Affect Centered Therapy (ACT) translates recent advances in several areas of psychotherapy into effective treatment for a range of Axis I and II disorders. ACT incorporates an understanding of the fundamental role of emotion in all dimensions of human functioning. ACT is derived from attachment theory. ACT is predicated on a developmental model that emphasizes socioemotional conditioning of the personality and of the central nervous system’s growth. ACT stresses the central role of childhood adversity and trauma in conditioning subsequent psychopathology.
Affect Centered Therapy (ACT) is predicated on a developmental model for psychopathology (Sroufe, 1997) and upon a Dynamic Systems approach to personality self-organization (Lewis, 2000). The distressed, maladapted personality is believed to develop according to the same principles as the healthy personality. The personality organizes itself in the context of the early environment, consisting primarily of the infant-caregiver dyad. The quality of this dyad determines the quality of the attachment bond. Within this dyad, the infant acquires the skills of affect regulation (Schore, 1994). Deficits in the dyadic relationship result in failures of affect regulation. This is termed deficit experience. Deficit experience renders the child vulnerable to the effects of subsequent adversity. Overt trauma or adverse experience in childhood can compound already existing difficulties of affect regulation. Trauma and adversity place an emotional load on the vulnerable child that he or she lacks the internal resources to carry.
Across adolescence, the personality reorganizes in preparation for reproduction and adult socialization. The personality structure that emerges over adolescence is conditioned by the socializations occurring in childhood and latency. In the personality disorders, the self structure is often compromised both by severe deficits during the attachment phase and by adverse or traumatic experience. The emergent personality of adolescence integrates maladaptively into a unified structure formed by responses to life experiences over developmental time. In the clinical disorders, the emergent personality structure appears fragmented into ego states, at least one of which is more or less adaptively functional. Other ego states exist to regulate emotions that would otherwise overwhelm the system. In a subset of clinical disorders termed the ingestive disorders, the fragments of the personality system, I.E., the ego states, facilitate emotion regulation through the agency of an abused substance.
ACT is a general approach to treatment of both clinical and personality disorders that focuses on affects and the central place of affect regulation in the distressed personality system as well as on trauma-resolution.
ACT Therapy
ACT is a general approach to treatment of both clinical and personality disorders that focuses on affects and the central place of affect regulation in the distressed personality system. ACT consists of three phases. In phase I, the client is taught basic skills for emotion regulation using the Affect Management Skills Training (AMST) protocol. AMST remediates deficits from childhood and prepares the client for the uncovering and resolution work of phase II.
Affect Management Skills Training
Affect Management Skills Training (AMST) is a structured protocol for remediating deficits in emotional regulation. Affects motivate human behavior (Izard, 1991; Nathanson, 1992). As noted, the ingestive disordered client uses the abused substance to manage disturbing affects that would otherwise be overwhelming. Beginning treatment by teaching affect management creates a win-win situation with the client and her unconscious. As the client learns these skills, she is immediately empowered and gains a sense of mastery. The client’s unconscious is aware that the client is learning to manage the disturbing affects and is then more willing to relinquish control through the abused substance. The structured protocol provides a decision tree that enables the therapist to identify missing resources and to uncover covert ego states. Once recognized, the missing resources can be installed, and the ego states can be co-opted into a helping role with the therapy.
Tactile Alternating Bilateral Stimulation (TABS) increases the effectiveness and efficiency of AMST. TABS is a means of alternately stimulating the right and left hemispheres of the brain. TABS is effected through tactile stimulation provided by a battery-powered device called a TheraTapper™ It is believed that the increased flux of information through the corpus callosum stimulates the brain’s information processing system allowing access to all dimensions of experience: behavior, affect, sensation, and cognition. With affect regulation in place, the client can now participate in uncovering and resolving the traumas she has been reenacting through the abused substance.
ACT Phase II
Phase II of ACT facilitates the client in uncovering and resolving the childhood experiences of adversity and trauma that set the client on a pathway toward his or her present pathology. Phase II is predicated on successful acquisition of the emotion regulation skills of phase I. The personality system will only change when it has acquired new skills for emotion regulation to replace the dysfunctional skills that constitute the current psychopathology. ACT’s phase II has been successfully applied to treatment for addictions, alcoholism, bulimia, anorexia, binge eating disorder, Crohn’s disease, obsessive-compulsive disorder (OCD), generalized anxiety disorder, sexual acting out, narcissistic personality disorder, and borderline personality disorder.
Traumaphor Associations
The abused substance is called a traumaphor, since its use suggests similarities with the archaic trauma. The second step in resolving the ingestive disorder consists of exploring the client’s behavioral, affective, cognitive, sensate, and memorial associations to the drug(s) of choice, or traumaphor(s), placed in an “empty chair.” ACT Treatment adapts Gestalt communication technique for an analytic purpose. The client is asked to visualize the drug of choice in a factually empty chair, and the therapist facilitates an exploration through a structured protocol. This protocol reveals what emotions the client is regulating by means of the abused substance and what emotions were directed against the client by the abuser in the past. The protocol assists the client in understanding the nature of his relationship to the abused substance and how it recreated some prior unresolved relationship. The traumaphor associations requires about one-half hour to complete and prepares the client for the third component of treatment, traumaphor focused processing.
Traumaphor Focused Processing
The traumaphor is the key that unlocks the neural network containing images, sensations, cognitions, and affects relating to the archaic, unresolved trauma. Traumaphor focused processing adapts the standard protocol of EMDR (Shapiro, 1995) to treatment of ingestive disorders. In this application, the client visualizes the traumaphor and identifies a negative belief about herself, an accompanying emotion, and physical sensations associated with the emotion. The client is asked to hold the image of the traumaphor, the emotion, the belief, and the sensation, and with TABS facilitation, the archaic, unresolved trauma is uncovered and resolved. Resolution, which is also known as abreaction, involves confronting the original traumatic situation, reexperiencing it, releasing the bound affect, and achieving cognitive meaning. The progress of resolution is tracked by client report through a measure called Subjective Units of Disturbance (SUD). As processing occurs, the level of disturbance of the traumaphor decreases. When processing is completed, a previously identified positive belief is installed using TABS while the client holds the image of the traumaphor. For example, one addict visualized a large bud of powerful marijuana. At the beginning of processing, his negative belief was “I am still fascinated by pot.” This was highly disturbing; SUD = 7. Following processing the disturbance had decreased significantly. At this point the positive belief, “I am free of fascination with pot”, was installed, using TABS to bring this to complete validity.
The Ingestive Disorders
ACT has been applied to treatment of the ingestive disorders. These disorders are characterized by use of a substance as a means of regulating emotions that would otherwise overwhelm the personality system. The abused substances may include alcohol, drugs, nicotine, or food.
The ingestive disorders include alcoholism, addictions to legal and illicit drugs, nicotine dependency, and the eating disorders. Each of these disorders is characterized by abuse of a substance: alcohol, drugs, nicotine, or food. The abused substance facilitates the three R’s: regulation, reenactment, and reexperiencing (Omaha, 1998; Omaha, 2001).
Regulation The abused substance enables the individual to regulate current disturbing emotion that would otherwise be overwhelming.
Reenactment The abuse substance facilitates reenactment of unresolved, archaic trauma.
Reexperiencing The abused substance facilitates a vicarious reexperiencing in a more or less dissociated state of unprocessed emotions assembled with the trauma(s) at the time(s) of occurrence.
A Syncretic Theory And Therapy
“Syncretic” means the process of growth of a system through accretion of tenets and propositions from a variety of sources. The theory upon which ACT is founded brings together concepts and ideas from genetics, developmental neurobiology, developmental psychology, dynamic systems theory, attachment theory, object relations, information processing, dissociation theory, trauma theory, and ego state theory. ACT unites therapeutic concepts from Eye Movement Desensitization and Reprocessing (EMDR), attachment therapy, Gestalt therapy, ego state therapy, and relapse prevention.
ACT Theory For The Ingestive Disorders
ACT is a psychodynamic model for the ingestive disorders. It traces the causes of present behaviors and dysfunctions to events in infancy, childhood, and preadolescence. The primary causes of the ingestive disorders are deficit experience and trauma or adversity. Deficit experiences occur when the dyadic, attuned, mutually responsive relationship between infant and the primary maternal caregiver fails for whatever reason. Sometimes the primary maternal caregiver has to return to work, and the day care provider cannot adequately attend to all of the infant’s needs. Sometimes the relationship is adversely impacted by maternal substance abuse. ACT Theory states that deficit experiences during the period from birth through the third year result in an impaired attachment. Failures of the attachment stage of development produce deficiencies in emotional regulation. The greater the failures in attachment, the more severe the deficiencies in emotion regulation. By the onset of adolescence, individuals whose childhoods are characterized by failed attachment have difficulty recognizing, tolerating, or regulating negative as well as positive emotions.
Adversity or trauma is a second cause of adolescent and adult onset ingestive disorders. Trauma occurs on a range from less severe, called adverse experience, to more severe, termed trauma. At the less severe end of the spectrum are neglect, abandonment, and physical or emotional unavailability. Severity increases with verbal, emotional, and psychological abuse. This can include double binding, shaming, devaluating, and denigrating. Physical abuse and sexual abuse are at the most severe end of the scale. Childhood trauma is known to prevent consolidation of identity. In object relations terms, trauma prevents separation and individuation of the self from inner representations of the parents or primary caregivers. The images, sensations, and emotions associated with traumatic events are stored in a state-specific, excitatory form in which they are more likely to be triggered by internal or external stimuli than is more adaptive material (Shaprio, 1995). Trauma theory proposes that the trauma(s) will be reenacted in a disguised form. ACT Theory hypothesizes that addictions, alcoholism, eating disorders, and nicotine dependency are forms of trauma reenactment.
The Genetic Basis For The Ingestive Disorders
Humans inherit an emotion processing system. The objective of this system is to resolve disturbing emotions adaptively. The robustness of this emotional processing system is inherited. Alcoholics, for example, are believed to have inherited deficiencies in the endorphinergic neurotransmitter system. This deficiency reflects the genetic impairment of one aspect of the emotional regulatory system. Alcoholism is not a disease, nor are nicotine dependency, addictions, or the eating disorders. They are not inherited. They are disorders with a heritable component, the robustness of the emotional regulatory system.