I wrote yesterday about the morning session on "Narrative therapy and trauma processing" in the third day of an "Emotion-focused psychotherapy: Level 2 workshop series" that I'm attending at the University of Strathclyde.  A couple of months ago, in my first post about this whole workshop series, I wrote "As a psychotherapist who is primarily cognitive-behavioural in orientation, why am I putting in all this time & effort to deepen my understanding & skills in Emotion-focused therapy (EFT)? Well, EFT/Gestalt techniques have widely infiltrated a whole series of areas in CBT. So Arntz & colleagues' very successful schema therapy draws heavily on EFT - see, for example, their book "Schema therapy for borderline personality disorder" and extending the approach out to Axis I disorders too, their forthcoming publication "Schema therapy in practice". Paul Gilbert's CBT-related Compassionate Mind work also incorporates EFT/Gestalt derived methods - see "Compassion: Conceptualisations, research and use in psychotherapy" - and Kristin Neff's paper "Self-compassion and adaptive psychological functioning" (available in free full text from Neff's website) demonstrates significant increases in self-compassion and decreases in self-criticism three weeks after a 20 to 30 minute Gestalt two chair dialogue exercise. Work on PTSD can also draw on these experiential methods, and the current surge of interest in imagery overlaps into this territory as well - see the recent "Oxford guide to imagery in cognitive therapy".

And of all the EFT approaches that other therapies have incorporated, probably the stand-out import has been chair work ... and that's the topic of this afternoon's workshop.  In fact we're going to look at "two chair work for conflict splits".  In later seminars we'll be exploring other aspects of this approach like "empty chair work for unfinished business".  When, as a non-EFT psychotherapist, one initially comes across the idea of asking clients to dialogue between different aspects of themselves or between themselves and someone else who isn't actually in the room ... well it can seem a bit artificial, forced and even embarrassing.  I did a first workshop with Les Greenberg seven years ago, followed fairly rapidly by a more formal level 1 training with Les, Jeanne Watson, Antonio Pascual-Leone, and Robert Elliott (who is running today's training).  Subsequently I've been to workshops with both Arnoud Arntz and Paul Gilbert.  I use "chair work" pretty regularly and clients frequently report it as one of the most emotionally moving & memorable aspects of their therapy.  This matters.  In his paper "Emotional processes in psychotherapy: evidence across therapeutic modalities", Whelton wrote "At the present time there is an interest in emotion research in therapy that cuts across all therapeutic modalities. Emotional processing and depth of experiencing, two heavily-researched emotion process categories of the behaviourists and humanists respectively, have been shown to have a robust association with outcome. There is accumulating evidence that both the in-session activation of specific, relevant emotions and the cognitive exploration and elaboration of the significance and meaning of these emotions are important for therapeutic change". 

Nearly twenty years ago, in his seminal paper "Emotion and two kinds of meaning: cognitive therapy and applied cognitive science", the great CBT researcher John Teasdale wrote "The clinical cognitive approach assumes that emotional reactions are mediated through the meanings given to events. Cognitive therapy aims to change emotion by changing meanings. It focuses on specific level meanings, evaluating the truth value of particular beliefs ... This focus on meaning at a specific level causes problems, e.g. the contrasts between 'intellectual' and 'emotional' belief, between 'cold' and 'hot' cognition, and between explicit and intuitive knowledge ... the Interacting Cognitive Subsystems (ICS) approach ... suggests a therapeutic focus on holistic rather than specific meanings, a role for 'non-evidential' interventions, such as guided imagery, and a rational basis for certain experiential therapies."  There is a danger that cognitive therapists can find themselves all too easily working at the level of "cold" rather than "hot" cognitions.  In their fascinating paper "Clients' emotional processing in psychotherapy: a comparison between cognitive-behavioral and process-experiential therapies", Jeanne Watson & Danielle Bedard wrote "The authors compared clients' emotional processing in good and bad outcome cases in cognitive behavioral therapy (CBT) and process-experiential therapy (PET) ... Twenty minutes from each of 3 sessions from 40 clients were rated on the Experiencing Scale. A 2 x 2 x 3 analysis of variance showed a significant difference between outcome and therapy groups, with clients in the good outcome and PET groups showing significantly higher levels of emotional processing than those in the poor outcome and CBT groups, respectively ... The results indicate that CBT clients are more distant and disengaged from their emotional experience than clients in PET."  And I would emphasise, even just comparing clients in the CBT group, a deeper level of emotional processing - working more with "hot" cognitions - was associated with better clinical outcome.  I find it valuable to keep a rough notion of what level we are on the "Experiencing scale" (PDF here) when I'm working with clients.

It's not a question however of the more the better.  In the abstract of their paper "Optimal levels of emotional arousal in experiential therapy of depression", Carryer & Greenberg reported "Objective: To determine the relationship between length of time spent expressing highly aroused emotion and therapeutic outcome. Method: Thirty-eight clients ... treated for depression with experiential therapy, were rated on working alliance and expressed emotional arousal ... in their three highest arousal sessions ... Results: Hierarchical regressions showed that a nonlinear pattern of expressed emotional arousal predicted outcome significantly above the alliance. This combination predicted 30% of outcome variance on the BDI ... An optimal frequency (25%) of highly aroused emotional expression was found to relate to outcome, with deviation from this optimal frequency predicting poorer outcome. Conclusions: Too much or too little emotion was found to be not as helpful as a moderate amount. It was concluded that expressed emotional arousal in experiential therapies has a more intricate relationship with therapeutic outcome than has previously been shown and that it is moderate amounts of heightened emotional arousal that improve predictions of therapeutic outcome."  And for some clients, even "moderate amounts of heightened emotional arousal" will be unhelpful initially - see the series of blog posts on Marylene Cloitre's fine work starting with "Improving treatments for complex PTSD and for survivors of child abuse" for hard data on the value of getting these issues right therapeutically. 

As Greenberg & Pascual-Leone point out in their paper "Emotion in psychotherapy: A practice-friendly research review" "Four distinct types of emotion processes are identified in the literature as useful in therapy, depending on a client's presenting concerns: emotional awareness and arousal; emotional regulation, active reflection on emotion (meaning making), and emotional transformation."  And in a startling article last year - "Increasing emotional competence improves psychological and physical well-being, social relationships, and employability" - Nelis & colleagues reported on an broad based group training focusing on "teaching theoretical knowledge about emotions and on training participants to apply specific emotional skills in their everyday lives. Sessions were centered on the four core emotional competencies: identification, understanding, regulation, and utilization."  Outcomes were exciting - "This study builds on earlier work showing that adult emotional competencies (EC) could be improved through a relatively brief training ... Results of Study 1 showed that 18 hr of training with e-mail follow-up was sufficient to significantly improve emotion regulation, emotion understanding, and overall EC. These changes led in turn to long-term significant increases in extraversion and agreeableness as well as a decrease in neuroticism. Results of Study 2 showed that the development of EC brought about positive changes in psychological well-being, subjective health, quality of social relationships, and employability. The effect sizes were sufficiently large for the changes to be considered as meaningful in people's lives."

OK, my focus is becoming over-broad.  See tomorrow's post to drill down more into the emotional evocation and processing of chair work.