Emotionally focused therapy

Emotionally focused therapy (EFT), also known as emotion-focused therapy and process-experiential therapy, is a usually short-term (8–20 sessions) structured psychotherapy approach to working with individuals, couples, or families. It includes elements of Gestalt therapy, person-centered therapy, constructivist therapy, systemic therapy, and attachment theory.^[1]

Emotionally focused therapy proposes that human emotions have an innately adaptive potential that, if activated, can help clients change problematic emotional states or unwanted self-experiences. Emotions themselves do not inhibit the therapeutic process, but people's inability to manage emotions and use them well is seen as the problem. Emotions are connected to our most essential needs.^[2] Therefore, the focus on emotions is a common factor among various systems of psychotherapy; one prominent therapist has said: "The term emotion-focused therapy will, I believe, be used in the future, in its integrative sense, to characterize all therapies that are emotion-focused, be they psychodynamic, cognitive-behavioral, systemic, or humanistic."^[3]

Overview

Emotionally focused therapy (EFT) is an empirically supported humanistic treatment^[4] that arose out of the theoretical integration of research on psychotherapy with ideas from constructivist psychology, emotion theory, and attachment theory. It views emotions as centrally important in the experience of self and others, in both adaptive and maladaptive functioning, and in therapeutic change. From the EFT perspective, change occurs by means of emotional awareness and arousal, regulation of emotion, reflection on emotion, and transformation of emotion taking place within the context of an empathetically attuned relationship. In EFT an important goal is to arrive at the lived experience of a maladaptive emotion (e.g., chronic fear and shame) in order to transform it. The transformation comes from the client accessing a new primary adaptive emotional state in the therapy session.^[5] Using the notion of transforming emotion with emotion, the therapist guides clients to express emotions that pull for compassion and connection.

Emotionally focused therapy for couples (EFT-C) was originally developed in the 1980s by Sue Johnson and Les Greenberg.^[6] Johnson found that couples in distress were caught in a dreadful dance of negative interactions that kept them stuck and unable to resolve their conflicts. Emotion regulation is involved in three major motivational systems central to couples therapy: styles of attachment, identity or working models of self and other, and attraction or liking.^[7]

More recently, emotionally focused therapy has also been used with families. Emotionally focused family therapy (EFFT) uses the emotionally focused approach with families, specifically children and parents. EFFT sessions are conducted either weekly or biweekly for approximately 10–15 sessions. Because of its emotional intensity, EFFT is not recommended for all families.^[8]

Strengths

1. EFT is collaborative and respectful of clients, combining experiential person-centered therapy techniques with systemic therapy interventions.
2. Change strategies and interventions are specified through intensive analysis of psychotherapy process.^[9]
3. EFT has been validated by over 20 years of empirical research. There is also research on the change processes and predictors of success.^[10]
4. EFT has been applied to different kinds of problems and populations, although more research on different populations and cultural adaptations is needed.^[10]
5. EFT for couples is based on conceptualizations of marital distress and adult love that are supported by empirical research on the nature of adult attachment.^[11]

Emotion response types

Although EFT posits that each person's emotions are organized into idiosyncratic emotion schemes that are highly variable both between people and within the same person over time,^[12] nevertheless emotional responses can be classified into four broad types: primary adaptive, primary maladaptive, secondary reactive, and instrumental.^[13]

Primary adaptive

Primary adaptive emotion responses are initial emotional responses to a given stimulus that have a clear beneficial value—for example, sadness at loss, anger at violation, and fear at threat. Sadness is an adaptive response when it motivates us to reconnect with someone or something important that is missing. Anger is an adaptive response when it motivates us to take assertive action to end the violation. Fear is an adaptive response when it motivates us to avoid or escape an overwhelming threat. In addition to emotions that indicate action tendencies (such as the three just mentioned), primary adaptive emotion responses include the feeling of being certain and in control or uncertain and out of control, and/or a general felt sense of emotional pain—these feelings and emotional pain do not provide immediate action tendencies but do provide adaptive information that can be symbolized and worked through in therapy. Primary adaptive emotion responses "are attended to and expressed in therapy in order to access the adaptive information and action tendency to guide problem solving."^[14]

Primary maladaptive

Primary maladaptive emotion responses are also initial emotional responses to a given stimulus; however, they are generally dysfunctional responses based on emotion schemes that are no longer useful (and that may or may not have been useful in the past) and that were often formed through previous traumatic experiences. Examples include sadness at the joy of others, anger at the genuine caring or concern of others, fear at harmless situations, and chronic feelings of insecurity (fear) or worthlessness (shame). For example, a person may respond with anger at the genuine caring or concern of others because as a child he or she was offered caring or concern that was usually followed by a violation; as a result, he or she learned to respond to caring or concern with anger even when there is no violation. The person's angry response is understandable, and needs to be met with empathy and compassion even though his or her angry response is not helpful.^[15] Secondary maladaptive emotion responses are accessed in therapy with the aim of transforming the emotion scheme through new experiences.^[16]

Secondary reactive

Secondary reactive emotion responses are complex chain reactions where a person reacts to his or her primary adaptive or maladaptive emotional response and then replaces it with another, secondary emotional response. In other words, they are emotional responses to prior emotional responses. ("Secondary" means that a different emotion response occurred first.) They can include secondary reactions of hopelessness, helplessness, rage, or despair that occur in response to primary emotion responses that are experienced (secondarily) as painful, uncontrollable, or violating. They may be escalations of a primary emotion response, as when people are angry about being angry, afraid of their fear, or sad about their sadness. They may be defenses against a primary emotion response, such as feeling anger to avoid sadness or fear to avoid anger; this can include gender role-stereotypical responses such as expressing anger when feeling primarily afraid (stereotypical of men's gender role), or expressing sadness when primarily angry (stereotypical of women's gender role).^[16] "These are all complex, self-reflexive processes of reacting to one's emotions and transforming one emotion into another. Crying, for example, is not always true grieving that leads to relief, but rather can be the crying of secondary helplessness or frustration that results in feeling worse."^[17] Secondary reactive emotion responses are accessed and explored in therapy in order to increase awareness of them and to arrive at more primary and adaptive emotion responses.^[18]

Instrumental

Instrumental emotion responses are experienced and expressed by a person because the person has learned that the response has an effect on others, "such as getting them to pay attention to us, to go along with something we want them to do for us, to approve of us, or perhaps most often just not to disapprove of us."^[15] Instrumental emotion responses can be consciously intended or unconsciously learned (i.e., through operant conditioning). Examples include crocodile tears (instrumental sadness), bullying (instrumental anger), crying wolf (instrumental fear), and feigned embarrassment (instrumental shame). When a client responds in therapy with instrumental emotion responses, it may feel manipulative or superficial to the therapist. Instrumental emotion responses are explored in therapy in order to increase awareness of their interpersonal function and/or the associated primary and secondary gain.^[19]

The therapeutic process with different emotion responses

Each type of emotion response calls for a different intervention process by the therapist.^[20] Primary adaptive emotions need be more fully allowed and accessed for their adaptive information. Primary maladaptive emotions need to be accessed and explored to help the client identify core unmet needs (e.g., for validation, safety, or connection), and then regulated and transformed with new experiences and new adaptive emotions. Secondary reactive emotions need empathic exploration in order to discover the sequence of emotions that preceded them. Instrumental emotions need to be explored interpersonally in the therapeutic relationship to increase awareness of them and address how they are functioning in the client's situation.

It is important to note that primary emotion responses are not called "primary" because they are somehow more real than the other responses; all of the responses feel real to a person, but they are classified into these four types in order to help therapists distinguish the functions of the response in the client's situation and how to intervene appropriately.

Therapeutic tasks in EFT for individuals

A therapeutic task is an immediate problem that a client needs to resolve in a psychotherapy session. In the 1980s, researchers such as Laura North Rice (a former colleague of Carl Rogers) applied task analysis to transcripts of psychotherapy sessions in an attempt to describe in more detail the process of clients' cognitive and emotional change, so that therapists might more reliably provide optimal conditions for change.^[21] This kind of psychotherapy process research eventually led to a standardized (and evolving) set of therapeutic tasks in EFT.

The following table summarizes the standard set of EFT therapeutic tasks as of 2012.^[22] The tasks are classified into five broad groups: empathy-based, relational, experiencing, reprocessing, and action. The task marker is an observable sign that a client may be ready to work on the associated task. The intervention process is a sequence of actions carried out by therapist and client in working on the task. The end state is the desired resolution of the immediate problem.

In addition to the task markers listed below, other markers and intervention processes for working with emotion and narrative have been specified: same old stories, empty stories, unstoried emotions, and broken stories.^[23]

Stages and steps in EFT for couples

Johnson (2008) summarizes the nine treatment steps in Sue Johnson's model of EFT for couples.

"The therapist leads the couple through these steps in a spiral fashion, as one step incorporates and leads into the other. In mildly distressed couples, partners usually work quickly through the steps at a parallel rate. In more distressed couples, the more passive or withdrawn partner is usually invited to go through the steps slightly ahead of the other."^[24]

Stage 1. Stabilization (assessment and de-escalation phase)

• Step 1: Identify the relational conflict issues between the partners
• Step 2: Identify the negative interaction cycle where these issues are expressed
• Step 3: Access attachment emotions underlying the position each partner takes in this cycle
• Step 4: Reframe the problem in terms of the cycle, unacknowledged emotions, and attachment needs

During this stage the therapist creates a comfortable and stable environment for the couple to have an open discussion about any hesitations the couples may have about the therapy, including the trustworthiness of the therapist. The therapist also gets a sense of the couple's positive and negative interactions from past and present and is able to summarize and present the negative patterns for them. Partners soon no longer view themselves as victims of their negative interaction cycle; they are now allies against it.

Stage 2. Restructuring the bond (changing interactional positions phase)

• Step 5: Access disowned or implicit needs (e.g., need for reassurance), emotions (e.g., shame), and models of self
• Step 6: Promote each partner's acceptance of the other's experience
• Step 7: Facilitate each partner's expression of needs and wants to restructure the interaction based on new understandings and create bonding events

This stage involves restructuring and widening the emotional experiences of the couple. This is done through couples recognizing their attachment needs, and then changing their interactions based on those needs. At first their new way of interacting may be strange and hard to accept, but as they become more aware and in control of their interactions they are able to stop old patterns of behavior from reemerging.

Stage 3. Integration and consolidation

• Step 8: Facilitate the formulation of new stories and new solutions to old problems
• Step 9: Consolidate new cycles of behavior

This stage focuses on reflection of new emotional experiences and self-concepts. It integrates the couple's new ways of dealing with problems within themselves and in the relationship.^[25]

Styles of attachment

Johnson & Sims (2000) describe four attachment styles:

1. People who are secure and trusting perceive themselves as lovable, able to trust others and themselves within a relationship. They give clear emotional signals, and are engaged, resourceful and flexible in unclear relationships. Secure partners express feelings, articulate needs, and allow their own vulnerability to show.
2. People who have a diminished ability to articulate feelings, tend not to acknowledge their need for attachment, and struggle to name their needs in a relationship. They tend to adopt a safe position and solve problems dispassionately without understanding the effect that their safe distance has on their partners.
3. People who are psychologically reactive and who exhibit anxious attachment. They tend to demand reassurance in an aggressive way, demand their partner's attachment and tend to use blame strategies (including emotional blackmail) in order to engage their partner.
4. People who have been traumatized and have experienced little to no recovery from it vacillate between attachment and hostility.

Efficacy

Some studies have shown that EFT-C may be effective when treating couples with marital conflicts.^[26] Some researchers have claimed that 70–75% of couples move from distress to recovery, and that 90% show significant improvements.^[27]

Emotion focused couples therapy for trauma survivors

Criticism

In a 2015 article in Behavioral and Brain Sciences on "memory reconsolidation, emotional arousal and the process of change in psychotherapy", Richard D. Lane and colleagues summarized a common claim in the literature on emotionally focused therapy that "emotional arousal is a key ingredient in therapeutic change" and that "emotional arousal is critical to psychotherapeutic success".^[28] In a response accompanying the article, Bruce Ecker and colleagues (creators of coherence therapy) disagreed with this claim and argued that the key ingredient in therapeutic change involving memory reconsolidation is not emotional arousal but instead a perceived mismatch between an expected pattern and an experienced pattern; they wrote:^[29]

The brain clearly does not require emotional arousal per se for inducing deconsolidation. That is a fundamental point. If the target learning happens to be emotional, then its reactivation (the first of the two required elements) of course entails an experience of that emotion, but the emotion itself does not inherently play a role in the mismatch that then deconsolidates the target learning, or in the new learning that then rewrites and erases the target learning (discussed at greater length in Ecker 2015). [...] The same considerations imply that "changing emotion with emotion" (stated three times by Lane et al.) inaccurately characterizes how learned responses change through reconsolidation. Mismatch consists most fundamentally of a direct, unmistakable perception that the world functions differently from one's learned model. "Changing model with mismatch" is the core phenomenology.^[29]

Other responses to Lane et al. (2015) argued that their emotionally focused approach "would be strengthened by the inclusion of predictions regarding additional factors that might influence treatment response, predictions for improving outcomes for non-responsive patients, and a discussion of how the proposed model might explain individual differences in vulnerability for mental health problems",^[30] and that their model needed further development to account for the diversity of states called "psychopathology" and the relevant maintaining and worsening processes.^[31]

See also

Notes

References

• "Website on research-supported psychological treatments". American Psychological Association, Division 12. 2013. Retrieved 30 October 2014. 
• Angus, Lynne E; Greenberg, Leslie S (2011). Working with narrative in emotion-focused therapy: changing stories, healing lives. Washington, DC: American Psychological Association. ISBN 9781433809699. OCLC 698451460. 
• Ecker, Bruce (January 2015). "Memory reconsolidation understood and misunderstood". International Journal of Neuropsychotherapy. 3 (1): 2–46. doi:10.12744/ijnpt.2015.0002-0046. 
• Ecker, Bruce; Hulley, Laurel; Ticic, Robin (January 2015). "Minding the findings: let's not miss the message of memory reconsolidation research for psychotherapy" (PDF). Behavioral and Brain Sciences. 38: e7. doi:10.1017/S0140525X14000168. PMID 26050698. 
• Elliott, Robert (March 2010). "Psychotherapy change process research: realizing the promise" (PDF). Psychotherapy Research. 20 (2): 123–135. doi:10.1080/10503300903470743. 
• Elliott, Robert (2012). "Emotion-focused therapy" (PDF). In Sanders, Pete. The tribes of the person-centred nation: an introduction to the schools of therapy related to the person-centred approach (2nd ed.). Ross-on-Wye: PCCS Books. pp. 103–130. ISBN 9781906254551. OCLC 859577725. 
• Elliott, Robert; Watson, Jeanne C; Goldman, Rhonda N; Greenberg, Leslie S (2004). Learning emotion-focused therapy: the process-experiential approach to change. Washington, DC: American Psychological Association. ISBN 9781591470809. OCLC 52554018. 
• Flanagan, Catherine M (March 2010). "The case for needs in psychotherapy". Journal of Psychotherapy Integration. 20 (1): 1–36. doi:10.1037/a0018815. 
• Greenberg, Leslie S (2002). "Evolutionary perspectives on emotion: making sense of what we feel". Journal of Cognitive Psychotherapy. 16 (3): 331–347. doi:10.1891/jcop.16.3.331.52517. 
• Greenberg, Leslie S (2011). Emotion-focused therapy. Theories of psychotherapy series. Washington, DC: American Psychological Association. ISBN 9781433808579. OCLC 655301581. 
• Greenberg, Leslie S (November 2012). "Emotions, the great captains of our lives: their role in the process of change in psychotherapy". American Psychologist. 67 (8): 697–707. doi:10.1037/a0029858. 
• Greenberg, Leslie S (2015) [2002]. Emotion-focused therapy: coaching clients to work through their feelings (2nd ed.). Washington, DC: American Psychological Association. ISBN 9781433819957. OCLC 903873710. 
• Greenberg, Leslie S; Paivio, Sandra C (1997). Working with emotions in psychotherapy. The practicing professional. New York: Guilford Press. ISBN 9781572309418. OCLC 36705776. 
• Greenberg, Leslie S; Rice, Laura North; Elliott, Robert (1993). Facilitating emotional change: the moment-by-moment process. New York: Guilford Press. ISBN 9780898629941. OCLC 27897484. 
• Greenberg, Leslie S; Safran, Jeremy D (1987). Emotion in psychotherapy: affect, cognition, and the process of change. The Guilford clinical psychology and psychotherapy series. New York: Guilford Press. ISBN 9780898620108. OCLC 14214819. 
• Kimbrel, Nathan A.; Meyer, Eric C.; Beckham, Jean C. (January 2015). "A clinician's perspective on memory reconsolidation as the primary basis for psychotherapeutic change in posttraumatic stress disorder (PTSD)" (PDF). Behavioral and Brain Sciences. 38: e8. doi:10.1017/S0140525X1400017X. PMC 4697761. PMID 26050699. 
• Lane, Richard D.; Ryan, Lee; Nadel, Lynn; Greenberg, Leslie S. (2015). "Memory reconsolidation, emotional arousal and the process of change in psychotherapy: new insights from brain science" (PDF). Behavioral and Brain Sciences. 38: e1. doi:10.1017/S0140525X14000041. PMID 24827452. 
• Lebow, Jay L, ed. (2008). Twenty-first century psychotherapies: contemporary approaches to theory and practice. New York: John Wiley & Sons. ISBN 9780471752233. OCLC 123332183. 
• Mancini, Francesco; Gangemi, Amelia (January 2015). "The relevance of maintaining and worsening processes in psychopathology" (PDF). Behavioral and Brain Sciences. 38: e14. doi:10.1017/S0140525X14000375. PMID 26050677. 
• Pascual-Leone, Antonio; Greenberg, Leslie S; Pascual-Leone, Juan (July 2009). "Developments in task analysis: new methods to study change". Psychotherapy Research. 19 (4): 527–542. doi:10.1080/10503300902897797. 
• Patihis, Lawrence (2015). "Let's be skeptical about reconsolidation and emotional arousal in therapy" (PDF). Behavioral and Brain Sciences. 38: e21. doi:10.1017/S0140525X14000272. PMID 26050685. 
• Rice, Laura North; Greenberg, Leslie S, eds. (1984). Patterns of change: intensive analysis of psychotherapy process. New York: Guilford Press. ISBN 9780898626247. OCLC 8762790. 
• Safran, Jeremy D; Greenberg, Leslie S, eds. (1991). Emotion, psychotherapy, and change. New York: Guilford Press. ISBN 9780898625561. OCLC 22665279. 

EFT for couples

• Dessaulles, Andre; Johnson, Susan M.; Denton, Wayne H. (October 2003). "Emotion-focused therapy for couples in the treatment of depression: a pilot study". The American Journal of Family Therapy. 31 (5): 345–353. doi:10.1080/01926180390232266. ISSN 0192-6187. 
• Goldman, Rhonda N; Greenberg, Leslie S (March 2013). "Working with identity and self-soothing in emotion-focused therapy for couples". Family Process. 52 (1): 62–82. doi:10.1111/famp.12021. 
• Greenberg, Leslie S; Goldman, Rhonda N (2008). Emotion-focused couples therapy: the dynamics of emotion, love, and power. Washington, DC: American Psychological Association. ISBN 9781433803161. OCLC 163614069. 
• Greenberg, Leslie S; Johnson, Susan M (1988). Emotionally focused therapy for couples. New York: Guilford Press. ISBN 9780898627305. OCLC 17413289. 
• Johnson, Susan M (2004) [1996]. The practice of emotionally focused couple therapy: creating connection. Basic principles into practice series (2nd ed.). New York: Brunner-Routledge. ISBN 9780415945684. OCLC 54408228. 
• Johnson, Susan M (2008). "Emotionally focused couple therapy". In Gurman, Alan S. Clinical handbook of couple therapy (4th ed.). New York: Guilford Press. pp. 107–137. ISBN 9781593858216. OCLC 213008213. 
• Johnson, Susan M; Sims, Ann (2000). "Attachment theory: a map for couples therapy". In Levy, Terry M. Handbook of attachment interventions. San Diego: Academic Press. pp. 169–191. ISBN 9780124458604. OCLC 42622207. 
• Jordan, Karin (July 2011). "Counselors helping service veterans re-enter their couple relationship after combat and military services: a comprehensive overview" (PDF). The Family Journal. 19 (3): 263–273. doi:10.1177/1066480711406689. 
• Najafi, Maryam; Soleimani, Ali Akbar; Ahmadi, Khodabakhsh; Javidi, Nasirudin; Kamkar, Elnaz Hoseini (July 2015). "The effectiveness of emotionally focused therapy on enhancing marital adjustment and quality of life among infertile couples with marital conflicts". International Journal of Fertility & Sterility. 9 (2): 238–246. ISSN 0192-6187. PMC 4518493. PMID 26246883. 
• Ruzgyte, Edita; Spinks, Donald (2011). "Emotionally focused therapy". In Metcalf, Linda. Marriage and family therapy: a practice-oriented approach. New York: Springer Pub. Co. pp. 341–364. ISBN 9780826106810. OCLC 663951666. 

EFT for families

• Heatherington, Laurie; Friedlander, Myrna L; Greenberg, Leslie S (March 2005). "Change process research in couple and family therapy: methodological challenges and opportunities" (PDF). Journal of Family Psychology. 19 (1): 18–27. doi:10.1037/0893-3200.19.1.18. 
• Palmer, Gail; Efron, Don (2007). "Emotionally focused family therapy: developing the model" (PDF). Journal of Systemic Therapies. 26 (4): 17–24. doi:10.1521/jsyt.2007.26.4.17. 
• Sexton, Thomas L; Schuster, Rachael A (June 2008). "The role of positive emotion in the therapeutic process of family therapy". Journal of Psychotherapy Integration. 18 (2): 233–247. doi:10.1037/1053-0479.18.2.233. 
• Stavrianopoulos, Katherine; Faller, George; Furrow, James L (January 2014). "Emotionally focused family therapy: facilitating change within a family system". Journal of Couple & Relationship Therapy: Innovations in Clinical and Educational Interventions. 13 (1): 25–43. doi:10.1080/15332691.2014.865976.