EFT Distinctive Features and Influences, parte I,II

Robert Elliott é co-autor com L. Greenberg e outros, da Terapia Processual-experiencial, focada nas emoções. Colabora com a Sociedade na Especialização em Psicoterapia, através do treino em TPE/EF. Nesta entrevista, tida em Lisboa a 11 de Fev 2010, aborda, entre outros tópicos, as características distintivas da P-E/EFT.

Robert Elliott is, with Leslie Greenberg and others, co-originator of Emotion-focused Therapy.  He is intervening in the Society’s Psychotherapy Specialization, offering EFT training, as Les Greenberg does. This 50 minutes conversation took place the 11th February 2010, at Lisbon. The distinctive features of P-E/EFT were among other topics discussed.

A.H.: Thank you so much Robert for willing to have this conversation. How would you describe Process-Experiential /Emotion Focused Therapy main and distinctive features?

R.E: There are a set of characteristics I think that set Process - Experiential Emotion Focused Therapy apart. It’s no one feature, I think it’s the combination of those things. First of all this is a neo-humanistic therapy - is a therapy based on humanistic principles that have been reformulated and renewed on the basis of contemporary emotion theory and thinking about attachment and things like that. So is neo-humanistic, is also process oriented – the original name of the therapy was process-experiential because we wanted to capture this sort of intense look at the therapeutic process and the differentiation of the therapeutic process into tasks and responses and modes of engagement and all the different elements. So there’s quite a high degree of process differentiation in the therapy. So it is very process oriented. And it’s also, of course, emotion focused. We do see emotion as this sort of crux of the change process for clients, and also as the sort of core of what it means to be human so it’s emotion focused. There’s a particular exploratory response style that the therapist provides in the relationship with the client that’s kind of a delicate kind of feeling your way into what’s not quite clear, that’s on the edge of what the client’s been able to say, and that exploratory but at the same time empathic response style – which is not non directive but it’s also not directing the content – it’s a sort of guiding the client deep to a deeper process. I think that’s fairly distinctive.

A.H.: You are following and you are leading?

R.E.: We’re both following and leading at the same time. It’s really a kind of mutual process. And the therapy is also evidence based. So it’s built on a program of research, first into particular therapeutic tasks – which is how clients resolve certain issues that they bring into therapy – and then outcome research and more recently randomized clinical trials and things like that. So we have these things. They kind of come together in a package in Process-Experiential Emotion Focused Therapy which I think we’ve believed is distinctive.

A.H.: How is EFT distinct from other approaches and models of therapy?

R. E.: Right! I think what I’m saying is that it’s actually that combination of things. I mean, there are other emotion focused therapies and there are other evidence-based therapies and there are other humanistic therapies and there are other process-oriented therapies, right? But somehow to bring all those things together… I think that’s what makes it distinctive, yes. So we’re not claiming we’re totally unique in anyone particular feature but it’s the package.

A.H.: Can we identify clear phases or stages in EFT?

R.E.: I think that therapy in general has to be stages and that includes EFT. I think there’s an opening and relationship building stage of the therapy, there’s a main working phase in which there’s deep exploration and restructuring that happens and there’s a closing phase where we help the client to consolidate their gains and sort of aim themselves out of the therapy and beyond the therapy. So that’s true whether it is psychodynamic, cognitive-behavioral, EFT, right?…

A.H.: Empathy appears as a core feature and skill in EFT. Do you see empathy as a core construct in EFT or just a mean to achieve a goal?

R.E.: It is a core concept and a core process. The whole therapy is based on empathy. You can’t do EFT effectively without this solid foundation of empathy, both in terms of the immediate therapeutic process but of course also the skill of the therapist - this therapist needs to be highly skilled in empathy and I think that things like chair processes, two-chair work, empty-chair work actually place greater demands on the therapist empathy than other kinds of therapeutic work. So empathy is absolutely foundational. I think the therapy is potentially dangerous without that solid foundation of empathy. And at the same time… we do see empathy as having two different roles to play in the change process. First empathy is a core change process too, so the process of being known, the empathic process is healing to clients and takes clients a long way in their journey, even without the tasks. And secondly empathy is the foundation for doing things like chair work or focusing. All of them need to be based on empathy. So empathy is both a means to an end and an end in itself in the therapy.

J.S.: You think it’s healing in it self?

R.E.: I do think empathy is healing in itself, right, yeah. And if you look at the research literature person-centered therapy actually holds up pretty well in terms of the outcome literature. EFT looks to me like it’s a little bit better. The comparative studies, the effect sizes, looks like it does a bit better but person-centered therapy does quite well also. I think empathy does get you a long way and without it you can’t have effective EFT either.

A.H.: Depending on each client’s process, it looks as tasks can take less than half the time an EFT process takes. If this is really the case, what is going on during the remaining therapy time?

R.E.: What do we do the rest of the time we are not doing chair work? (laugh). First of all you can’t do chair work until somewhere around session four because the client has to have internalized you as an empathic presence, strongly enough to be able to take their eyes off you to look at the other chair, right? So before that they’re too busy worrying about…, right? So there’s this beginning phase of the therapy, which is the relationship building phase and alliance formation, where you’re not doing chair tasks and then you can’t do a chair task every session. It’s very intense, it needs to be worked into, it needs to be processed afterwards and sometimes you stop in the middle and do something else and come back to the chair task. So even in a session that’s mostly chair work or unfolding, or one of the other main active tasks, even in those sessions at least half of it it’s not chair work. And then you can’t sort of bang on with chair work every single session. The client needs a breather, there’s different kinds of work that can be done using other kinds of… we would say basically straight empathic exploration. And so the mix of the straight empathic exploration and different kinds of tasks I think is more effective than simply trying to… and of course the clients don’t present the markers in every session. So, you know, we’re not going to do chair work, two-chair work unless there’s a marker for it.

A.H.: So you find that Isn’t there an excessive focus on tasks in EFT training manuals

R.E.: Yes, so our books, you know, especially the first book, the 1993 book Facilitating Emotional Change, with Greenberg, Rice and Elliott, that book was criticized - and I think rightly – for the lack of emphasis on the relational conditions on empathy and an almost exclusive focus on the chair tasks, focusing systematic evocative unfolding. And people like Germain Lietaer and others took us to task for just the very thing, you know, excessively focusing on those tasks. Now, we tried to readdress that in the Learning Emotion Therapy book, the 2004 book, so we put the relational work upfront, we have extensive coverage to empathy and also relationship building processes and they come before the active tasks. I think we get a better balance there in the 2004 book. But of course the chair work is, you know, it’s sexy and exciting and it’s what people always want to see and want to talk about. It’s flashy, right?

J.S.: So EFT is also marker guided?

R. E.: Yeah its marker guided, yeah. That was the other distinctive feature that I forgot to mention, right? Yes, its marker guided.

A.H.: Do EFT clients have «homework» assignments between sessions? And if they do, of what kind, with which purpose?

R.E: The most common form of homework we give, in fact the only kind of homework I give, as a therapist is what we call awareness homework which is can you pay attention to some process that we’ve been working on the sessions so if the client was working with their critic I might say see if you can be aware of when your critic comes up and what happens during the week, right? One of my clients is struggling with,… one of my clients with social anxiety is working on her sense of ugliness. Many clients with social anxiety have this feeling that they’re ugly. It’s not just a belief in their head but is a sort of deep embodied feeling that they’re ugly. So this just came up at towards the end of the session, I said (we talked about it) this sounds like it might be pretty important for us to work on but during the week maybe pay attention to times when you feel ugly and also what you’re doing to make yourself feel ugly. So that’s awareness homework and that’s going to set up for us to do some more focus work in the therapy next time, probably - on this ugly making critic process. Or, you know, we might say pay attention to times during the week when you find yourself feeling really anxious and bring those in and we can work with those and do some kind of unpack and unfold them. So that’s the kind of homework we give.

A.H.:We have seen a lot of efforts to create manualized treatments, above all empirically-supported. How do you see this trend?

R.E.: A manual is a funny thing, right? I mean you can write a ten page description of the therapy and call it a manual and people do that. So you can write a little tiny thing and call it a manual, right? Or you can write a three hundred page book - like the Learning Emotion-Focused Therapy book is a manual also. It’s a complex one. And Bill Stiles in his review of it said this is the most detailed therapy manual that’s ever been written because we try to get down to the nitty gritty of the therapeutic process in a very specific way and all these different processes. So that’s on one end of it and then you’ve got a bunch of gradations in between of more or less detailed manuals. So then, I mean, in a way it’s a kind of marketing thing…

A.H.: Hum hum, they result useful in a lot of ways for learning, for teaching, for training…

R.E.: That’s right. And trainees love [manuals]… for selling, for selling the therapy, for getting grants… and students like them too because they make them feel more comfortable or safe. So the manuals have their uses. The important thing about a manual is… a good manual describes the therapist responsiveness. So, all therapies have to respond to their clients in a differentiated way. They can’t just plug everyone into the same process. All manuals have to do that. The good ones…

A. H.: Have to be complex?

R.E.: That’s right. They have to build that complexity and that responsiveness. If they don’t do that then it’s basically not a good manual.

J.S.: What about the therapist creativity in these treatment manuals?

R.E.: I think there’s room for creativity within a manual. For example, I mean, think about different kinds of art… different… literature, or… you create an artistic work within structures. They sometimes break through them but there’s something about structure, which is a kind of bed for creativity. And I think manuals are like that too, you know? The manual provides the structure and the therapist can be creative within that and the highest level of mastery of the therapy – EFT included – is to be able to create new structures, new tasks. You haven’t really mastered EFT or some other therapy until you actually can begin to create new tasks.

A.H.: Can we turn into the influences on EFT?


Part II

A.H.: What are the major influences in EFT? And given those influences in EFT development, what would you say have been the major changes to this model over time?

R.E.: Yes, I think there’s two questions: What were the original influences, were did it come from and then what influences has it picked up along the way… like a snowball rolling down in the hill or something… So, of course, in the person-centered approach in the 1960’s there was a great divide between those who would work with Carl Rogers in the counseling scene in the 1950’s and who had come to emphasize the therapist offered conditions, so that were focused on the therapist contribution. And then in the late 50’s and early 60’s Rogers and Gendlin and others began to look at the client process – what does the client do? – Because they haven’t really looked at that before then. And say start looking at what the client did and they started differentiating - the Client Experiencing Scale came out of that – and then Laura Rice came and start talking about the evocative function and looking at the clients. So there was a split that occurred in the 60’s, and so we had two branches: what’s called the classic, or relational person-centered approach and what came to be called experiential therapy, which is originally Gendlin and focusing and then Rice and Greenberg and folks like and me and other folks. So that’s the big split, between folks who focused mostly on the therapist relational conditions and people began to differentiate… ok, so, influences for EFT: of course we’re powerfully influenced by the relational conditions or the empathy genuineness and then we took on board Gendlin’s work and then Rice looking at developing task analysis. Now, task analysis came out of cognitive science, so looking at how experts solved problems, Newell & Simon and the fundamental insight was that clients are experts too! Clients have expertise, particularly if you catch clients actually resolving something, then you can study what they did. And so cognitive science was another influence. So then we went into the 70’s and the 80’s and contemporary work on emotion started to develop and Greenberg and Safran in particular, picked that up - a modern emotion theory - and started elaborating it and emotion research, so that became a big influence, starting in the mid 80’s, was that came in. And that eventually led to the therapy being relabeled as Emotion Focused Therapy. And along the way, of course, we also picked up an interest in attachment theory. So, that’s in the mix too although it’s not a big part and we don’t write about it that much but that’s in there also. Contemporary influences…

A.H.: And the Dialectical Contructivism?

R.E.: Yeah, so Piaget… well, actually what happened with that was that one of Les Greenberg’s teachers and one of Laura Rice’s colleagues at York University in Toronto was one Pascual-Leone who was a student of Piaget’s and so Pascual-Leone sort of extended Piaget’s constructivism into a sort of doctrine of what he called Dialectical Constructivism and that’s the other sort of basis of task analysis. So that’s in there, certainly. Is there something else I’m leaving out and you’re going to remind me of?

J.S.: Gestalt Therapy?

R.E.: Oh yes! Gestalt! Sorry! Yes, ok. That’s in there also. Well, you know, Laura Rice was studying a task from client-centered therapy, that she did encountered in her own clients in Chicago in the 50’s, called systematic evocative unfolding and Les decided to go get gestalt training to see if they could find something in that tradition that would be amenable to study and so he went to a Gestalt Training Institute and at some point he butted heads with them about the importance of the relationship - because he kept saying, you know, the relationship was really important and this was the 70’s when you basically you wouldn’t want to encourage client dependency - you would want to take clients to be self supporting. So Gestalt folks in that era… (it’s changed since then but) Gestalt folks in that era were really allergic to things like therapists being nice to their clients and being warm and empathic and things. It’s like the dark side of Fritz Pearls… Anyway, where I’m going with this story is finally they said to him – the Gestalt trainers at the Institute said to Les – well, if you don’t like how we do it why won’t you go start your own therapy! (laughs). So the amusing thing, of course, is that today a lot of gestalt therapists say that they do EFT, right? I’ve got a gestalt colleague in Scotland who’s a wonderful gestalt training therapist and she is seeing clients in my research and she came to me in this week and she said I’m so afraid I’m messing up the therapy, because I did this thing where I had the client enact attacking himself, you know? And I said you mean you worked with a self interruption split and you teach her enactment? She said yeah, yeah, I said fine, no problem, right… what else? And she gave me something else… that’s self soothing, right? You know? So basically there’s a huge amount of overlap between what we do and Gestalt and we look at each other’s therapy and we say well it looks like my therapy. The main difference with Gestalt is the theory, the use of emotion theory and there’s process differentiation laying out the task. So I can tell my colleague what she’s doing better than she can because we’ve got this language for it and…

A.H.: So what would you say have been the major changes to this model over time? To the EFT?

R.E.: Yeah… let’s see… we start developing the therapy in 1985 - it was really before when the Emotion Theory was differentiated. So that got added with Greenberg and Safran and then during the 90’s that got sort of clarified and added. Emotion Theory got put in there and that really helped clarify our theoretical base. And the other thing we’ve done was we added tasks. So when we started in 1985 we didn’t have empty-chair work formulated. We knew there was an empty-chair task but it hadn’t been mapped yet. So that got done in the late 80’s and then we added narrative work and we added meaning creation, but the most recent one we’ve added is self soothing. So we’ve just mapped the self soothing task. All of us have been doing it for years but we’ve never had a map for it. Now we’ve got a formulation – the markers and the stages and things like that. So, basically… part of what happens is that we keep adding tasks, right? We’re up to I think fourteen now.

A.H.: How much is contemporary psychotherapy evolution somehow being influenced by EFT practices and theorizing? And if it is, into what extent is this recognized?

R.E.: yeah… I mean, that’s interesting. It could be an occasion for me to complain about how people don’t recognize our work more (laugh)… but what’s really got me, capture my interest in the last months or so is the influence of EFT on psychodynamic therapy. So the work of Diana Fosha, Leigh McCullough, and Hanna Levenson, and these are three contemporary psychodynamic therapists who practiced in emotion-focused way and…

A.H.: Recognizing it?

R.E.: Yes! Yes. In different ways and, you know, Hanna Levenson, for example, has stopped using transference interpretations and has replaced that with chair work. That’s a really interesting thing, right! And I think that’s fascinating, so my group in Strathclyde and I we’ve started getting these videos of these contemporary psychodynamic therapists and looking at their work and actually we were really impressed with them. Like Diana Fosha, she’s a wonderful therapist!

A.H.: You could look inside. What a privilege!

R.E.: Yeah, yeah! So that’s a place that’s been recognized. Now there’s overlaps with CBT on schema therapy and… you know, there’s various kinds of CBT that are actually fairly close and it’s a little hard to tell whether, you know, where Jeff Young got - his use of chair work in schema focused therapy. It’s little hard to tell, but… I mean Aaron Beck now says that he never said that the relationship between cognition and emotion was only one way. He says he always said it was two ways, right? So, is that influence? It’s not recognition but…

A.H.: It’s a strange way of recognition.

R.E.: There’s an interesting story that Les tells about Laura Rice and that’s that Aaron Beck approached Laura Rice and – I think approximately in early 70’s – and asked if she wanted to work with him and she said no thank you, right? But that’s just interesting, right?

A.H.: So, looking into this evolution what would you like to see in EFT in the coming years as an evolution, how is the future?

R.E.: Well I’d like to see us… of course humm … doing more training with more therapists, I’d like to see us developing ways of working with new client groups. You know, right now we got pretty good solid empirical evidence based for working with depression, with post trauma and with couples. Those are really solid. But what we haven’t done much with so far is anxiety, so I’d like to see us, and we’re starting to do the work now - I’m working with social anxiety and, that folks, people in Ireland and Toronto, are working with generalized anxiety disorder, with difficulties. So moving into anxiety (and that will stretch us and help us grow as EFT therapists). Eating disorders - Les’s group in Toronto is working with eating disorders now, and that’s a really interesting and important area to develop. So I’d like to see us expanding in other client groups and populations and as we do that we’ll both learn how to work better, more effectively with those client groups but we will also develop the therapy further, it will push us, so that’s certain. And that will lead to developing more tasks. One of the reasons why we’ve formulated self-soothing now is because we are working with these clients with social anxiety who live in this collapsed state, you know?

A.H.: They regulate…

R.E.: Their critic is so severe that they just get into to this collapsed state and they can’t somehow recover from it. And then the self-soothing process turns out to be really important in the therapy. So the client group has lead us to develop the therapy more. I’d also like to see the humanistic therapies to be recognized more. The humanistic therapies in general have really strong evidence base that’s not really recognized in the field and I’d like to see us doing more research and be more political, actually, about how we use our research evidence so that we can be recognized for what we do do, so.

J.S.: The last book from Sandra Pavio and Pascual-Leone - EFT for Complex Trauma - is a new development…

R.E.: It is work that’s going back into the early nineties actually, but they were able to put it together I think, finally. I haven’t even got my copy of it yet, it was just published this month, I don’t even know…

J.S.: In January

R.E.: In January, right… so I’m waiting eagerly to see that. But I’ve been following the work of Sandra Paivio on working with trauma - child sexual abuse most, is what she works with. I’ve been following that work for years, I think is fascinating and important. And it’s part of what lead us to the establish this evidence base for the effectiveness of EFT with post-trauma, right? Unfortunately not PTSD. In these studies they don’t diagnose PTSD, they just work with people that have got difficulties with having been traumatized as kids.

A.H.: So this turns us into effectiveness, can we turn into Effectiveness?

(Continue to part 3 e 4 )