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Maximizing the Transformational Power of AEDP Using Groups in Community Mental Health Settings

Heather Sanford LCSW, MPA

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The Professional is Personal

Soft landing and curative curiosity

Then the New York Times and a little bit of hope

Internal pressure to shout it from the rooftops!

In 2016 – I began a position at Tompkins County Whole Health in Ithaca, NY running an outpatient program for adults with Serious Mental Illness and Substance Use problems. This was a new program licensed by the Office of Mental Health. I loved the job. It was really hard and I was so anxious and worried that I couldn’t do it and that it wouldn’t take long for everything to fall apart. I had been an anxious mess internally my whole life, but highly functional. I knew I needed therapy, but I had had a very bad experience in traditional talk therapy a few years before. Out of desperation to feel better, I tried again and landed in the lap of an AEDP therapist. My experience with her was… very strange. I was pretty sure she was nuts, not like any therapist I had ever known, and certainly not how I was trained as a social worker. I was curious, so I kept seeing her. I found this AEDP approach to be a soft landing, a place where space to breathe was offered, even if I wasn’t ready to receive the love that was available. I didn’t have access to the feelings and fully depended on my thinking brain to “figure out” what was going on for me.

One day I saw an article in the New York Times by Hilary Jacobs Hendel titled “It’s not Always Depression, Sometime it is Shame.” Initially I read the article because I was interested in better understanding the experience of my program participants in order to help them. I had no idea the effects that reading this would have on my life. I preordered her book. When it finally arrived, I read it in one night. Finally, things started to make sense for me. I still wasn’t ready to engage with the world emotionally, but I could understand how and why AEDP worked. I became curious about my own experiences. I always thought I was a good therapist because I didn’t have emotions that got in the way of my ability to do my job. It turns out I had lots of emotions, they were just well protected by layers of defenses and so much anxiety and depression.

I wanted so much to share this new information with the people in my program. I knew this information was vital to healing – in my head – but still had no idea what it felt like to experience the transformational power of AEDP.

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The Setting: Personalized Recovery Orientated Services�

Who: People, mostly insured with Medicaid and Medicare, struggling with Severe Mental Illness. Many also deal with substance use barriers

Where: Tompkins County Mental Health- Ithaca, NY

What: Psychiatric rehabilitation program focused on helping people find or return to a satisfying life

Back to the program - PROS was created for people in NYS who struggle Severe Mental Illness and substance use. Frequent diagnoses include: Schizophrenia, Bipolar Disorder, PTSD or Major Depressive Disorder. Participants must experience mental illness to such a degree that it interferes with their ability to function in daily life, maintain employment, housing and relationships. Many of the program participants also struggle with problematic substance use. These people are mostly insured by Medicaid or Medicare. A population who often does not have access to AEDP therapy, often times, not really even having access to reliable, consistent therapy in the community mental health system. There are just so many people in need and so few resources. Many of the PROS participants were only being seen every other week or less in therapy. I believed that they needed more, but I am only one person so I couldn’t see people as often as I believe they needed to be seen either.

Services in the PROS program are mostly delivered in a group format. Some groups are open, people can come and go each week and others are closed, people need to sign up in advance, committing to attendance for the 12 week session. These two different models gave me the opportunity to try two different kinds of groups with this material, a psychoeducation group and a processing group for participants after they had finished the initial group. To begin the process, I wrote a 12-week curriculum for the program focusing on basic Emotions Education.

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The Motivation

Help people get “unstuck”

Create more accessibility for people to AEDP

Decrease painful aloneness

Treat trauma that interferes with progress in life goals

My motivation for creating this curriculum and infusing AEDP principles into groups really was to create more accessibility for people to experience AEDP, and to help people get unstuck.

Program participants have often been “in the system” for years, with several hospital admissions, medication trials and attempts at healing through various modalities of treatment. There was so much trauma that was essentially ignored. People learned skills to manage symptoms, but the effects of trauma continued to exacerbate their symptoms and increase the overarching sense of hopelessness. Although PROS is focused on rehabilitation and supporting the creation of a life of value for each person, the “flavor” of the program was one of acceptance – accepting that their lives were never going to change and that they could only expect to survive, not thrive. This seemed strange since one of the principles of PROS is hope! People were so stuck and my heart was breaking.

Groups offered at PROS were mainly focused on teaching DBT skills, ACT and CBT skills. These traditional modalities teach important skills to increase distress tolerance, recognize and reframe distorted thinking and provide people with enough skills to be able to work with their emotions. As is true in traditional therapy models, the interventions offered in the PROS program focused on “fixing the broken parts” and not searching for glimmers of hope and transformation. This was the missing piece for so many people. Participants work so hard day in and day out using their coping skills and still find themselves being triggered everyday as they go about their life. They often see themselves as broken, sick and hopeless. Without meaningful trauma work, they weren’t going to keep moving forward. I just needed to figure out a way to provide good trauma treatment in a group format.

Since the program participants were already in the habit of using their thinking brains to learn skills, including a strong focus on psychoeducation of AEDP themes into this group curriculum, paved the way for deeper healing. The PROS program provides services mostly in group formats. This sets up a perfect environment to create a space where people experience accompaniment by the facilitator as well as the other participants.

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Facilitation

The stance of the facilitator is the same in groups as in individual work.

Healing from the get-go

Establishing safety and undoing aloneness

Moment to moment tracking

Holding the hope

Be a Glimmer Detective

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In Practice

Formal groups with set curriculum – open and closed

12 week 45 minutes focused heavily on psychoeducation and building connection

8 module group focusing on a balance of experiential and psychoeducational elements

Processing groups – closed and only available for those who had completed the 12-week group already

The initial curriculum included 12 45 minutes group sessions focusing on understanding the basics of the Change Triangle and emotions as described by Hilary Jacobs Hendel – Defenses, Inhibitory emotions like Anxiety, Guilt and Shame, core emotions, and finding your authentic core neurobiological self. Other topics that were included were understanding and practicing self-compassion, neuroplasticity, and expanding one’s ability to notice sensations in the body and be able to stay with these sensations. Each session focused mostly on understanding how trauma has and currently effects their lives and views of themselves. This initial curriculum helped create a foundation of understanding and shared language to keep moving forward in healing, as the focus of the Emotions Education group transitioned from psychoeducation to experiential.

At some point after a few months of facilitating these groups, one of the participants contacted Hilary Jacobs Hendel and told her that she had a huge fan group in Ithaca! Hilary reached out and then we began working together to refine the curriculum to make it accessible to the masses. Hilary and I began teaching Emotions Education 101 courses to people all over the world in an 8 week 90 minute format. Additionally, we began train the trainer classes to support others in teaching this simple, yet effective curriculum. I was thrilled with how well this curriculum was received by a world wide audience, but was unsure about the appropriateness of such experiential work with the population at PROS.

When we first started with the new curriculum, I was afraid that it was “too much” for the participants at PROS, believing that they weren’t ready to move from mostly psychoeducational groups to a more experiential focus. However, I decided to give it a try! Through the process of doing this, I began using the new curriculum with participants in the PROS program. The biggest transition was the incorporation of more experiential exercises into the curriculum. Each session included a brief opening exercise designed to help participants settle into their bodies and be open to the information presented. Metaprocessing followed the opening exercise, leading into a didactic portion providing information about the topic of the day. The second exercise was used to deepen the experience and then the groups are closed with metaprocesessing to make the implicit, explicit and the explicit experiential. Topics of the revised curriculum include: Making space for all emotions, Defenses, Anxiety, Guilt and Shame, Core Emotions focusing on Sadness, Anger, Expansive emotions – joy, delight and pride in the self and ending with Connecting with the authentic self.

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Simplifying, not Watering Down

Slowing Down

Connection

Use of Self

Power of Psychoeducation

Incorporation of In the Moment Experiences

Accompaniment

Receptive Affective Experience, Making the Implicit Explicit and the Explicit Experiential

Do this with me - cross your arms in front of your chest (demonstrate crossing arms). Notice which arm is on top, mine is my left. This feels pretty natural, I don’t even think about it. I cross my arms the same way every time. Now, cross your arms again purposefully positioning the other on top. It feels weird and awkward right? If you crossed your arms this way for a while, it wouldn't take long before it started to feel more natural and then you may cross your arms this way without even noticing it! That is how we change patterns of behavior or thinking in our brains and bodies.

First, we have to just notice what is going on, so that requires us to slow down, way down. Using simple exercises and metaprocessing to help participants experience something new, discussing this in a group setting reducing aloneness and provides more space for change, allowing the seed of hope to grow! Groups are great for celebrating success! As people notice shifts in themselves, or even better – in others – they can celebrate this together!

In the group setting I was able to share little bits of myself, my own struggles and growth. Though I was afraid to do this at all when I started in this position. I didn’t want anyone to know that I had such a hard time with anxiety and depression, even causing weeks stuck in bed and barely able to function. I didn’t want my participants (or administration) to know that I was “crazy” or be worried that I wasn’t able to run the program. When I shared my struggles with depression and then asked those in the group what it was like to hear that from me, one participant replied, “well I can talk to you now because you really do get it. You aren’t just talking from a textbook.”

During processing of the participants’ experiences during the exercises, I would share my own internal experience and the effects of the participants’ experience on me. In time, other participants also began to give feedback and responses to each other from their hearts saying things like, “when you shared that I got goosebumps!” and “I am angry on your behalf! This only deepened the relationships of the members of the group.

Incorporating psychoeducation helps participants to understand their experiences and feel less “crazy.” When participants are able to see themselves as something other than “sick or broken” so many doors of healing can open for them. Participants in closed groups also benefited from portrayals right during the group! After one moving experience with a participant working through an anger portrayal with her mother, others were scrambling to participate in thei own portrayal because they wanted to experience the same transformation that they saw in the eyes and face of their peer.

One of my favorite moments in group years ago, was when a participant who was the youngest in the group by far and usually didn’t have much to say, responded during metaprocessing saying that “I will hold all of you with love in my intestines. I would have said heart, but there is more surface area in my intestines and I feel like I have more room to hold people I care about now.”

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“I will hold all of you with love in my intestines. I would have said heart, but there is more surface area in my intestines and I feel like I have more room to hold people I care about now.” - W

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If you Just Believe… Amazing things happen!

Client Stories

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Resources

Jacobs Hendel, H. (2018). It’s Not Always Depression. Random House.

Fosha, D. (2000). The transforming power of affect: A model for accelerated change. Basic Books.

Fosha, D (2021) Undoing Aloneness and the transformation from suffering into flourishing. American Psychological Association.