In It’s Not Always Depression, Hilary Jacobs Hendel seeks to distill accelerated experiential dynamic therapy (AEDP) into an easy-to-read guide for both patient and therapist. A major tenet of AEDP is the recognition that often the patient’s initial complaints of depression or anxiety are inhibitory or secondary emotions. These secondary emotions arise from defenses against “core emotions” that have not been fully processed or experienced because of perceptions that they are invalid, too overwhelming, or not socially acceptable. Core emotions can be things like fear, anger, sadness, disgust, joy, excitement, or sexual excitement. The therapist’s goal is to help the patient identify inhibitory emotions, trace them to their sources earlier in life, and physically experience the underlying core emotion.
AEDP is a therapeutic modality that was developed by Diana Fosha in the early 2000s that draws upon principles of psychodynamic therapy by acknowledging intrapsychic and childhood etiologic forces in the development of adult psychopathology, particularly affective and interpersonal problems. AEDP goes beyond the intellectual exercise of traditional dynamic therapy by placing emphasis on in-session vulnerability and the physical experience of defended-against affect within the supportive dyadic relationship with a therapist. It posits that as true emotions are physically felt, described, validated, and interpreted within the supportive therapeutic relationship, inherent human “transformance strivings” are catalyzed to bring about enduring healing. It also draws upon techniques from dialectical behavioral therapy (DBT), cognitive processing therapy (CPT), and exposure with response prevention (ERP), to name a few, in eliciting cognitions and underlying affect and tolerating and metabolizing this affect.
Hendel begins her presentation of AEDP with a visual aide she calls “The Change Triangle,” a representation of how defenses generate inhibitory emotions like shame, guilt, and anxiety that block the experience and processing of core emotions like anger, fear, disgust, sadness, excitement, and sexual excitement. She describes how circumventing defenses and processing core emotions leads to what is termed the “Openhearted State of the Authentic Self” (somewhat analogous to the “Wise Mind” of DBT.) She then discusses how these defensive patterns have their basis in trauma. She uses an expanded definition of trauma which she categorizes as both “Small t Trauma” and “Big T Trauma,” indicating that for the basis of healing, the objective severity of any trauma is less important than the degree to which it affected enduring patterns of pathology. She does well to avoid reducing all psychopathology to bad parenting or passing moral judgment on well-intentioned but misguided parent–child interactions of the past. She nevertheless appropriately acknowledges childhood trauma of many varieties as fertile therapeutic ground for understanding patterns of adult dysfunction. She even goes so far as to invite her clients to “self-parent,” utilizing their now adult perspective to provide compassion and healing to their childhood selves.
The purpose of Hendel’s book is to make heavily theoretical ideas accessible to even the lay reader while still providing useful guidance to both young and seasoned clinicians. For those with psychotherapeutic training, it is well-understood that a narrative example is often worth a thousand theoretical treatises. Hendel follows this wisdom by introducing the above principles and then spending most of the book bringing them to life with a plethora of compelling, real-world examples. She even goes a step further by chronicling her own personal journey with the therapeutic principles she describes. She also includes many exercises that both patient and therapist can utilize to discover how these principles might be at play in their own lives. By taking this tack, Hendel manages to write a book that is useful both as standalone bibliotherapy and as an ancillary resource to both patient and clinician. While much of what is included in the book overlaps with other theoretical orientations and accepted therapeutic techniques, the greatest strength of this book is perhaps its accessibility and readability. Its formulation of some commonly seen clinical scenarios provides pragmatic solutions for improving emotional health in both patient and practitioner. I also found its endorsement of the positive emotions of joy, gratitude, and pride in the self to be a refreshing counterbalance to the negative valence emotions that often receive disproportionate treatment by other works.
Forensic evaluation is often concerned with seeking to characterize the truth of clinical scenarios for the education of legal audiences. This frequently precludes case formulation and etiologic explanations that could be speculative or merely pragmatic to therapeutic work and not representative of objective truth. Because of this, forensic psychiatry has been considered by some to be a less psychotherapeutically-oriented discipline. I would argue, however, that this book remains highly relevant not just as a clinical tool for working with forensic patients for whom “Big T Trauma” is nearly ubiquitous but also for the maintenance of emotional health and the avoidance of emotion-based biases in the forensic evaluator. As we’ve seen AAPL as an organization increasingly embrace principles of resiliency and self-care for its members, Hendel’s work is a particularly timely primer for forensic psychiatrists on dealing with the emotional vicissitudes of the profession as clinicians and evaluators. As we navigate the complexities of the situations we confront in our various roles, we could all use greater access to the “Openhearted State of [our] Authentic Selves.” We could all benefit from diminished shame and greater self-compassion. An increased capacity to feel joy, gratitude, and pride in ourselves would be a salutary development. Perhaps selfishly, I’ve found this book to be even more relevant personally than professionally, but I suppose it is wisdom to note that the two go hand-in hand.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2022 American Academy of Psychiatry and the Law
