Emotion Focused Therapy by Antonio Pascual-Leone

Emotion Focused Therapy by Antonio Pascual-Leone

• EFT → experiential and humanistic therapy 

  • Formulated in 1985 by Leslie Greenberg, Laura Rice and Robert Elliott 

  • Unfolding a client’s moment by moment experience 

THEORETICAL BACKGROUND

• EFT originated from the theoretical tenets of Roger’s person centered therapy 

  • Strong therapeutic alliance premised on empathy 

  • Unconditional positive regard

  • Genuineness 

  • Notable non-directive (client is the expert of the change and the content) 

  • The therapist purposefully guides the process or manner in which topics are discussed

    • May ask the client to explore topics at hand or direct the client’s attention to certain aspects of internal experience 

• Greenberg → interest in Gestalt Therapy 

  • Gestalt therapists utillize therapeutic tasks 

    • Empty Chair Task:  client enacts a conversation as if they were addressing an important other with whom they are experiencing discord

    • Two-Chair Task: in which a client enacts two parts of the self: the inner critic and the part that is targeted by their criticism

  • Concept of therapeutic tasks is embedded into EFT 

• EFT old name Process-experiential Therapy because of the moment by moment therapeutic process 

• Focussing approach → therapists guide clients to reflect on their “felt sense” or somatic experience  

  • As a means of developing emotional awareness 

• Task analysis 

  • Important research method 

  • Researchers were interested in discovering not only what change had occurred but also HOW change had occurred 

• Emotion theory → emotions viewed as an evolutionary based mechanism meant to guide human functioning 

• Greenberg combined Satir’s work on systems therapy with emotion focused principles to create emotionally focused couples therapy 

EMOTION FOCUSED THEORY 

• Human functioning depends on schemes 

  • Schemes: multimodal networks of mentally represented information, including affect, motivation, behaviour, physiological experience and cognition 

• EFT views factors (cognition, affect, behavior) as linked (can’t disentangle) and simultaneously activated parts of an overall emotion scheme 

• Fear-based emotion scheme will involve 

  • Feelings of anxiety 

  • Thoughts about the anticipated threat 

  • Motivation or action tendency to escape 

  • Related physiological sensation or behaviours 

1. Emotion schemes

• Many emotion schemes are inherently adaptive 

  • For example, fear based emotion schemes may be distressing but are adaptive when encountering a potentially dangerous threat because they prompt us to escape danger. 

• Through learning and childhood experiences → develop maladaptive emotion schemes (do not prompt us to meet existential needs)

  • If one is repeatedly blamed during traumatic childhood experiences → develop maladaptive shame (characterised by pervasive and enduring self-blame) 

• Primary emotions:  immediate and direct reactions to stimuli

• Secondary emotions: emerge in response to other emotions, often in an attempt to protect oneself from painful feelings

2. Dialectical constructivism 

• EFT based on neoPiagetian concept of dialectical constructivism

  • NeoPiagetian concept of dialectical constructivism

• Emotion can be generated in a 

  • Bottom-up manner: biologically based, bodily felt sensations that emerge automatically

  • Top down: we can symbolize this felt sense into words which can generate emotion and meaning that in turn impacts our bodily sensations

• There is a cyclical generation of emotion and meaning through:

1. Bodily felt sensations 

2. Interpretation of these sensations^ 

3. (which) further impacts our felt sense 

3. Theory of change 

• Emotion schemes become → dysfunctional or maladaptive → e when they no longer help us to seek out existential needs or become of such intensity that they impair our ability to pursue existential needs

• When emotional memories are activated, they are amenable to memory reconsolidation, and new emotional experiences can be integrated to modify the memory

1. Awareness of emotion 

• Clients must move towards feelings and accept their emotional experience

•  Clients become aware of unmet needs and action tendencies

2. Down-regulation of emotion 

• Clients learn to self-soothe and manage the intensity of dysregulated, extreme emotion 

3. Arousal and expression of emotion 

• Increasing the arousal of an emotional experience can be an important part of fully engaging the process of change

4. Changing emotion with emotion 

• Through construction of meaning → novel adaptive emotions are expressed, which can be used as a tool used to transform or “undo” other maladaptive emotions 

5. Reflection on emotion 

• By cognitively reflecting on emotion, clients symbolize their emotional experience and generate meaning, which shapes emotion and contributes to the generation of new emotional experiences

CLINICAL APPLICATION OF EMOTION FOCUSED THEORY 

• Initial research centered on: 

  • Individual EFT for depression 

  • EFT for couples 

• Second phase → EFT for complex trauma by Sandra Paivio 

• Third phase 

  • Ben Shahar & Robert Elliott → emotion focused theory of social anxiety 

  • Joanne Dolhanty → EFT for eating disorders 

• Until recently emotion focus interventions were mostly for adults 

  • Emotion focused family therapy → for parents of children and teens with eating disorders 

• Emotion focused group therapy also being used for:

  • Incarcerated offenders of partner violence 

  • Eating disorders 

  • Self-criticism 

RESEARCH

• EFT vs CBT 

  • EFT more effective 

  • When controlling for researcher allegiance, between-group differences became nonsignificant, suggesting that EFT is at least as effective as cognitive behavior therapy

• 2021 meta-analysis by Elliott 

  • The type of humanistic therapy significantly moderated the pre–post mean effect size.

    • Types of humanistic therapy: e.g., EFT, Gestalt/psychodrama, person-centered, supportive-nondirective, other

  •  EFT had the largest mean pre–post effect size

  • EFT is at least as effective as 

    • CBT 

    • Person-centered counselling 

• Study by Elliott 2013 

  • Humanistic therapies that were more process-guiding

1. Individual Therapy 

• EFT reduced symptoms in the treatment of depression

• Significantly greater reduction in interpersonal problems

• Lower relapse rates following the treatment of depression, as compared with person centered therapy

• Quasi experimental study

  • EFT → superior to a delayed treatment condition 

  • Two conditions of EFT for trauma 

1. Chairwork 

2. Empathetic exploration 

• Results suggest that some clients may not be willing to participate in chairwork, although doing so may expedite change for clients with complex trauma when they are willing to engage in the enactment.

• EFT → efficacious and specific for individuals with lingering relationship difficulties 

2. Couples Therapy

• No significant betweengroup differences in effect sizes were observed

• Medium effect sizes were observed at therapy termination

• Small effect sizes were observed at a 6-month follow-up 

3. Group and Family Therapy 

• Lower rate of violent recidivism in the first 9 months

• Pre-post study for EFT group therapy for bulimia 

  • Participants → significant improvements in body dissatisfaction, mood, emotion regulation, self-efficacy, and the frequency of binge eating

• Pre-post study for EFT group therapy for self-criticism

  • Participants →  statistically and clinically significant improvements in depression, anxiety, and emotion regulation

TEST OF THEORETICAL TENETS

1. The therapeutic alliance

• The alliance is curative and a mechanism of change in its own right

• The alliance was a direct predictor of treatment outcome

• When therapists demonstrate empathy, genuineness, and unconditional positive regard, they act as role models for client

  • Clinicians can foster therapeutic presence

2. Emotional Arousal and Productivity 

• Moderate expression of emotion is preferable to either extreme expressions of intense emotion or a relative absence of an emotion

• EFT and person-centered therapy 

  • Clients’ reflection and expression on emotion were both found to contribute to treatment outcome 

• For depression 

  • Emotional arousal alone did not predict treatment outcome, but the expression of productive emotion was associated with improvement at treatment outcome 

3. Depth of Experiencing 

• Depth of experiencing refers to extent to which clients engage with and reflect on emotions as they develop a sense of personal meaning 

• Seminal study by Watson & Bedard 

  • Participants with good outcome had greater depth of experiencing than those with poor outcome 

• Meta - analysis 

  • Depth of experiencing predicted client treatment outcomes across various approaches, including EFT

  • Depth of experiencing mediated the impact of emotional arousal on treatment outcome

• EFT for trauma → when clients struggled early in treatment to achieve greater depth of experiencing, depth of experiencing (in the working phase) was the best predictor of treatment outcome 

4. Narrative Processes 

• Three narrative types in the Narrative Processes Coding System (Angus et al., 2019)

1. External narratives describe an event

2. Internal narratives refer to the client’s internal reactions to the event (e.g., thoughts, feelings)

3. Reflexive narratives highlight the significance of the event and the meaning of the client’s reactions

5. The Sequential Order of Emotions 

• specific kinds of emotion that can be used to transform other emotion

• Sequential Model of Emotional Processing 

  • emotional transformation occurs in a series of steps

    • one-stepforward, two-steps-back fashion

  • Emotional transformation begins with 

1. global distress, which is characterized by its vagueness, absence of a clear action tendency, and high arousal

2. primary maladaptive emotions, including fear, shame and rejecting or blaming anger

3. expression of unmet existential needs as well as negative self-evaluations

4. adaptive emotions, including self-compassion, hurt/grief, and healthy assertive anger

• Classification of Affective-Meaning States 

  • developed to identify the states outlined in the model

  • The model was demonstrated to predict treatment outcome in EFT.

  • Good and poor outcome groups were significantly differentiated by the expression of primary adaptive emotions

TRAINING 

• Supervision → process-based approach 

  • wherein the supervisee directs the content, and the supervisor directs attention to salient aspects of the trainee’s performance

• working alliance between the supervisor and supervisee → critical

• Therapists → often oriented to within-session processes through the use of process research tools to help develop their perceptual acuity of key client markers and experiencing

• Training focuses on 

  • Technical skills 

  • Interpersonal skills 

  • Empathic attunement 

  • Modelling and oversation 

  • Peer to peer role plays 

CLINICAL PRACTICE 

1. Giving a Rationale for working with emotion 

• useful to provide psychoeducation on the emotion focused approach

• Therapists should explain the rationale for exploring emotion, especially to clients who are afraid to express emotion

2. Moment by moment process diagnosis 

• emotion-focused therapists also highlight process diagnosis

• Process diagnosis:  dynamic, moment-by-moment case formulation in which the therapist continually evaluates the client’s current emotion state and emotional processing

• marker-based approach can be thought of as entailing a series of “if-then” guidelines

• Goldman → three stage process for case formulation in EFT 

a) describe the client’s emotional processing style 

b) identification of important criteria

c) identify new task markers and the impact of new meaning

3. Personalization of Emotion focused therapy 

• tailored to each individual client because it entails a process-directive, marker-based approach

  • keeping with the humanistic tradition, clients are viewed as the experts of their own lives and personal growth

• EFT for depression 

  • three phases of treatment, focused on alliancebuilding, maladaptive emotion schemes, and adaptive emotion states

  • Self-critical clients will be invited to participate in a two-chair intervention

  • Those with interpersonal distress will be invited to engage in an empty chair task for unfinished business

  • Those who engage in self-neglect by avoiding emotion and becoming overly logical, may benefit from systematic evocative unfolding or self-interruptive chairwork

• EFT for trauma → three phases 

1. development of the therapeutic alliance and shared understanding of the trauma

2. addresses self-related problems, such as self-criticism and shame, a

3. entails the expression of adaptive emotions (which are directed towards an imagined other, through either an empty chair task or empathic exploration) 

• EFT for GAD 

  • modified version of the self-critical two-chair task, 

    • Anxiety producer vs self who feels anxious 

  • clients learn that they are causing themselves to feel anxious, which implies that they have power to control their anxiety

• EFT for social anxiety focuses on shame anxiety 

4. Therapist factors 

• prefer to first learn about chairwork because it is a salient and novel intervention

• depends on more fundamental person-centered skills, including therapists’ ability to be empathically attuned and help clients deepen experience

• Therapists →

  •  recruit client participation in the task by explaining the rationale for tasks and seeking consent to engage in them 

  • develop strong process-diagnostic skills, to determine what the client is experiencing in a given moment, and what intervention is needed at that time

•  train therapists to be empathically attuned to clients