Last updated on 26th April 2020
"My father considered a walk among the mountains as the equivalent of churchgoing." Aldous Huxley
I'm a member of a therapists' Emotion-Focused Therapy (EFT) support group. We have been meeting every month or two for a while to talk about and practise using EFT methods. I wrote about this last month in the post "Therapeutic cross-breeding: EFT's approach to self-interruption splits applied to outdated coping modes in schema therapy". Although my primary training is in cognitive therapy I've mentioned before that therapists seem to be more likely to thrive, maintain their enthusiasm, and help clients to better outcomes, when they stay theoretically broad & integrative in their approach - see "Orlinsky & Ronnestad's 'How psychotherapists develop': three key recommendations for maintaining effectiveness". It is noteworthy too that in the most recent comparative reviews, higher process-guiding humanistic-experiential therapies like emotion-focused approaches have been shown to achieve slightly greater outcome effect sizes than CBT comparison approaches ... see the 2013 edition of the classic "Handbook of psychotherapy and behaviour change". Yesterday evening our EFT group met, caught up, talked about using EFT, and then ... for the second half of the evening ... we practised using the EFT "empty chair" method for working on "unfinished business". This is well described in Elliott, Watson, Goldman & Greenberg's helpful book "Learning emotion-focused therapy" (pp. 243-265) and there is web information too. Here's a very busy diagram that I use as an aide-memoire:
(this diagram is downloadable as a Powerpoint slide or as a PDF file)
I do like Emotion-Focused Therapy. I like the way it prioritises emotion ... how we feel is so central to the quality of our lives. I like the "roll up our sleeves & get speaking from our hearts & guts" style. I like the way that EFT's focus on feelings fits so well with the much broader, across different schools of psychotherapy, understanding that for lasting therapeutic change we often need to drop down under standard chatty conversations into the underground rivers of feelings. And I very much like the way that EFT tries to test its theories with research. So for example, with empty chair work there are at least a couple of studies: Paivio & Greenberg's "Resolving "unfinished business": Efficacy of experiential therapy using empty-chair dialogue" with its abstract reading "In this study, 34 clients with unresolved feelings related to a significant other were randomly assigned to either experiential therapy using a Gestalt empty-chair dialogue intervention or an attention-placebo condition. The latter was a psychoeducational group offering information about "unfinished business." Treatment outcomes were evaluated before and after the treatment period in each condition and at 4 months and 1 year after the experiential therapy. Outcome instruments targeted general symptomotology, interpersonal distress, target complaints, unfinished business resolution, and perceptions of self and other in the unfinished business relationship. Results indicated that experiential therapy achieved clinically meaningful gains for most clients and significantly greater improvement than the psychoeducational group on all outcome measures. Treatment gains for the experiential therapy group were maintained at follow-up." and Greenberg & Malcolm's "Resolving unfinished business: Relating process to outcome" with its abstract "This study related the process of the resolution of unfinished business with a significant other to therapeutic outcome in a population of 26 clients who suffered from various forms of interpersonal problems and childhood maltreatment. Clients were treated in emotion-focused, experiential therapy with gestalt empty-chair dialogues. Those clients who expressed previously unmet interpersonal needs to the significant other, and manifested a shift in their view of the other, had significantly better treatment outcomes. The presence of the specific process of resolution in the clients' empty-chair dialogues was also found to be a better predictor of outcome than the working alliance. Degree of emotional arousal was found to discriminate between resolvers and nonresolvers."
Emotion-Focused Therapy's careful exploration of two chair work on conflict splits has informed a whole series of other therapies ... for example Compassion-Focused Therapy and Schema-Focused Cognitive Therapy. I don't think other therapy school however have picked up so well on EFT's teaching on empty chair work on unfinished business. I think I've been lax myself. I'm confident that quite a few of the therapy conversations I've had with clients over the last few years ... especially about their relationships with their parents ... might well have benefitted if I'd encouraged the moving into empty chair/unfinished business work more. This is probably especially the case when the conversations have felt rather "heady" & poorly linked to feeling. Last month's post on self-interruption is relevant here too as I find it usual that when clients have "criticised" their parents (often for deeply understandable reasons) they pretty soon start to have second thoughts about the validity of their remarks. I think this self-interruptive process could often benefit from being explored as a dialogue as well.
And we then went on in the second half of the evening to practise these techniques on ourselves. In the pair that I worked in I volunteered to be "client" while my colleagues took the therapist role. I decided to talk to my father (who died 24 years ago) ... hence the quote at the start of this blog post. I haven't explored dialogue work with my dad before. He was a very fine man ... as with so many of his generation, not particularly emotionally literate ... but a very good man and a loving committed father. One of my regrets is that he & I didn't talk deeply about our feelings. I don't think he really knew how to. As I've discussed in the past, this kind of imagined dialogue work recruits many similar brain areas to when one is involved in real behaviour ... and it connects richly too to emotion. Fascinating to feel the powerful difference between chatting about my relationship with my dad (which I've done many times over the years with friends) and actually speaking with him in this dialogue format. Great to feel this kind of thing from the inside. I think in CBT training we often don't get into the experience like this enough. It reminds me of my friend James Bennett-Levy's research ... for example, his paper "Acquiring and refining cbt skills and competencies: Which training methods are perceived to be most effective?" with its abstract reading "Background: A theoretical and empirical base for CBT training and supervision has started to emerge. Increasingly sophisticated maps of CBT therapist competencies have recently been developed, and there is evidence that CBT training and supervision can produce enhancement of CBT skills. However, the evidence base suggesting which specific training techniques are most effective for the development of CBT competencies is lacking. Aims: This paper addresses the question: What training or supervision methods are perceived by experienced therapists to be most effective for training CBT competencies? Method: 120 experienced CBT therapists rated which training or supervision methods in their experience had been most effective in enhancing different types of therapy-relevant knowledge or skills. Results: In line with the main prediction, it was found that different training methods were perceived to be differentially effective. For instance, reading, lectures/talks and modelling were perceived to be most useful for the acquisition of declarative knowledge, while enactive learning strategies (role-play, self-experiential work), together with modelling and reflective practice, were perceived to be most effective in enhancing procedural skills. Self-experiential work and reflective practice were seen as particularly helpful in improving reflective capability and interpersonal skills. Conclusions: The study provides a framework for thinking about the acquisition and refinement of therapist skills that may help trainers, supervisors and clinicians target their learning objectives with the most effective training strategies."
And I think it was no accident that ... after my brief immersion in personal experience of dialogue work ... the next day was particularly precious in my work with clients. I was more ready to dip under conversations into deep feeling and it certainly seemed that this hugely benefitted the therapeutic work I did. Fascinating and worthwhile ... both the way that dialogue methods can take us deeper, and the way that therapists exploring methods for themselves can encourage and enrich the way we use the methods for our clients.