Leslie S. Greenberg
Emotion-focused therapy (EFT: Greenberg, 2002; Greenberg & Watson, 2006) views the relationship, characterized by the therapist’s presence and the provision of empathy, acceptance and congruence, as an affect-regulating bond. It also posits that this type of bond provides an optimal therapeutic environment for the facilitation of deeper emotional processing and experiencing. Empathy, acceptance and congruence not only create an optimal therapeutic environment in which clients feel safe to engage fully in the process of self-exploration and new learning, but also contribute to clients’ affect regulation by providing interpersonal soothing. Over time this interpersonal regulation of affect is internalized into self-soothing and enhances the capacity to regulate inner states. In this view, the therapist’s overall attitude, not only his/her techniques, are seen as influencing the client’s well-being. This chapter will discuss elements such as pacing and facial, tonal and postural communication of affect that create a therapeutic emotional climate. In addition to the climate’s role in promoting enhanced affect regulation, its role in providing the optimal environment for facilitating emotional processing will be discussed.
In our view the relationship serves a dual purpose in psychotherapy (Greenberg & Watson, 2006). First, the relationship is therapeutic in and of itself by serving an affect regulation function which is internalized over time. This function is accomplished by offering a soothing, affect-attuned bond characterized by the therapist’s presence and empathic attunement to affect as well as acceptance and congruence. Second, the relationship functions as a means to an end. The relationship offers the optimal environment for facilitating specific modes of emotional processing. Affect is much more likely to be approached, tolerated and accepted in the context of a safe relationship. The combination of functions results in a style of relating that involves a combination of both, following and leading, responding and guiding.
In the most general terms, EFT is built on a genuinely prizing (a term used in client-centred therapy in place of unconditional positive regard) empathic relationship and on the therapist being highly present, respectful and responsive to the client’s experience. At the same time, EFT therapists also assume that it is useful to guide the client’s emotional processing in different ways at different times. The optimal situation in this approach is an active collaboration between client and therapist, with each feeling neither led nor simply followed by the other. Instead, the ideal is an easy sense of co-exploration. Nevertheless, when disjunction or disagreement occurs, the client is viewed as the expert on his or her own experience, and the therapist always defers to the client’s experience. Thus, therapist interventions are offered in a non-imposing, tentative manner, as conjectures, perspectives, “experiments” or offers, rather than as pronouncements, lectures or statements of truth.
In this relational framework we have come to view a therapist who works in this way as an emotion coach (Greenberg, 2002). Coaching in this view entails both acceptance and change (Linehan, 1993). The therapist both promotes and validates awareness and acceptance of emotional experience and coaches clients in new ways of processing emotion. The non-directive following style provides change towards acceptance of what is while the more leading style provides guidance and introduces novelty and the possibility of change towards something new. In our view an EFT relationship differs from a CBT relationship in relying on empathic attunement and exploratory empathy as its main tool rather than creation of rapport and Socratic dialogue. Questions are not used much by therapists and the relational style in EFT is far less educative, challenging, disputational or change-oriented. In addition, believing that clients cannot leave a place before they have arrived at it, the focus in the relational dialogue is on acceptance and validation of emotion rather than on modification of cognition. It is only after validation of what is being experienced, as shown in the transcript below, that transformation via accessing new affect and creation of new meaning comes into play. The relational emphasis is more on facilitation of strength than on correction of error.
An example of a therapist responding to a depressed client’s sense of isolation after a divorce is given below to exemplify the type of empathic attunement and exploration characteristic of the relational style in EFT.
T53:
Do you think you could put your sister in the chair and talk to her?
C54:
No. [Pause]
T54:
It’s really a hard one for you. [Pause] What are you feeling right now?
C55:
[Small voice:] Scared. [=Vulnerability begins to emerge]
T55:
[Gently:] Scared. [Pause] Uh-huh. Just so scared about . . .
C56:
What will happen to the little [rueful laugh:] relationship that we have.
T56:
Uh-huh, scared that if you assert yourself here, you could lose her.
C57:
What change will it bring in her, towards me? I don’t think I could handle it. (T: mhm)
T57:
“If I assert my feelings or if I express my true feelings of jealousy towards her, will it ruin the shred of a relationship that we do have? (C: mhm) Will it ruin the little bit of e-mail I do get?” It might destroy even those little threads, and it’s so scary to think about not having that relationship. (C: mhmm mhm)
C58:
Yeah. It is such a risk. I don’t know if I can bear the loss. Without her it’s like I would have nothing.
T58:
Just a feeling that, “Without that connection I will be left totally alone.”
C59:
Yes, that’s how I would feel, totally alone, not anything to anybody.
T59:
Uh-huh, without any value to anyone.
C60:
Yes, it’s like feeling that I could die without anyone knowing.
T60:
No one would even know.
C61:
Yes. I feel tight in my throat. (T: mhm) My stomach hurts.
In the above segment, the therapist responds empathically to the client’s vulnerability in a prizing and congruent manner. This helps the client’s vulnerability emerge at C55, when she reports feeling scared. The therapist validates the scared feelings, and in C59 the client begins to articulate the unbearable sense of loss. This leads her towards focusing on a bodily felt sense of pain and the therapist, as shown below, guides her to regulate the feeling and to explore it to access the implicit meanings.
T64:
That’s good. [Pause] Good calming breaths. [Pause] [Whispers:] Take a minute, just to relax. Quiet down inside [long pause]. So there’s this feeling inside. What’s it like?
C65:
Sometimes it’s just like I want to go crawl in my bed and just stay in there and nobody bother me. [=Vulnerability emerges further]
T65:
Mhm, mhm. “I just want to shut my eyes and shut all the pain shut out (C: mhm, mhm) And shut all the people out. Yeah. (C: mhm) I just want to make all the pain go away.”
After a deepening to get to core vulnerability, the acceptance and validation by the therapist helps the client stay with the painful, vulnerable feelings, while the therapist listens for what is worst or most painful about the whole thing.
T68:
What hurts the most right now? I know it’s really hard. [Pause] What part of it is hardest?
C69:
It’s like I’m drowning, (T: [whispers:] drowning) and I keep reaching up, and I’ve been struggling since I was a kid.
T69:
[Whispering:] Like you’re drowning, and a little piece of you, one hand, one arm just keeps reaching up.
At the same time as witnessing and receiving the helpless aspects of her experience and making vivid the depths of the client’s despair, the therapist is listening for the genuine emergence of adaptive emotions and for the wants and needs in the personality. This begins to emerge above in the image of reaching up and is developed below, through exploring feelings tied to an episodic memory of a time in her childhood when she nearly drowned; her reorganization into a more resilient state is recognizable below in her reaching out for comfort and safety from others:
C74:
[Stronger:] And, and you know, reaching, and just keep reaching (T: mhm, hm) and I think it was one of my brothers who [rueful laughter:] realized I was drowning [laughs], you know, pulled me up, and uh, um, I don’t even know how old I was, but, but very traumatized by that.
T74:
And right now, it’s like you’re saying, “Is there anyone that can reach me and pull me up out of this?” (C: mhm)
The client then goes on to self-challenge her expectations:
C77: Mhm, And I’m reaching for something, somebody. (T: mhm, mhm) [large sigh] You know, thinking back, I think, OK, I did have an unrealistic expectation of getting married to Dave, and moving away. And that was just so exciting to me. [Self-reorganization taking place]
The end of this segment below reveals the significance of the relationship in helping her reorganize in a more resilient manner.
T88:
What are you experiencing right now?
C89:
I guess that’s why therapy is so important to me. I really need someone to help me find my way. And so it feels good in a way for me to be able to tell someone about these things.
T89:
I’m pleased to be here with you and that telling me about it is helping.
C90:
Uh-huh. And I don’t feel so desperately in need of someone in my family like my brother or sister to rescue me, or so angry when they’re too tied up in their own lives. But still I would like to hold onto my relationships with them. There are moments when I know I can make it. It’s just sometimes it feels so overwhelming and I go to that drowning place again.
T90:
So in spite of everything, you feel you can manage at times?
Deficits in empathy and emotional connection between infants and their caretakers have been found to affect areas of right brain development involved in empathy and compassion (Schore, 2003). When an empathic connection is made with the therapist, affect processing centres in the brain are effected and new possibilities open up for the client. This creates an optimal therapeutic environment in which clients feel safe to engage fully in the process of self-exploration and new learning, but also contributes to clients’ affect regulation by providing interpersonal soothing. Over time this interpersonal regulation of affect is internalized into self-soothing or the capacity to regulate inner states. These optimal therapeutic relational qualities thus facilitate the dyadic regulation of emotion through provision of safety, security and connection. This breaks the client’s sense of isolation, confirms self-experience, and promotes both self-empathy and self-exploration.
Emotion self-regulation.
In experimental psychology the regulation of emotion is usually defined in terms of the conscious or volitional self-regulation of emotion. Emotion regulation refers here to the set of control processes by which people voluntarily control their experience of their emotions. Emotion regulation, for example, is defined as the process by which individuals influence which emotions they have, when they have them and how they experience and express them (Gross, 1999). This view of emotion regulation generally sees appraisals as resulting in emotion and suggests that people have emotion, which they then need to regulate. This is a two-factor view of emotion regulation, in which one system is seen as generating emotion and another is seen as subsequently regulating emotion. This is a self-control view of emotion regulation.
A broader, one-factor view sees emotion regulation as intrinsic in the experience of generating emotion. In this broader view, regulation, rather than self-control, is seen as an integral aspect of the generation of emotion and coterminous with it (Campos, Frankel, & Camras, 2004), and appraisal and emotion are seen as occurring simultaneously to generate emotional meanings. Affective neuroscience supports this broader view of emotion regulation rather than the narrower two-factor, conscious control, view (Cozolino, 2002). Evidence shows that although the prefrontal cortex is connected to and can influence the amygdala, the amygdala is highly connected to many parts of the brain and to the prefrontal cortex and influences decisions (Le Doux, 1996; Damasio, 1999). Evidence from affective neuroscience also indicates the possibility that there is both implicit (right hemispheric) and explicit (left hemispheric) affect regulation (Schore, 2003). Emotion in this broader view thus is both inherently regulated and regulatory. The cognitive system is seen as receiving information from the emotion system as well as influencing it, and as guided by emotion, as well as making sense of emotion. Emotion systems thus can be transformed or regulated by processes other than cognition, such as by other emotions and by attachment (Greenberg, 2002).
Essential affective self-regulatory processes thus are involved in self-maintenance, rather than self-control, and these occur largely below conscious awareness. This probably occurs in the orbitofrontal cortex which takes over amygdala and lower level right hemispheric functioning in more complex processing (Schore, 2003; Lane & Nadel, 2000). Implicit affect regulation that occurs through right hemispheric processes is not verbally mediated, is highly relational, and is most directly affected by such things as relational and emotional communication, facial expression, vocal quality and eye contact.
In clinical work, regulation is not easily achieved through the cognitive system alone. A validating relationship is crucial to affect regulation. People with under-regulated affect have been shown to benefit from interpersonal validation as much as from the learning of emotion regulation and distress tolerance skills (Linehan, 1993; Linehan et al., 2002). Problems in vulnerable personalities arise most from deficits in the more implicit forms of regulation of emotion and emotional intensity. Although deliberate behavioural and cognitive forms of regulation – more left hemispheric process – are useful for people who feel out of control, over time it is the building of implicit or automatic emotion regulation capacities that is important for highly fragile personality disordered clients. Implicit forms of regulation often cannot be trained or learned as a volitional skill. Directly experiencing aroused affect being soothed by relational or non-verbal means – a more right hemispheric process (Schore, 2003) – is one of the best ways to build the implicit capacity for self-soothing. Being able to soothe the self develops initially by internalization of the soothing functions of the protective other (Stern, 1985). Soothing then most centrally comes interpersonally in the form of empathic attunement and responsiveness to one’s affect and through acceptance and validation by another person. The provision of a safe, validating, supportive and empathic environment in therapy helps soothe automatically generated under-regulated distress. Internalizing the soothing of the therapist is one of the best ways of developing implicit soothing. Empathy from the other over time is internalized and becomes empathy for the self, and this leads to a strengthening of the self (Bohart & Greenberg, 1997). Implicit soothing of distressing emotion can be developed. Often it is a relationship with an attuned other that is essential in developing this form of emotion regulation.
The nature of an emotion-regulating relationship
Therapists first create a warm, safe and validating climate by their way of being with the client. One of the central elements of this way of being is the affective climate created by facial, vocal, gestural and postural cues. The emotional climate has to do with the total attitude of the therapist: being perceptive and attuned to the client is communicated by means of therapists’ verbal expressions as well as body posture and vocal and facial expression. Clearly, the therapist’s overall attitude, not only his/her techniques, influences the client’s responses and the way the client’s feelings are experienced and expressed in the therapeutic relationship. Martin Buber (1958) wrote that a compassionate human face, when unadorned by pretence, role or assumption of superiority, offers more hope to another than the most sophisticated psychological techniques. In working with emotion, although the therapist may be an expert in the possible therapeutic steps that might be facilitative, it is made clear that the therapist is a compassionate human being who is a facilitator of client experience.
The therapist who conveys genuine interest, acceptance, caring, compassion and joy, and no anger, contempt, disgust and fear, creates the environment for a secure emotional bond. A recent analysis of the classic film Gloria: The Three Psychotherapies by Rogers, Perls & Ellis (Magai & Haviland-Jones (2002)) studied the emotional climate created by the therapists. This analysis revealed that each of these therapists, in their behaviour in the film, in their theories, and more generally in their personalities and personal lives, expressed and focused on very different emotions. Rogers showed interest, joy and shame. Perls showed contempt and fear, and Ellis anger and fear. Anyone who has seen these films can see that they created very different therapeutic environments.
The therapists’ facial, postural and vocal expressions of emotion clearly set very different emotional climates and are aspects of their ways of being. Clients’ right hemispheres respond to therapists’ micro affective communication as well as to their explicit words, and all these influence clients’ processes of dynamic self-organization. The categorical emotions, such as interest, anger, sadness, fear and shame, expressed by the therapist are important and strongly influence the relational environment. The vitality aspects of the therapist’s emotional expression, such as rhythm, cadence and energy, are also important in affective attunement.
Therapists’ facial communication of emotion is one of the central aspects of the emotional climate. As Levinas (1998) has argued, seeing the face of the other evokes experience in us. The face is a powerful if ambiguous text, from which much is read. Facial expression thus is a central aspect of relational attunement. People have been shown to read facial affect automatically at incredibly high speed, especially those affects, such as anger and fear, that are crucial to survival. Childhood abuse has been shown to affect the accuracy of interpretation of facial cues and to lead to the over-attribution of hostility to others’ facial expressions. Clients see their experience reflected in the therapist’s face and manner of response. If clients are having feelings, and they see that their therapist understands and validates what they are feeling, this gives credibility to their feelings and has an impact on clients. Clients thus learn some of who they are and how acceptable they are from the facial expressions of their therapists, which evoke in them certain feelings. Clients thereby are helped to acknowledge that they themselves do experience and that they communicate their feelings. Put more simply, a client feels “Oh, you get it, you get me, and I get that you get me too!”
For example when clients are experiencing grief or sadness, therapists respond to clients’ pain in different ways. Therapists’ faces register pain, maybe their eyes even fill with a tear, they lean in, listen closely (all of these are right brain to right brain communications; cf. Schore (2003)). Then to bring this experience into the room even further, and help solidify it with the client, therapists might ask clients what it’s like to share these feelings with them, how they experience the therapist or what their sense of the therapist is in the moment. The therapist also might ask what the client sees in his or her face, and how this makes the client feel. Therapists may also share with their clients their own sense of feeling close to them as clients share their feelings. This validates the client’s ability to be with these feelings, and to let them into the experience. In this way therapists deepen the dyadic experience (Fosha, 2004).
Therapists’ pacing is another of the more crucial ways of influencing the type of emotional climate. A slow pace, for example, is essential for working with sad emotions. The tone, energy, rhythm and cadence need to be appropriate to the emotion being worked with. A slow, soothing tone and manner are crucial in accessing core vulnerable emotions. An encouraging, more energetic tone is helpful in supporting the more boundary-setting emotions of anger and disgust.
Numerous studies have shown that a positive therapeutic alliance is associated with good outcome. The alliance reflects three important aspects of therapeutic work: the bond or the feelings the participants have towards each other, the level of agreement that exists between them about the goals of therapy, and the ways in which they will go about meeting those goals (Bordin, 1979). The development of collaboration has been established as an important, empirically supported aspect of the therapeutic relationship. Thus, as well as creating the emotional climate that secures a warm trusting bond, it is important to foster a collaborative alliance through the course of therapy, one to work with emotions: both avoided emotions and under- or over-regulated emotions.
We have identified a number of ways to assist in the development and maintenance of the therapeutic alliance to work with emotions. The first of these involves conveying that the primary focus of treatment is the client’s concerns and underlying painful feelings. The therapist conveys that a central intention of therapy is to help clients to open up and reveal their inner feelings, meanings and fears – to risk being vulnerable with their therapists in the hope that together they can come to a better understanding of the clients’ inner and outer worlds and effect meaningful change that will ameliorate clients’ sense of despair. Without this exploratory goal being adequately negotiated between the parties the therapy will likely end prematurely or not progress. From the start the client is implicitly being trained, by the therapist’s consistent empathic focus on the client’s internal experience, to attend to this internal experience.
Therapists in the early phase of therapy convey understanding, acknowledge the client’s pain, validate their struggles, and focus on the emotional impact of events in the client’s life. By the therapist’s attentive listening, presence and caring and by the attitude conveyed by the therapist’s face, body, hands and eyes that validates the client’s specialness, the client comes to feel seen, valued and respected and is thereby more inclined to trust and be open. By attending to clients’ core humanness and expressing unconditional confidence in clients’ strengths and capacities for growth, the therapist helps reveal clients’ uniqueness and strength. It is by seeing the possibility of growth in another being that this possibility is stimulated.
The deeply held therapeutic attitude of empathy and positive regard or prizing of the client and a focus on strengths and resources help create an emotional bond of trust and respect and help develop the safe environment and a secure base for the exploration that will take place as the therapy progresses. In addition to creating a bond, a rationale is provided, right from the start, that the goal of treatment is for the person to access and become aware of underlying feelings and needs involved in their difficulties. If, however, their emotions are under-regulated, the goal is set of finding better ways of coping with feelings that seem overwhelming. People are told that their feelings provide important information about how they are reacting to situations and that it is important to get clear on what their emotions are telling them. There is a strong emphasis from the start on validating and accepting the pain that people feel. When people come to therapy they do so because they are suffering and feel some form of pain – it feels like something in their life or inside of them is broken. It is with the quickness and sureness with which the therapist can grasp the nature of the client’s chronic enduring pain that an emotional bond and collaboration to work on it will be created. Once the chronic enduring pain has been articulated, the person’s sense of isolation is broken. There is a sense of relief that it has been spoken, that someone understands and that the person now is not so alone in the struggle. Hope is created and agreeing to work on resolving the chronic enduring pain creates an alliance, spurred by this hope. Resolving the articulated enduring pain becomes the goal of treatment and the basis for the working alliance.
Sharing a rationale
It is necessary, in the early phase of therapy, to provide a rationale as to how working with emotion will help achieve goals. For some clients the importance of focusing on emotion is self-evident as they recognize that their emotions are the source of their distress; for others it is a totally new way of viewing problems. First, a general rationale is given that emotions provide information about one’s reactions to situations and about central concerns and that awareness of these, the ability to deal with them and their message is central to healthy functioning. People are informed, in a respectful, conversational way, that lack of awareness, suppression and dysregulation can lead to distress, and the relationship between depressive symptoms such as hopelessness and rumination and avoidance of underlying emotions is highlighted.
As treatment progresses, more specific aspects of a rationale are provided. When, for example, it is judged necessary to explicitly direct clients to attend to internal experience, it can be explained that their body is telling them something about how they reacted and it is important to receive that message. When a feeling is interrupted in the moment, the client’s attention is brought to the interruption and the difficulties produced by the person’s fear and avoidance of emotion are discussed. Rationales are offered in as individualized a form as possible, relevant to the shared understandings of the client’s unique problems. The general rationale, however, is that feelings are adaptive guides to action, provide information about reactions, need to be acknowledged and reflected on, and, if dysfunctional, need to be transformed. As the treatment proceeds, the therapist also needs to obtain the client’s agreement to engage in more evocative processing tasks like chair work and imagery that best fit with the client’s state, the focus of treatment and the agreed-upon goals in therapy.
Therapists thus, right from the first session, work to acknowledge the depths of clients’ pain and provide validation rather than trying to talk them out of their feelings. This provides hope and begins the process of alliance formation. Therapists strive to create an environment in which their clients can express their pain and vulnerability without fear of being evaluated. The opportunity for clients to share the full intensity of their feelings of despair in therapy and to feel recognized and validated can be experienced as a tremendous relief, as they no longer have to put up a front and cover up how badly they feel.
Developing the bond
Bond creation is the major task in the first three to five sessions. It is an important part of building the initial alliance and continues to be important throughout treatment. The emotional climate set by the therapist in the early sessions strongly influences what will follow. Creating an emotion-friendly environment is important to help clients access and focus on their painful feelings. At the beginning of treatment therapists accept clients’ experiences as they are presented. They do not attempt to challenge their clients’ views, nor do they suggest alternative responses. Instead, as therapists convey their understanding and concern for their clients they begin to build their understanding of their clients’ functioning and ways of processing their experience.
Throughout therapy it is important to help clients feel validated so that they can reveal the depth and extent of their feelings without fear of criticism or of being shamed. Empathy and compassion are antidotes to shame, and a genuine acceptance ensures that the therapist does not shame the client (see Gilbert, Chapter 6, this volume; Greenberg & Paivio, 1997a, 1997b; Wheeler, 1996). Most importantly, EFT therapists do not convey the message that clients’ feelings have to change, or that their feelings are invalid or mistaken. The primary objectives, especially initially, thus are to help the client feel safe and understood and to facilitate the client’s self-disclosure. If clients are to reveal vulnerable aspects of their subjective selves they need to feel safe knowing that they will be understood. The trust and support that develop between the participants help the client to share painful aspects of their experience that may be difficult to talk about and share with another. The process of revealing self to an understanding and supportive other contributes to the development of a therapeutic bond, which in turn facilitates and enhances the emotion-work that follows. The bond is strengthened as clients begin to become more aware and experience the relief and benefits of exploring their experience.
In addition to providing a safe and responsive emotional climate, attuned to clients’ feelings, therapists facilitate different types of processing and also utilize specific interventions that have been found to help clients resolve particular cognitive-affective problems: for example, directing attention inwards when the client is external, promoting dialogues between parts of self to facilitate integration, facilitating a broader view of a significant other with empty chair work, focusing on an unclear felt sense and evocatively unfolding to promote an understanding of problematic reactions (Greenberg, Rice & Elliott, 1993).
Therapeutic presence
In order to establish a positive alliance it is important for therapists first to be present to their clients. A question often asked by trainees is: what does one need to do to help a constricted client access feeling? But this implies that it something one needs to do to the client. My answer is that the ability to access emotions depends first and foremost on the type of relationship created. It is the therapist’s ability to be present that will help the client access emotion. A qualitative analysis of therapists’ experience of presence revealed that therapeutic presence involves being receptively open and sensitive to one‣s own moment-by-moment, changing experience; being fully immersed in the moment; feeling a sense of expansion and spaciousness; and being with and for the client (Geller & Greenberg, 2002). It is these qualities that will help create the climate that will lead clients to attend to their moment-by-moment affective experience. It is important that therapists are able to be receptive and open to their clients’ emotional experiences. The kind of “presence” that seems to be therapeutic is the state of mind in which there is an awareness of moment-by-moment emotional reactions as well as thoughts and perceptions occurring in the client, in the therapist and between them in the therapeutic relationship. This means that therapists need to let go of their own specific concerns, the quarrel with their spouse this morning, the falling value of the dollar or an upcoming vacation, and truly show up in the session. To be present for clients is to empty oneself, to clear a space inside so as to be able to listen clearly in the moment to the narratives and problems that clients bring. Therapists need to see their clients’ faces and hear their voices. It is through the therapist’s undivided and focused attention that clients feel valued and are able to clearly discern their own concerns and difficulties. By giving clients their full attention therapists are able to resonate more fully with their clients’ feelings and their experience of events and provide the level of empathic responding that will be most optimal at different points during the session.
Dialogue of this type often leads to heightened moments of meeting or what Buber (1958) referred to as I–Thou contact. In these moments people share living through an emotional experience together. Here an intersubjective experience is lived while it is occurring: it is a shared experience of attending to and experiencing the same thing at the same time and knowing that the other is co-experiencing the same thing. Each person experiences something of the other’s experience and knows that this is occurring. This creates a strong bond, a sense of togetherness that breaks any sense of existential isolation and promotes trust and openness. It also is a lived moment of experience that remains indelibly stamped in memory. These moments produce therapeutic change both in the people’s sense of self and their way of relating.
We see the Rogerian conditions of empathy, positive regard or acceptance, and congruence (Rogers, 1957) as part of a single therapeutic way, that of being fully present with the other. Empathy has been established as one of the three empirically supported aspects of the relationship, one that correlates highly (e.g., r = .32) with outcome (Bohart et al., 2002). Thus, I will briefly discuss below each of the client-centred attitudes. However, while we talk about each as if it were distinct from the others, as we have said, it is more accurate to see them as part of a single therapeutic way of trying to be fully present with and understand another (Geller & Greenberg, 2002). Without being fully present it is not possible to communicate affect-regulating empathy. While it is possible to empathize with another without necessarily feeling accepting, this would be cold, clinical empathy. Similarly, while it is possible to convey intentionally that you understand another and care for them, if this is without sincerity one risks appearing artificial and not someone to be trusted with the most precious and vulnerable aspects of the client’s psyche. As Rogers highlighted, empathy without positive regard and genuineness can be used in the service of manipulation and thus it is important to distinguish between compassionate and non-compassionate forms of empathy (Gilbert, 1989; Bohart & Greenberg, 1997).
A recent study looked at clients who were being treated for depression in cognitive-behavioral and process experiential psychotherapy. It found that clients’ perceptions of the Rogerian relationship conditions were highly correlated with clients’ ratings of the therapeutic alliance in both approaches (Watson & Geller, 2005) and were associated with changes in clients’ level of self-esteem, and their self-report of interpersonal difficulties, while therapists’ acceptance of their clients was predictive of changes in depression.
Empathy
It is clear that unless therapists are empathically attuned to clients’ feelings and meanings they will not be able to perceive their clients’ goals nor work with them to identify the tasks that might be helpful in their realization. Some of the essential steps in affect regulation are awareness, labelling and differentiation of emotions, followed by modulation and evaluation of the response. Empathic responding by therapists helps clients become aware of their emotional experience, label it in awareness and modulate it so that it is not overwhelming or excessively muted so that its message is lost. Empathic understanding responses and empathic affirmations amplify the client’s experience so that it can be apprehended more clearly, while evocative reflections and empathic conjectures facilitate its differentiation, modulation and evaluation (Greenberg, Rice & Elliott, 1993). Empathic exploration facilitates the client turning inwards to explore and unpack their inner subjective world views and feelings about events (Elliott, Watson, Goldman, & Greenberg, 2003). At the same time as empathy and validation provide support and understanding, they also highlight the subjectivity of clients’ perceptions and experience. EFT therapists highlight the constructed nature of events by emphasizing the subjectivity of the clients’ perceptions and construals of reality. For example, the use of the word “seems” in phrases like “It seems so hopeless” suggests that a depressogenic construal is a subjective state that is open to reformulation, and may be time-limited.
Acceptance
Humans have evolved to be highly influenced by the minds of those they interact with, and the experience of acceptance in the mind of a valued person can have profound effects on physiological processes (Gilbert, Chapter 6, this volume). Warmth, compassion, openness and respect towards the client and his/her experience, caring for the client as a separate person, with permission to have his or her own feelings and experiences, is a crucial aspect of therapy. The sense that another is accepting and can be trusted, to the extent that one perceives the other as congruent and sincere, is very important to the sense that one is valued and liked by the other. Acceptance by another affirms one’s existence and fosters a sense of belonging and participation as it simultaneously allows one to accept one’s own experience. Acceptance of experience does not mean that the therapist evaluates it as good; rather it is a type of acknowledgement that this is what the client is experiencing in the moment; the experience is what it is. Acceptance also involves unconditional confidence in the inner core of possibility in the client. Through sensing the therapist’s unconditional acceptance of their experience, clients lose their preoccupation with their therapists and their energy becomes available to turn inwards and contact their own experience. Reduction of interpersonal anxiety leads to capacity for tolerance of more intrapersonal anxiety. Clients are able to face and accept more of their experience with the unconditional acceptance of another.
Congruence
The positive real relationship is a very important aspect of therapy and enhances the alliance and client progress (Gelso & Hayes, 1998). Congruence or authenticity can at an initial level of analysis be broken into two separate components (Lietaer, 1993): (1) awareness of one’s own internal experience, and (2) transparency, the willingness to communicate to the other person what is going on within. The deeper level intentions include, in addition to valuing and understanding the other, the intentions to facilitate the other’s development, to be accepting and non-critical of the other, to confirm the other’s experience, to focus on their strengths, and above all to do the other no harm. These intentions, and more, are what determine whether congruence is therapeutic. If one had a genuine desire to harm, being congruent would not be therapeutic.
The case of transparency or the communication component of congruence is much more complicated than the self-awareness component. It seems that being facilitatively transparent involves many interpersonal skills (Greenberg & Geller, 2001). This component involves the ability not only to express what one truly feels but to express it in a way that is facilitative. Transparency thus is a global concept for a complex set of interpersonal skills embedded within a set of therapeutic attitudes. These skills depend on three factors: first, on therapist attitudes; second, on certain processes such as facilitativeness, discipline and comprehensiveness; and third, on the interpersonal stance of the therapist.
The set of skills involved in facilitative congruent communication is best explicated by looking at congruent interaction in terms of the interactional stance taken by therapists as described by a circumplex grid of interpersonal interactions (Benjamin, 1996). This grid is based on the two major dimensions of autonomy/control and closeness/affiliation. Consistent with interpersonal theory, this grid outlines a set of complementary responses that fit each other and that interactionally “pull” for each other. Thus attack pulls for defensiveness or withdrawal, and affirmation pulls for disclosure and revelation. The skill of congruent responding involves not reacting in a complementary fashion to a negative interpersonal “pull” of the client, like recoiling when attacked, but rather to act in such a way as to “pull” for a more therapeutically productive response from one’s client, such as clear expression. This would be achieved by an empathic understanding response to an attack rather than by recoiling.
What to do when the therapist is not feeling affirming but is feeling angry, critical and rejecting, and can’t get past this feeling to something more affiliative? As we have said, an interactional response in order to be faciltatively congruent involves first connecting with the fundamental attitudes or intentions of trying to be helpful, understanding, valuing, respecting and non-intrusive or non-dominant. This will lead to these feelings being expressed as disclosures. If the interpersonal stance of disclosing the difficult feeling is adopted, rather than the complementary stances of expressing it by attacking, or rejecting, or seducing, then this congruent response is more likely to be facilitative. It is not the content of the disclosure that is the central issue in being facilitative; rather it is the interpersonal stance of disclosure in a facilitative way that is important. What is congruent is the feeling of wanting to disclose in the service of facilitating, and the action of disclosing. The different ways of being facilitatively congruent in dealing with different classes of difficult feeling thus are to some degree specifiable. They all involve adopting a position of disclosing. Expressing a feeling that could be perceived as negative, in a stance that is disclosing, rather than expressing it in the stance that usually accompanies that feeling, will help make it facilitative because disclosing is an affiliative and non-dominant form of interaction whereas being angry is clearly non-affiliative and may be dominant. Disclosure implicitly or explicitly involves willingness to explore, or an interest in exploring, with the other what one is disclosing. For example, when attacked or feeling angry therapists do not attack the other but rather disclose that they are feeling angry. They do not use blaming, “you” language. Rather they take responsibility for their feelings and use “I” language that helps disclose what they are feeling. Above all they do not go into one up, escalatory, positions in this communication, but openly disclose feelings of fear, anger or hurt. When the problem is one of the therapist’s experiencing non-affiliative, rejecting feelings or loss of interest in their clients’ experience, the interactional skill involves being able to disclose this in the context of communicating congruently that the therapist does not wish to feel this. Or therapists disclose these feelings as problems getting in the way and that they are trying to repair so that they will be able to feel more understanding and closer. The key in communicating what could be perceived as negative feelings in a congruently facilitative way is to communicate them in a non-dominant, affiliative disclosing way with appropriate non-verbals. Both timing and type of client need to be considered in deciding whether or not to disclose.
In addition to presence and being with the client, EFT therapists also lead and guide client processing – an activity that we have termed “coaching”. Emotion coaching involves a partnership of co-exploration in a growth-promoting process aimed at helping people achieve goals of emotional awareness, regulation, reflection and transformation (Greenberg, 2002). It involves facilitating awareness of emotions, and new ways of processing the emotion, and provides guidance in ways of soothing or regulating the emotion. Awareness in turn involves helping clients verbally label emotions while they are being felt, helping them accept the emotion and talking with clients about what it is like to experience an emotion. In addition, coaching clients involves facilitating the utilization of adaptive emotions, usually anger and sadness, to guide action and transform maladaptive emotions, usually fear, shame or anger. It is important to note that people often cannot simply be taught new strategies conceptually for dealing with difficult emotions, but rather have to be facilitated experientially to engage in the new process and only later explicitly taught what to do. For example, accessing anger or getting to an emotionally experienced need or goal may be very helpful in overcoming a sense of depressive hopelessness or defeat. However, explicitly teaching people that this is what they should do is not nearly as helpful as interpersonally facilitating this by asking them at the right time in the right way what it is they feel or need.
Some clients, however, are extremely externally focused and helping them contact their feelings can be challenging. A persistent gentle pressure to focus on current internal experience is required by means, first, of empathic responding and emotion enquiries, and later, by process directives that focus the client’s attention on internal experience. The client is encouraged to become aware of internal experience and to develop mindfulness (Perls, Hefferline & Goodman, 1951; Kabat-Zinn, 1990; Katzow & Safran, Chapter 5, this volume). Later process directives, such as suggesting the client repeat key phrases that stimulate emotion in the session, can be used to intensify experience and make it more vivid. A balance needs to be struck between allowing clients to tell their story and tracking their reactions, and explicitly directing their attention internally. Questions that are used in this phase and throughout therapy are: What are you aware of as you say this? What is happening in your body? What is it like inside right now?
Using empathic exploratory responses and emotion awareness questions, the therapist therefore works to help clients approach, tolerate, regulate and accept their emotional experience. Acceptance of emotional experience as opposed to its avoidance is the first step in emotion awareness work. Having facilitated the acceptance of emotion rather than its avoidance, the therapist then helps the client in the utilization of emotion. Here clients are helped to make sense of what their emotion is telling them and to identify the goal/need/concern that it is organizing them to attain. Emotion is used both to inform and to move.
Helping people arrive at, accept and regulate their feelings involves helping them do the following (Greenberg, 2002):
The relationship is first and foremost an affect-regulating bond that is, in and of itself, facilitative of psychological change conducive to growth and well-being. Second, the therapeutic relationship, characterized by presence, empathy, acceptance and congruence, helps clients to feel safe enough to face dreaded feelings and painful memories. Once an alliance has been consolidated the therapist guides clients towards new ways of processing emotion, coaching them to become aware of, regulate, reflect on and transform their emotions. It is in the blending of these various elements that successful therapy emerges. EFT suggests that people’s experiences and meanings are not easily subdivided into cognitive and emotional domains, indeed there is little evidence that the brain processes data in such ways, rather emotions are part and parcel of appraisal processes and therefore need to be open to introspection and opportunities for new learning. Working with emotion processes directly through the relationship is central to EFT rather than approaching them only through a cognitive route. As this volume shows, many therapists are now beginning to recognize the importance of this domain, especially with the therapeutic relationship acting as an emotional regulator, validator and educator.
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