
models can make for a greater range of patient choice as well as
potential alternatives for more refractory cases.
To further examine the effectiveness of AEDP on subgroups
within our sample, a secondary analysis divided patients into two
groups based on the number of pretreatment symptom scales that
were elevated to clinical levels for a given patient. This division
showed a clear bimodal distribution, making two groups which we
labeled the “clinical group” and the “subclinical group.” The
clinical group was elevated on an average of 8 symptom scales out
of a total of 16 subscales, versus the subclinical group, whose
scores were elevated on an average of two subscales.
Notably, the effect sizes in the clinical group, which had more
complex problems, appeared even larger than the group as a
whole, showing the strength of AEDP with the more complicated
cases within our sample. In the clinical group, large effect sizes
ranged from d1.12 to d1.78 on patients’ main target
problem, depression, experiential avoidance, emotion regulation,
and general symptom distress. Avoidance of emotion (experiential
avoidance) and emotion regulation are both targets of AEDP,
which shows that AEDP methods appear to produce substantial
change in these domains.
In addition, large effects were seen on the decrease in negative
automatic thoughts, despite the fact that automatic thoughts spe-
cifically and cognitions in general are not targeted for restructuring
in AEDP. In AEDP theory negative automatic thoughts are seen as
either forms of defense used to avoid core emotion, and then
therapists seek to bypass them, or else as internalizations of neg-
ative parental messaging, and then they are worked with experi-
entially. Thus, it appears that a focus on relational work and
emotion processing may be an alternative method from the ap-
proach of cognitive– behavioral therapy (Beck, 2011) to substan-
tially reduce such detrimental ways of thinking.
The subclinical group presented with a similar level of pretreat-
ment subjective distress as the clinical group despite having fewer
pretreatment symptom scales that were elevated beyond a clinical
threshold. Although the subclinical group was less symptomatic
according to validated scales, these patients experienced them-
selves as suffering, and thus still appeared to be in need of
treatment. Similar to the clinical group, the subclinical group also
demonstrated notable improvement, with effect sizes for depres-
sion, global severity index, experiential avoidance, and negative
automatic thoughts exceeding 1.0. Even though their pretreatment
average score for emotion regulation problems was similar to the
(nonclinical) population mean, the group still achieved the im-
provement of moderate effect size. Overall, the effect sizes were
smaller for the subclinical group than the clinical group at least in
part because these patients had less room to improve.
Yet, in some nonpathological measures that centered on positive
capacities, the subclinical patients started out close to the popula-
tion mean and then went on to exceed it. Thus, notably, although
the mean score for self-compassion at pretreatment for the sub-
clinical group was about the same as population mean, these
patients improved more than two thirds of standard deviation
beyond the population mean. Along these same lines, the MHC-SF
for those in the subclinical group showed that those who started
out in the moderately functioning range improved to the category
of Flourishing. These findings show initial support, at least in
subclinical populations, for the AEDP aim of not only in facilitat-
ing therapeutic changes from the negative range to the normal
range but also in facilitating improvement from normal range to
stronger functioning and flourishing.
The present study strongly indicates that we continue examining
AEDP as an effective approach to treat subclinical populations and
also explore its potential as a preventive and health-promoting
intervention in future studies. The study of subclinical populations
has important implications for individuals at risk for mental dis-
orders (Cuijpers et al., 2014; Fava & Mangelli, 2001). Recent
research supports therapeutic work with subclinical populations
and indicates that preventative mental health strategies play an
important and cost-effective role in averting mental health disor-
ders (Arango et al., 2018). It will also be worth examining whether
AEDP can be used to bring those who it has helped recover from
substantial symptomology to go on to surpass moderate levels of
functioning that they achieved posttreatment in the current study.
Both clinical and subclinical groups improved their capacity to
access, experience, and process emotion, as evidenced in their
improvement in their experiential avoidance and emotional regu-
lation. The facilitation of and exposure to specific emotional
experiences has been shown to improve participant outcome
(Greenberg & Pascual-Leone, 2006; Lilliengren, Falkenström,
Sandell, Mothander, & Werbart, 2015). These findings are consis-
tent with the dyadic regulation and processing of emotional expe-
rience, one of the main mechanisms of change in AEDP. An
additional proposed mechanism of change in AEDP centers on
experiential work with experiences of healing and positive change
through the technique of metaprocessing, which aims to bring
patients past alleviation of suffering and into flourishing (Fosha &
Thoma, 2020).
These proposed mechanisms of change in AEDP will need to be
refined into testable hypotheses and then tested by using multiple
methods from process research, systematic case studies, and also
process-outcome studies. One potential avenue of research is an
intensive analysis of in-session therapist-patient interactions to
examine whether those improved cases show more episodes of
successful dyadic regulation in which patient and therapist process
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10 IWAKABE ET AL.
and work through patients’ painful or positive emotions in session.
This would require developing scales that can efficiently code the
occurrence of effective dyadic regulation and distill the essential
steps and components leading to change (Elliott, 2010). The pres-
ent study, nonetheless, provides sufficient support that this mech-
anism is worth testing in the future.
One of our goals was to encourage a continuous research en-
gagement with AEDP therapists and to build a sustainable research
culture within the international AEDP therapeutic community.
This study sets the AEDP PRN in place in order to examine
process and outcome of AEDP in the AEDP community at large.
It also supports AEDP effectiveness and its findings are similar to
those found in psychotherapy meta-analyses (Cuijpers, 2017). As
a pre–post study, however, the current study lacks the controls for
internal validity embedded in randomized controlled trial studies
(RCTs). Spontaneous remission of depression for adult within 6
months is estimated to be about 30% (Whiteford et al., 2013).
Supportive therapy based on nonspecific factors can produce mod-
erate effect size (Cuijpers et al., 2012). Our results showed that
67.7% of the patients who received AEDP made reliable changes
on depression and 74.2% on general symptom severity. We need to
complement the emphasis on external validity in the present trial
with testing the effect of AEDP in a controlled research design
with comparison groups and an emphasis on internal validity. With
the increasing involvement of AEDP therapists in research studies,
a future goal is to build a design that involves independent practice
based RCTs. Future RCTs may also focus on testing the effective-
ness of AEDP for treating specific disorders to further refine our
understanding of its effectiveness and the breadth of application in
various clinical settings. A natural extension of the current study
will be to study the effectiveness of AEDP for depressive disor-
ders, in light of its strengths in improving depressive symptoms
and related variables such as negative rumination, emotion regu-
lation, and self-compassion demonstrated in the current study.
Using the RCT design while setting treatment parameters and the
severity of psychopathology comparable to those studies on other
evidence approaches will provide a more exact test of the effec-
tiveness of AEDP.
The present study excluded prospective participants with a
history of psychotic disorder and current substance abuse disorder,
mostly focusing on depression, anxiety, and interpersonal prob-
lems. Further, although fidelity was supported by the use of
advanced and certified AEDP therapists and by incorporating
supervision meetings, future studies may include expert raters to
monitor therapists’ adherence and treatment fidelity and to sys-
tematically test therapist effects. AEDP prizes the therapist’s flex-
ibility and responsiveness, which needs to be more operationally
defined and contrasted against adherence empirically (Owen &
Hilsenroth, 2014). Future goals include evaluating the mainte-
nance of gains at follow-up and also gathering a larger sample of
patients showing greater diversity both in their clinical problems
and their cultural backgrounds in order to fully assess the effec-
tiveness of AEDP.
There were a small number of patients who showed some deteri-
oration. Since we used a stringent criterion for judging clinically
significant change (Jacobson et al., 1999), the range for reliable
change was small, contributing to categorizing cases with minor
deterioration into the deterioration category. Of note is that two
patients who showed deterioration on three outcome scales also
showed significant improvements in other areas. Therefore, their
results were mixed. Five patients showed worsening on experiential
avoidance and four patients on emotion regulation. A close look at
these particular cases showed that these patients were working on
issues related to their past traumatic experiences toward the end of
their treatment. For example, one patient who worked on difficult,
painful emotions associated with her past traumas made significant
improvement on depression; however, her scores on emotion regula-
tion and experiential avoidance were lower at posttreatment. A closer
look at subscale scores on DERS indicated that although she was
significantly more accepting of her emotional responses and acquired
more emotion regulation strategies, her emotional clarity and aware-
ness were significantly lowered. Previous empirical work on emotion-
exposure based treatment for depression has shown nonlinear patterns
of change, with some symptoms worsening before they improve
(Hayes, Laurenceau, Feldman, Strauss, & Cardaciotto, 2007). It may
be the case that a small number of patients were only part way through
this process by the end of treatment. It may also be relevant to note
here that we had a very low dropout rate, at only 11.3%, which is a
little more than half the rate found in a recent meta-analysis of dropout
rates (Swift et al., 2017). Thus, it may also be the case that we retained
in treatment patients who might otherwise have simply dropped out,
which, when considering those patients who deteriorated, may still be
considered an overall strength of AEDP with these patients, in that
treatment was provided and improvements were still made on some
scales. These complex pictures of deterioration urge us to conduct a
series of systematic case studies so that both the unique pattern of
deterioration in each case as well as common contributing factors
associated with deterioration can be identified and studied.
Future studies will help elucidate mechanisms of change related to
outcome, including the role of the working alliance, explicit
relational-experiential interventions, emotional processing and
AEDP’s focus on positive emotional experience through metathera-
peutic processing, as well as therapist effects. However, we need to
examine the relative contributions of both common factors and
change mechanisms unique to AEDP in a rigorous and differentiated
manner. Relationship factors such as the therapeutic alliance, empa-
thy, and collaboration that have been consistently found to be related
to outcome in various approaches are also important in AEDP. We
need to take a step further towards specifying which particular com-
ponents of these relational constructs are shared with other approaches
and which are specific to AEDP (Weinberger, 2014). Process-
outcome research focusing on AEDP-specific processes will also help
rule out the possibility that outcomes are due in part or in whole to
factors common to all psychotherapies. We predict that the improve-
ments in interpersonal functioning in AEDP patients, as well as the
improvements in depression, negative cognitions and experiential
avoidance will contribute to better interpersonal and emotional envi-
ronments so that therapeutic gains will be maintained. To examine
this prediction, 6- and 12-month follow-up data from the patients of
the present study will be analyzed to evaluate the long-term effec-
tiveness of AEDP.
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Received December 19, 2019
Revision received July 15, 2020
Accepted July 21, 2020
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14 IWAKABE ET AL.
... Accelerated Experiential Dynamic Psychotherapy (AEDP) is a psychotherapeutic model that works to process emotional and relational experiences and prioritizes secure attachment through the therapeutic relationship. AEDP has been tested and found to be effective in research clinical trials through both in-person and telehealth platforms, alleviating depression and a range of symptoms in 16 sessions or fewer (Iwakabe et al., 2020). It may be a particularly relevant psychotherapeutic approach in these unprecedented and changing times, targeting inner experiential-emotional processing, while reducing attention to temporary or concrete external conditions (Ronen-Setter & Cohen, 2020). ...
... "When a tight focus on present moment affective and relational experience is held, dyadically regulated, and experienced through to completion, the patient goes from being defensively closed off from genuine contact to shedding his defenses against closeness and allowing himself to be open and vulnerable and receive the therapist's real care and compassion" (Frederick, 2021, p. 14). The AEDP effectiveness study (Iwakabe et al, 2020) has provided empirical support for the effectiveness of AEDP in providing "meaningful and significant improvements across a range of psychological symptoms, including depression, experiential avoidance, general symptom distress, difficulties in emotion regulation, and patients' main target problems…with a significant decrease in negative automatic thoughts…and improvement in nonpathological measures that centered on positive capacities, such as self-compassion and self-esteem (Fosha, 2021, p. 10). ...
... As discussed in the literature review, AEDP is a healing-oriented, attachment-based and experiential mind-body treatment model that is effective in addressing relational and attachment trauma (Iwakabe et al, 2020). The reflections of psychotherapists who are well-trained and skilled in AEDP were chosen for this qualitative study. ...
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COVID-19 has not only killed and infected millions of people worldwide but has also resulted in unprecedented psychosocial stressors that continue to have profound mental health consequences for many people, exacerbating pre-existing psychological suffering and contributing to the onset of new stress related conditions. It has also resulted in a major revolution in the delivery of mental health treatment abruptly shifting psychotherapeutic practice to online technology. Psychotherapists need to be prepared for how their clinical work may change. This qualitative research study has been phenomenological in nature, attempting to capture and contribute to the literature on the lived experience of psychotherapists in navigating the transition through a global pandemic and exploring how the accompanying shift to telehealth has impacted clinical practice and the therapeutic relationship, if at all. A single-session, semi-structured interview lasting approximately one hour was conducted over Zoom with 15 mental health clinicians certified in an integrative psychotherapeutic attachment-based treatment model Accelerated Experiential Dynamic Psychotherapy (AEDP). Research findings and data were analyzed using a thematic coding process and principles of grounded theory. Significant findings of this study included the identification of factors that might negatively impact the online therapeutic relationship and the recognition of ways to strengthen and enhance telehealth effectiveness with an attachment-based and relational lens. Advantages and disadvantages of telehealth practice were identified and explored in addition to the effects of shared trauma on the therapeutic relationship and the post-traumatic growth and resilience of the therapist. Implications for theory, practice and social work education are discussed. Limitations included the small size and homogeneity of the study sample.
... AEDP's theoretical framework brings together understandings and empirical findings from affective neuroscience, attachment theory, emotion theory, relational psychoanalysis, recognition science, and positive psychology (Fosha, 2008;Russell, 2015). Transdiagnostic in its focus (Gleiser et al., 2008;Iwakabe et al., 2020) AEDP targets a set of central psychopathological processes (Lamagna, 2021: Lamagna & Gleiser, 2007, specifically the individual's unwilled and unwanted aloneness in the face of overwhelming emotional experience (Fosha, 2017) believed to underlie a variety of diagnoses and symptoms, such as depression, anxiety, and various maladaptive behaviors and interpersonal patterns (see Sauer-Zavala et al., 2017). However, rather than focusing solely or even primarily on psychopathology, AEDP therapists systematically focus on adaptive affective change processes (Fosha, 2021a), psychological processes with transformational potential that underlie resilience, and well-being (Russell, 2015). ...
... Recently, programmatic empirical investigations of AEDP have begun. Several systematic case studies have documented the course of AEDP treatment (e.g., Iwakabe et al., 2020;Markin et al., 2018; This document is copyrighted by the American Psychological Association or one of its allied publishers. ...
... Finally, a randomized controlled trial of an internet-based psychotherapy for anxiety and depression based on AEDP principles showed moderate-to-large effects (Johansson et al., 2013). Building on these early initiatives, Iwakabe et al. (2020) developed a practice research network (PRN) in the international AEDP community to test the effectiveness of AEDP in community-based settings, that is, the private practice settings in which AEDP is usually practiced (see Castonguay et al., 2013, for further elaboration of the PRN paradigm). The AEDP PRN involves collaborative, bidirectional relationships between AEDP clinical practitioners and researchers. ...
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Accelerated experiential dynamic psychotherapy (AEDP; Fosha, 2000, 2021b) is an integrative, healing-oriented, mind-body, affect-focused therapy. A posttreatment outcome study demonstrated AEDP's effectiveness (Iwakabe et al., 2020) on a variety of measures of psychological functioning. This study sought to address AEDP's long-term effectiveness. As previously reported, 63 adult patients completed a 16-session AEDP treatment with qualified therapists in private practice in the United States, Canada, Israel, Japan, and Sweden. Forty patients responded to 6-month follow-up and 52 responded to 12-month follow-up. Results indicate that patients maintained their posttreatment therapeutic gains, both 6 and 12 months later. Large effect sizes (d = 0.74 to d = 1.60) both for reductions on measures of psychopathology (e.g., depression, negative automatic thoughts, experiential avoidance) and improvements on measures of positive mental health (e.g., well-being, self-compassion) were obtained. Patients with more pervasive and severe problems tended to have larger effect sizes (all ds > 1.0) and a larger proportion of them achieved clinically significant change over 6 and 12 months than patients with subclinical symptomatology. Piecewise growth modeling was used to confirm these results, with attrition over the follow-up period taken into account. Consistent with the above findings, piecewise growth modeling similarly showed that patients significantly improved from pre- to posttreatment and maintained gains from posttreatment through the 6- and 12-month follow-up. These results provide empirical support for the long-term effectiveness of AEDP for alleviating a variety of psychological problems and enhancing positive functioning. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... Empirical research on AEDP is in progress. This includes a task analysis of metaprocessing (Iwakabe & Conceição, 2016), systematic case studies (e.g., Markin et al., 2018;Vigoda Gonzalez, 2018), studies documenting the efficacy of Internet-therapy based AEDP (e.g., Johansson et al., 2017), and an effectiveness study of a 16-session course of AEDP as implemented in a practice-research network (Iwakabe et al., 2020). However, to date there have not been studies on client subjective experience of changes in AEDP. ...
... Here, the changes did not happen simply by relieving his distress but by the client's negative self-beliefs becoming positive. A recent outcome study on AEDP found that clients achieved reliable change on negative cognition (Iwakabe et al., 2020). Although AEDP does not explicitly target negative thoughts or beliefs, the affirming therapist stance may help reduce negativity toward the self in its clients. ...
... In the future, we hope to conduct studies that assess 'healing from the get-go' experiences in early sessions of many different clients in therapeutic dyads with many different therapists and correlate those findings with outcome data, which is now possible with data from a large effectiveness study of AEDP that is ongoing (Iwakabe et al., 2020). ...
... These evidenced-based models share several common underpinnings: Resource, something that the client experiences as calming to prevent dysregulation during the remembering and relaying of traumatic experience [39] guidance for the client to sense trauma related emotions, beliefs, images in or around the body, techniques for titrating the amount of trauma related thoughts, feelings and sensations that emerges, and finally, techniques to process and release trauma related feelings and reprocess trauma-induced negative beliefs [24]. ...
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Trauma can result in many long-term symptoms including emotional dysregulation, depression, addiction, and PTSD. When triggered by trauma, patients typically experience the world through a myopic lens. Helping clients observe and sense their trauma sequelae in the broader sensory awareness of Presence appears to help clients more easily process and resolve traumatic experience. The Presence Psychotherapy Trauma Protocol (PPTP) provides specific open-ended questions in session to help clients orient to Presence Awareness which can then be utilized to resolve trauma. Options to help clients sense their traumatic experience in the expansive awareness of Grounded Presence, Spacious Presence, Relational Presence, or Transcendent Presence create multiple regulating, processing, and attachment healing opportunities. PPTP’s concept of Reflective View is introduced which provides the clinician with prompts to help the client identify who they are as Presence Awareness early in session. This paper demonstrates, through a case example, how Presence Awareness and specifically Reflective View help clients access, tolerate, and process trauma in a broader sense of Presence Awareness.
... Emotion-based therapeutic approaches currently exist, and some are well researched including Greenberg's emotion focused therapy (Pascual-Leone & Greenberg, 2007) or Fosha's accelerated experiential dynamic psychotherapy (Iwakabe et al., 2020). These approaches involve some of the interventions mentioned above. ...
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The primary purpose of this article is to introduce emotion-based interventions to clinicians that may not be familiar with such techniques. The article explains how emotion-based interventions could help transform the effectiveness of psychotherapy beyond that of traditional interventions alone, which are associated with cognitive behavioral or psychodynamic psychotherapy. Research suggests that techniques of emotional awareness, emotional validation, self-compassion, understanding the origin of emotions, forgiveness, grief work, and memory reconsolidation could offer novel interventions to improve therapeutic outcomes. A clinical example of panic disorder is provided to demonstrate how emotional interventions would be distinguished for traditional cognitive and behavioral interventions. Clinicians are encouraged to integrate emotional interventions in conjunction with cognitive and behavioral techniques that they may already currently be familiar with to optimize their clinical practice.
... The effectiveness of AEDP is demonstrated with 62 clients in private practice settings (Iwakabe et al., 2020). Improvements on depression, psychological symptoms, experiential avoidance, emotion regulation, negative thoughts, interpersonal problems as well as self-compassion and self-esteem achieved a large effect size. ...
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The term hikikomori, or social withdrawal, was first coined in the late 1980s in Japan to describe adolescents and young adults who isolated themselves at home, withdrew from most social engagement, such as work or school, and had almost no relationships with others (except family members and online contacts) for longer than 6 months. Hikikomori often results from emotional injuries such as rejection, or failures that have not been addressed or even noticed. In the current case illustration, the problem of hikikomori is depicted through a client named Ken, a 40‐year‐old single man who, following graduation from university, became lodged in a 15‐year cycle of repeatedly finding employment, quitting within the first year, and going into reclusive isolation. Ken underwent affect‐oriented integrative psychotherapy for 4 years. The importance of processing emotional pain and highlighting positive emotional experiences to build a positive sense of self in working with hikikomori will also be discussed.
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Chronic and repeated exposure to relational and developmental trauma can result in a presentation that differs from posttraumatic stress disorder (PTSD), with a unique cluster of complicated symptoms, and has thus been labeled as complex PTSD (CPTSD). Many such individuals meet criteria for PTSD while also exhibiting additional symptomology not accounted for in a traditional PTSD diagnosis. This case study provides an overview of the differences between PTSD and CPTSD, using empirical evidence to illustrate the necessity of distinguishing between these two differing diagnoses and subsequently the need for differing treatment approaches. The purpose of this case study is to examine the benefits of using a three-phase, integrative model for an individual with CPTSD. Specifically, it explores the delivery of Courtois and Ford’s (2013) sequenced, relationship-based approach to the treatment of complex trauma. This model was chosen due to the emphasis on attachment and because it allows for clinicians to tailor interventions to the unique individual while also providing an overarching structure to treatment. This treatment analysis is demonstrated via the hybrid case of "Chloe,” who serves as a meaningful representation of a psychotherapy patient with a history of chronic relational and developmental trauma who presents to treatment with symptoms concurrent with a CPTSD diagnosis. Chloe’s composite case example is based on the author’s actual, de-identified psychotherapy cases in addition to clinical examples in the relevant literature. Using the format of a pragmatic case study (Fishman, 1999, 2013), Chloe’s case is analyzed through qualitative processes and quantitative measures. An in-depth illustration of this hybrid patient’s course of treatment provides an avenue for describing key clinical issues related to the treatment of CPTSD and the utility of an integrative treatment approach. Chloe’s case study is intended to be a resource for clinicians seeking more knowledge and understanding of the impact of chronic developmental and relational trauma and the implications this has for effective treatment.
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Although psychotherapy research has traditionally focused on decrease in distress, emotion research suggests the important role of positive emotional experience in healing and growing. Objective: The present study investigates the relationship between positive emotional experiences and working alliance. Method: We chose to investigate this relationship in accelerated experiential dynamic psychotherapy (AEDP), taking advantage of the modality's focus on both negative and positive emotional experiences. Fifty-eight clients receiving 16-sessions individual AEDP reported on their post-session levels of working alliance and positive emotions (enlivenment affect, positive relational affect, and peacefulness). The alliance-emotion relationship for each emotional categories was tested with separate disaggregated cross-lagged panel models. Results: Across the three categories, higher positive emotions at the end of the previous session were associated with higher working alliance at the end of the next session. On the other hand, working alliance did not contribute to any of the positive emotions in the next time point. Furthermore, the three emotion categories showed different patterns of development. Conclusion: The findings suggest that fostering positive emotions may be a promising venue to enhance working alliance. Furthermore, differentiating specific positive emotions is likely important both for research and practice.
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Background In New Zealand and elsewhere, the workloads and counselling impact of counsellors in private practice have been seldom researched despite them comprising a substantial proportion of practitioners. Aim This study sought to establish a profile of one self-employed counsellor's caseload over several years, assess the impact of counselling using the Outcome Rating Scale (ORS) and provide an example of collaborative, practice-based research (PBR). Method A retrospective client review of client records included demographic information and ORS scores. Analyses identified the nature of any clinical change and its association with client demographics. Results The average age of 720 clients was 41.5 years; 44% were male; and 71% were Pākehā versus 23% Māori. The average number of sessions was 2.4. For the 274 clients with first- and last-session ORS scores, repeated ANOVAs revealed significant changes in ORS scores over time, irrespective of client characteristics and no significant interactions between any of the variables and gains over time. The effect size (0.9) was ‘large’, and Reliable Change Index indicators were comparable to overseas studies using adult subjects in public health settings. Discussion The counsellor's caseload profile was similar to an earlier one and the gain in clients’ ORS scores was comparable to those in several other countries and not associated with clients’ demographic data. There are several reasons for counsellors to collaborate with others in analyses of their practice. This research provides a useful example of such collaboration.
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The coronavirus (COVID-19) pandemic created an unprecedented physical and mental health crisis on an international scale. Clients and therapists alike navigated the fears and uncertainty surrounding the virus, often in an environment of social isolation. The following paper presents a brief overview of the unique stressors and psychosocial factors impacting therapeutic work in the time of the coronavirus pandemic, including fears of the virus and social transmission, relational stressors due to isolation, grieving in isolation, fear of death, financial challenges, and the transition to telehealth. In addition, this paper aims to provide specific interventions and helpful approaches for psychotherapists navigating the novel challenges and demands to their clinical work through an AEDP (Accelerated Experiential Dynamic Psychotherapy) perceptive. This includes finding an entry point for accessing the pain: undoing aloneness; moving through the pain: dyadic affect regulation; and paying close attention to vitality within suffering: searching for transformance. Recommendations for the health and care of the clinician are also discussed, such as attuning to self-needs, anticipating and detecting dysregulation, staying with the good, meaning-making, identifying and responding to burnout, and the importance of receiving personal therapy and clinical supervision.
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This paper, using the methodology of moment-to-moment microanalysis of videotape-based clinical transcripts, explores how Nicole Vigoda Gonzalez’s (2018) case study manifests AEDP’s fundamental transformational phenomenology in clinical action. Vigoda Gonzalez’s highly effective AEDP therapy of Rosa is informed by AEDP’s first "avatar" or iteration (prior to 2008), at the time, a three-state phenomenology. Yet, a close reading of the case reveals the very transformational phenomena, systematically and abundantly reflected in the author’s clinical data, that necessitated the theoretical and clinical developments of AEDP’s second avatar (post-2008) and the current four-state model of transformational change. It is a validation both of the soundness of this student therapist's clinical work and of the accuracy and power of AEDP’s healing-oriented transformational theory that constructs not in the author’s repertoire are nevertheless reflected and illustrated in the unfolding of Rosa’s treatment. This most interesting and unusual experience further illustrates how a descriptive phenomenology, guided by AEDP’s North Star, i.e., its orientation toward the wired-in healing within, can constitute an empirically sound alternative to the manualization of psychotherapeutic treatments. Also uncannily, this parallels the emphasis in Owen's (2013) multicultural orientation (MCO) framework on the need for "values" or "virtues," such as cultural humility, to "inform therapeutic activities as an alternative to the focus on multicultural competencies."
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Social anxiety disorder (SAD) is associated with considerable individual suffering and societal costs. Although there is ample evidence for the efficacy of cognitive behavior therapy, recent studies suggest psychodynamic therapy may also be effective in treating SAD. Furthermore, Internet-based psychodynamic therapy (IPDT) has shown promising results for addressing mixed depression and anxiety disorders. However, no study has yet investigated the effects of IPDT specifically for SAD. This paper describes a randomized controlled trial testing the efficacy of a 10-week, affect-focused IPDT protocol for SAD, compared with a wait-list control group. Long-term effects were also estimated by collecting follow-up data, 6, 12, and 24 months after the end of therapy. A total of 72 individuals meeting diagnostic criteria for DSM–IV social anxiety disorder were included. The primary outcome was the self-report version of Liebowitz Social Anxiety Scale. Mixed model analyses using the full intention-to-treat sample revealed a significant interaction effect of group and time, suggesting a larger effect in the treatment group than in the wait-list control. A between-group effect size Cohen’s d = 1.05 (95% [CI]: [0.62, 1.53]) was observed at termination. Treatment gains were maintained at the 2-year follow-up, as symptom levels in the treated group continued to decrease significantly. The findings suggest that Internet-based affect-focused psychodynamic therapy is a promising treatment for social anxiety disorder.
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Research studies focusing on the psychometric properties of the Beck Depression Inventory (BDI) with psychiatric and nonpsychiatric samples were reviewed for the years 1961 through June, 1986. A meta-analysis of the BDI's internal consistency estimates yielded a mean coefficient alpha of 0.86 for psychiatric patients and 0.81 for nonpsychiatric subjects. The concurrent validitus of the BDI with respect to clinical ratings and the Hamilton Psychiatric Rating Scale for Depression (HRSD) were also high. The mean correlations of the BDI samples with clinical ratings and the HRSD were 0. 72 and 0.73, respectively, for psychiatric patients. With nonpsychiatric subjects, the mean correlations of the BDI with clinical ratings and the HRSD were 0.60 and 0.74, respectively. Recent evidence indicates that the BDI discriminates subtypes of depression and differentiates depression from anxiety.
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This article explores key aspects of the termination process in a 16-session treatment protocol of accelerated experiential dynamic psychotherapy (AEDP). AEDP theory and its empirical support are described; interventions used throughout termination are demonstrated with verbatim clinical exchanges; and potential challenges faced during termination are addressed. Congruent with AEDP's healing orientation, termination is reframed as completion and launching: Although treatment ends, the change process begun in therapy can continue, as does the therapist's care for the patient. AEDP interventions during termination include (a) relational strategies to foster connection and undo aloneness; (b) the highlighting of patient resilience and the celebration of growth; (c) affirmative work with defenses around loss; (d) coregulation of patient's emotional experience; (e) experiential, bodily-rooted affective strategies to process and transform negative emotions; and (f) thorough exploration and processing of ensuing, vitalizing positive emotions and in-session experiences of change-for-the-better (i.e., metatherapeutic processing), to expand these and promote enhanced well-being and flourishing. Therapists aim to (a) elicit and process emotions related to the completion of treatment; (b) celebrate patients' affective achievements; and (c) convey trust and confidence in an ongoing transformational process, predicted to yield not only diminishment of symptoms and suffering but also upward spirals of flourishing. AEDP suggests that in providing patients a new, positive attachment experience of togetherness as therapy ends, termination offers a unique opportunity to disconfirm patients' earlier attachment-based expectations, revise inner working models, and help patients grow in self-confidence as they face, accept, and thrive in the wake of loss. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Psychotherapy has primarily focused on ameliorating symptoms and psychopathology. This is in contrast to positive psychology, which has focused on bringing about what Keyes (2002) has called "flourishing." Accelerated experiential dynamic psychotherapy (AEDP) seeks to bridge the two traditions by both relieving suffering through processing painful negative emotions to completion and then going on to foster flourishing, in session and beyond, through a technique called metatherapeutic processing. After a brief summary of the AEDP approach, the aim of this article is to elaborate specifically on metatherapeutic processing, where a focus on savoring and exploring the positive affects that accompany the change process itself can set into motion an upward spiral of positive affect that broadens and builds the treatment's effectiveness. We provide a how-to primer on metatherapeutic processing as well as annotated transcript material from three cases to illustrate the application of the technique. We describe how metatherapeutic processing can organically foster, from the bottom-up, positive feeling states labeled transformational affects, such as gratitude, love, hope, curiosity, and zest, freeing up these vital energies that were latent within the client. We go on to propose that although metatherapeutic processing was conceived of within the framework of AEDP, it is a technique that can be integrated into a wide variety of psychotherapies, to activate flourishing in session and beyond. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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It is not yet clear what mental disorders are and what are the causal pathways that lead to them. That makes it difficult to decide what the targets and outcomes of psychotherapies should be. In this paper, the main types of targets and outcomes of psychotherapies are described, and a brief overview is provided of some of the main results of research on these types. These include symptom reduction, personal targets and outcomes from the patient's perspective, improvement of quality of life, intermediate outcomes depending on the theoretical framework of the therapist, negative outcomes to be avoided, and economic outcomes. In line with the dominance of the DSM and ICD systems for diagnoses, most research has been focused on symptom reduction. This considerable body of research, with hundreds of randomized trials, has shown that for most mental disorders effective psychotherapies are available. There is also research showing that psychotherapies can result in improvement of quality of life in most mental disorders. However, relatively little research is available on patient‐defined outcomes, intermediate outcomes, negative outcomes and economic outcomes. Patients, relatives, therapists, employers, health care providers and society at large each have their own perspectives on targets and outcomes of psychotherapies. The perspective of patients should have more priority in research, and a standardization of outcome measures across trials is much needed.
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Given recent attention to emotion regulation as a potentially unifying function of diverse symptom presentations, there is a need for comprehensive measures that adequately assess difficulties in emotion regulation among adults. This paper (a) proposes an integrative conceptualization of emotion regulation as involving not just the modulation of emotional arousal, but also the awareness, understanding, and acceptance of emotions, and the ability to act in desired ways regardless of emotional state; and (b) begins to explore the factor structure and psychometric properties of a new measure, the Difficulties in Emotion Regulation Scale (DERS). Two samples of undergraduate students completed questionnaire packets. Preliminary findings suggest that the DERS has high internal consistency, good test–retest reliability, and adequate construct and predictive validity.
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The psychological sequelae of prolonged and repeated exposure to relational trauma can manifest into a challenging clinical picture typically known as Complex PTSD. Accelerated Experiential Dynamic Psychotherapy (AEDP) is a multimodal and integrative model particularly designed to address attachment disturbances and extreme forms of affective avoidance and dysregulation commonly seen in survivors of relational trauma. Conducting this treatment in a language that is not the patient’s native tongue may interfere with emotional processing, a key component of AEDP. The purpose of this study is twofold. First, it aims to examine the benefits of experiential and attachment-based models for the treatment of "Rosa," a bilingual woman and survivor of relational trauma, who presented to treatment with depressive and Complex PTSD-like symptom. Second, the study explores whether actively incorporating Rosa’s bilingualism and ethnic identity into the treatment enhanced her capacity for emotional processing and other related aspects of AEDP. This exploration constitutes an ideal avenue for documenting the clinical challenges one may encounter in doing psychotherapy with bilingual trauma survivors. For in this type of therapy, the affective processing of traumatic memories can be lost in translation. This requires the creation of an individualized treatment plan that can address these barriers, amplifying the emergence of relational safety and ultimately facilitating the patient’s new experience of core state (Fosha & Yeung, 2006), an integrated state of clarity, ease, and self-compassion.