Emotionally focused therapy

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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 incapability 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[edit]

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. Using attachment theory, she developed a treatment to help these couples in distress. Today, EFT-C is one of the most empirically validated types of couples therapy.[7] It has been found that 70–75% of couples move from distress to recovery, and that 90% show significant improvements.[8] These results appear to be less susceptible to relapse than those from other approaches.[citation needed] 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.[9]

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.[10]

Strengths of EFT[edit]

  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.[11]
  3. EFT has been validated by over 20 years of empirical research. There is also research on the change processes and predictors of success.[12]
  4. EFT has been applied to different kinds of problems and populations, although more research on different populations and cultural adaptations is needed.[12]
  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.[13]

Emotion response types[edit]

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,[14] nevertheless emotional responses can be classified into four broad types: primary adaptive, primary maladaptive, secondary reactive, and instrumental.[15]

Primary adaptive[edit]

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."[16]

Primary maladaptive[edit]

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.[17] Secondary maladaptive emotion responses are accessed in therapy with the aim of transforming the emotion scheme through new experiences.[18]

Secondary reactive[edit]

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).[18] "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."[19] 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.[20]

Instrumental[edit]

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."[17] 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.[21]

The therapeutic process with different emotion responses[edit]

Each type of emotion response calls for a different intervention process by the therapist.[22] 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 (Elliott 2012)[edit]

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.[23] 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.[24] 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.[25]

Task marker Intervention process End state
Empathy-based tasks Problem-relevant experience (e.g., interesting, troubling, intense, puzzling) Empathic exploration Clear marker, or new meaning explicated
Vulnerability (painful emotion related to self) Empathic affirmation Self-affirmation (feels understood, hopeful, stronger)
Relational tasks Beginning of therapy Alliance formation Productive working environment
Therapy complaint or withdrawal difficulty (questioning goals or tasks; persistent avoidance of relationship or work) Alliance dialogue (each explores own role in difficulty) Alliance repair (stronger therapeutic bond or investment in therapy; greater self-understanding)
Experiencing tasks Attentional focus difficulty (e.g., confused, overwhelmed, blank) Clearing a space Therapeutic focus; ability to work productively with experiencing (working distance)
Unclear feeling (vague, external or abstract) Experiential focusing Symbolization of felt sense; sense of easing (feeling shift); readiness to apply outside of therapy (carrying forward)
Difficulty expressing feelings (avoiding feelings, difficulty answering feeling questions) Allowing and expressing emotion (also experiential focusing, systematic evocative unfolding, chairwork) Successful, appropriate expression of emotion to therapist and others
Reprocessing tasks [situational-perceptual] Difficult/traumatic experiences (narrative pressure to tell painful life stories) Trauma retelling Relief, validation, restoration of narrative gaps, understanding of broader meaning
Problematic reaction point (puzzling over-reaction to specific situation) Systematic evocative unfolding New view of self in-the-world-functioning
Meaning protest (life event violates cherished belief) Meaning creation work Revision of cherished belief
Action tasks [action tendency] Self-evaluative split (self-criticism, tornness) Two-chair dialogue Self-acceptance, integration
Self-interruption split (blocked feelings, resignation) Two-chair enactment Self-expression, empowerment
Unfinished business (lingering bad feeling regarding significant other) Empty-chair work Let go of resentments, unmet needs regarding other; affirm self; understand or hold other accountable
Stuck, disregulated anguish Compassionate self-soothing Emotional/bodily relief, self-empowerment

Stages and steps in EFT for couples (Johnson 2008)[edit]

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 slighly ahead of the other."[26]

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

  • 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)[edit]

  • 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[edit]

  • 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.[27]

Styles of attachment[edit]

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.

Emotion focused couples therapy for trauma survivors[edit]

See also[edit]

Notes[edit]

References[edit]

EFT for couples[edit]

EFT for families[edit]

Further reading[edit]

Videos[edit]

External links[edit]