Motivation and emotion/Book/2015/Emotion-focused therapy

Emotion focused therapy:
What is EFT, how does it work, and what does research say about its effectiveness?

Multimedia presentation (3 min)

Overview

Emotion-focused therapy has theoretical foundations that draw from humanistic psychology, emotion theory, and dialectical constructivism. Its framework recognises the significance of emotions in the context of human function and dysfunction. Emotion-focused therapy encourages a collaborative relationship between therapist and patient, and considers that the best therapeutic environment is one that is genuine and unconditionally positive (Pos & Greenberg, 2007). Emotion-focused therapy has proven effective in assisting couples (Denton, Burleson, Clark, Rodriguez & Hobbs, 2000), in treating depression (Dessaulles, Johnson & Denton, 2003) and eating disorders (Wnuk, Greenberg & Dolhanty, 2015), and in helping clients to recover from the trauma of child abuse (Paivio & Nieuwenhuis, 2001). Clients who are able to practice mindfulness and who have active methods of expression are most likely to benefit from emotion-focused therapy (Elliott, 2012).

Case Study Angus has been diagnosed with depression. He feels very alone and is constantly tired. He is plagued by feelings of hopelessness and low self-worth. Angus has begun seeing a psychologist who is specially trained in emotion-focused therapy. Throughout this chapter we will draw on Angus' experience with emotion-focused therapy to help highlight some of the key concepts you'll need to learn

What is emotion focused-therapy?

EFT is a form of psychotherapy specifically focused on working with the emotions of the patient. At the foundation of emotion-focused therapy are core values that draw on emotion as a source of meaning for the individual. These core values include experiencing, wholeness and growth (Elliott & Greenberg, 2007). Sessions are focused on guiding the client to activate maladaptive or dysfunctional emotions so they may be better understood. Adaptive or functional emotions are attended to and validated to encourage and promote functional emotional expression (Greenberg, 2004). EFT follows a structured approach, with specific therapeutic tasks such as attending, active expression and self-reflection guiding each session (Elliott & Greenberg, 2007). A patient’s progress through therapy follows several phases of treatment (Pos & Greenberg, 2007), which reflect different principles of emotional change (Greenberg, 2004; 2006). According to the foundations of emotion-focused therapy, targeting emotions is an important course of treatment because emotions are crucial to the way humans function, dysfunction and change (Elliot & Greenberg, 2007).

Key Concept Emotion-focused therapy draws on values from humanistic psychology, emotion theory and dialectical constructivism.

Theoretical foundations

Humanistic psychology

Humanism emphasises the uniqueness of human beings, and has a very optimistic and positive view of human nature (Weiten, 2010). Humanists argue that we are constantly striving for personal growth and to fulfill our potential. This theoretical approach focuses on self-actualisaton, which is the concept that we can all reach our potential if we exist in environments that are encouraging and supportive of our personal growth (Durand & Barlow, 2003). However, because we exist in environments inevitably filled with obstacles, our personal growth is often prevented or delayed.

Emotion theory

Emotion theory regards human emotion as a functional tool used to assist us in making the best decision to meet our needs in a given situation (Elliott, 2012). Emotion is considered to play an essential role in the way we construct our sense of self. Emotions help us to adapt. We use emotion to navigate through our ever-changing environment and to direct us to make choices we believe may serve us best in that given situation (Greenberg, 2006). If we experience sadness or grief it may be because a certain need or goal isn’t being met. If we experience elation or happiness, it may be because we’ve achieved something in line with our personal values. The amygdala plays a crucial role in the formation of human emotion. It interprets whether incoming sensory information should be considered of value or potentially threatening (Greenberg, 2004). Based on these interpretations we form emotional memories of what situations should be considered positive or negative, and our outward emotional expression is a reflection of that.

Key Concepts Emotion schemes are the way we organise information based on our experience. Emotion reactions are our outward expressions of emotion. These can include primary adaptive, primary maladaptive and secondary reactive reactions to situations or events.

Emotion is comprised of emotion schemes and emotion reactions. Emotion schemes are implicit structures of the way we organise our experience (Elliott, 2012). Emotion reactions are the explicit ways we experience emotions and can be adaptive, maladaptive or reactive in nature (Greenberg, 2007; Elliott & Greenberg, 2007). Primary adaptive emotions are an individual’s most basic, direct and immediate responses to a situation. Secondary reactive emotions are delayed emotional responses to situations that don’t necessarily reflect that situation but are responses to another, primary emotion. Maladaptive emotions are direct but are believed to be based on a misinterpretation of a situation (Greenberg, 2007; Elliott & Greenberg, 2007).

Dialectical constructivism

Dialectical constructivism regards emotion as crucial in human experience. It argues that our cognitive processes work simultaneously with our emotions to construct various versions of our ‘self’ (Greenberg & Pascual-Leone, 2001). Emotion and cognition are seen as dialectic or opposing forces that work side by side to help individuals process and store information about their experience (Emmerling, 2013).

Putting it all together

EFT focuses centrally on the emotions of the patient. The therapist works collaboratively with the patient to help 'coach' and equip them with tools that will hopefully aid in the construction of a stronger, more adaptive sense of self. Emotion-focused therapy teaches the patient to work with their emotions to improve their well-being. This focus on emotion is in keeping with emotion theory's idea that human emotions are a functional tool that assist us in constructing our sense of self and helping us to adapt.

Humanistic psychology can be seen in EFT's aim to encourage the patient to engage in actions both in and outside therapy that foster independence, self-development and personal growth (Elliott & Greenberg, 2007). This reflects back to humanists' beliefs that individuals are constantly striving to achieve their potential through personal growth. Each of the core values of emotion-focused therapy reflect a humanistic approach, emphasising the uniqueness of the human experience and appreciating that humans are ultimately in control of their lives. EFT draws from dialectical constructivism in its balance of using cognitive processes to work through emotional problems.

How does it work?

Core values

Emotion-focused therapy follows core values (Table 1) that are centred around enabling the client to experience and understand their emotions in a safe therapeutic environment (Elliott & Greenberg, 2007; Elliott, 2012).

Table 1.

The core values of emotion-focused therapy

Value	Explanation
Experiencing	Human experience provides a foundation on which thought, feeling and action rest
Presence/authenticity	Genuine relationships with other people are the important for functioning and healing
Agency/self-determination	Humans are ultimately in control of their experiences and choose how to construct their lives
Wholeness	People are best understood by considering their individual facets and parts, as opposed to viewing them as a whole
Pluralism/diversity	Individual difference should be nurtured, understood and encouraged
Growth	People have a natural tendency towards psychological growth

These values represent what emotion focused therapy regards as central to fostering change in an individual. The therapeutic environment is safe, supportive, and unconditionally positive, with an emphasis on the therapist developing a genuine relationship with the client (presence/authenticity). The therapist must understand that an individual’s mental representation of emotions is based on various schemes (experience), and the client has the capacity to choose the way they shape their environment (agency/self-determination). Emotion-focused therapy fosters the consideration and acceptance of the parts that make up a client (wholeness), and encourages and promotes individual difference (pluralism/diversity). Finally, the therapist values the innate tendency of individuals to seek psychological growth and development (growth).

Key Concepts The core values of emotion-focused therapy, such as wholeness, experiencing, and growth, are centred around fostering a positive and safe therapeutic environment in which the patient feels supported in exploring their emotions.

Principles of treatment

Angus' relationship with his therapist and his progression through therapy is marked by the relationship and therapeutic tasks of emotion-focused therapy (Table 2) (Elliott & Greenberg 2007). Relationship tasks help guide the bond between therapist and patient during sessions. The development of a close bond built on trust and unconditional positive regard is very important. Therapeutic tasks help guide the therapist through the progress of the patient during sessions.

Let's have a look at these in more detail.

Case Study Angus feels he can trust his psychologist. He feels comfortable sharing his feelings and emotions with her because no matter what he reveals, she seems to understand and remain non-judgmental. At the beginning of each session, they decide together what they need to work on together. They also reflect on his overall treatment goal, which is to be able to control his negative emotions. His psychologist encourages him to engage in some form of physical activity once a week, and to try and do something he enjoys.

Table 2.

Tasks of emotion-focused therapy

Relationship Tasks	Therapeutic Tasks
Empathetic attunement – this involves the therapist understanding and monitoring the client’s emotional experience. Empathy requires the therapist to surrender any preconceived ideas about the patient, and endeavour to become finely attuned to what they are feeling and what the significance of that feeling is for them.	Experiential processing – the therapist should assist the client by working with them on different tasks at different times, based on the client’s immediate state. These tasks are could include the client attending to what they are aware of at any given time; using self-reflection to interpret their experience and using action-planning to consider how they may think, act or feel differently in the future.
Task collaboration – this task involves the therapist and client working together to set goals. These may be for overall treatment outcomes and smaller goals to direct each session.	Task completion/focus – the completion of therapeutic tasks is a goal of emotion-focused therapy. Successful completion of a task takes time and often many attempts, with the therapist guiding the client through each of these. The client will not progress until they are emotionally ready to do so.
Therapeutic bond – the therapeutic bond is considered a crucial component of emotion-focused therapy. The therapist seeks to achieve this bond through empathy, acceptance and by always being genuinely present in each session.	Self-development – the therapist should strongly encourage the client to engage in actions both in and outside of therapy that foster independence, self-development, and personal growth.

Phases of treatment

The client travels through three phases during their treatment (Pos & Greenberg, 2007).

Consider the conversation that might take place between Angus and his therapist during each of these phases.

The stage first is bonding and awareness. During this phase the client develops a relationship with the therapist and begins to understand why focusing and working on emotion is an important first step in treatment. Here, a focus of treatment is established and the therapist and client work collaboratively to understand, explore and explain their underlying issues.

Angus – "I am sad all the time. It is a sadness that I cannot explain or understand" Therapist - "Your sadness is important. It is telling us that what is causing that feeling is important to you. Let’s try and understand why you feel sad"

The second stage is evocation and exploration. The patient is asked questions designed to evoke emotion. These emotions are the explored until the patient arrives at the deepest level of primary emotion.

Therapist - "Let's try and focus on the place where you keep your feelings. How does it feel inside that place?" Angus - "I feel heavy, and black, and dark. All the time" Therapist - "Can you try and label that feeling with a single word?" Angus - "Helpless"

The third stage is transformation and generation of alternatives. During this phase the therapist offers guidance in finding different ways for the patient to emotionally respond to situations.

Therapist - "When you feel helpless, what does that feel like? What do you think of when you go to that place?" Angus - "I just feel useless, then I get sad about feeling useless. I feel helpless because I have no want or drive to do anything else, then I feel frustrated because I haven't always been this way." Therapist - "You feel helpless because you don't have any motivation and you're comparing that to a time when you did, and that's causing you frustration." Angus - "Yeah. So I feel helpless because I can't do anything and frustrated because I don't know how I got here" Therapist - "Let's try and focus on another way for you to direct your thoughts when you feel helpless, so that you're not making the comparison to a time when you didn't feel like this. I believe avoiding that comparison will help with your frustration."

Key Concepts The patient will experience three phases of treatment as they progress through therapy: bonding and awareness, evocation and exploration and transformation of alternatives. These phases of treatment signify a patient's journey of emotional change, through awareness, regulation and finally transformation.

Principles of emotional change

A patient's journey through emotion-focused therapy follows three stages of emotion change (Greenberg, 2004). The first stage is awareness, in which the patient becomes increasingly aware of their emotions. During this stage the therapist will work with the client to help them accept, understand and tolerate their emotions. The second stage is regulation, during which the patient learns how to identify which emotions need to be regulated. The final stage involves transforming on emotion, usually maladaptive, into another more adaptive emotion.

Concept check

1 True or False? Emotion-focused therapy is only effective in treating individuals with depression True False 2 Which is true of emotion-focused therapy? It is a humanistic approach to therapy It has a theoretical basis in emotion theory and behaviourism It has a theoretical basis in emotion theory and dialectical constructivism It is a non-humanistic approach to therapy 3 True or false. Growth is a core value of emotion-focused therapy? True False 4 The relationship task empathetic attunement is concerned with The patient trying to be more 'in tune' with the therapist The therapist pretending to care about the patient, even when they don't The therapist understanding and monitoring the patient's emotion experience The therapist aligning their feelings with the patient 5 Experiential processing, task completion/focus and self-development are all examples of Relationship tasks Core values Therapeutic tasks Core tasks 6 True or false. The second phase of treatment involves the therapist suggesting different ways for the patient to emotionally respond False True 7 The principles of emotional change occur in the following order Bonding and awareness, evocation and exploration, transformation Regulation, awareness and transformation Awareness, regulation and transformation Experiencing, wholeness and growth

Is it effective?

Emotion-focused therapy has proven to be effective in treating relationship dissatisfaction, depression, eating disorders and the trauma associated with child abuse.

Levels of marital satisfaction increased in couples who underwent emotion-focused therapy (Denton, Burleson, Clark, Rodriguez & Hobbs, 2000). Couples experiencing marital dissatisfaction were divided into either a therapy group or a wait-list group. Both groups were administered questionnaires measuring levels of marital satisfaction prior to the treatment commencing. The therapy group then underwent 16 sessions of emotion-focused therapy. The wait-list group underwent the same 16 sessions of emotion-focused therapy, but after an 8 week delay from the baseline testing. Levels of marital satisfaction were measured again in both groups post-treatment. Results showed that participants in the therapy group were significantly more satisfied with their marriage after completing their EFT sessions in comparison with the wait-list group. Participants in the wait-list group were also more satisfied with their marriages after completing the 8 EFT sessions. An examination of individual scores showed that participants with low levels of education and low levels of ‘cognitive complexity’ showed the highest increase in marital satisfaction from pre- to post- therapy.

EFT has also been shown to be effective in treating depression. Dessaulles, Johnson & Denton (2003) studied couples consisting of a female partner who met the diagnostic criteria for a major depressive episode. Couples were divided into two treatment groups, one of which underwent emotion-focused therapy and the other underwent pharmacological treatment. Females receiving EFT revealed their levels of depression decreased from pre- to post-treatment, and from post-treatment to a 6 month follow up. Comparatively, females who prescribed medication showed improvement post-treatment but not at their 6 month follow-up. Therefore, participants who received EFT as treatment continued to see a reduction in symptomology for 6 months following treatment, however participants who received medication only did not experience this same reduction.

Emotion-focused therapy was used to treat adults suffering from a range of psychological symptoms following abuse in childhood (Paivio & Nieuwenhuis, 2001). Participants identified pre-treatment that they were hoping to gain help dealing with feelings about the abuse, negative self-esteem, interpersonal issues, emotional dysregulation and distress. Participants were administered dependent measures within 1 week of admission, and were assessed again post-treatment. 22 participants began therapy immediately and the next 24 were placed on a waiting list. All participants achieved significant improvements across a range of disturbances. There was no difference between the treatment effects for both groups pre- and post-treatment, indicating the effects of EFT were comparable for both experimental and control groups. These treatment effects were maintained at a 9 month follow up.

Women who met the met the diagnoses of binge-eating disorder, bulimia nervosa or eating disorder otherwise not specified were treated with emotion-focused therapy (Wnuk, Greenberg & Dolhanty, 2015). Participants underwent 16 sessions of EFT and their symptomology was assessed via questionnaire pre and post-treatment. The study showed EFT was associated with significant decreases in bingeing episodes, psychiatric distress and self-efficacy.

References

Denton, W.H., Burelson, B.R., Clark, T.E., Rodriguez, C.P. & Hobbs, B.V. (2000). A randomised trial of emotion-focused therapy for couples in a training clinic. Journal of Marital and Family Therapy, 26(1), 65-78. doi:10.1111/j.1752-0606.2000.tb00277.x.

Dessaulles, A., Johnson, S.M. & Dention, W.H. (2003). Emotion-focused therapy for couples in the treatment of depression: a pilot study. The American Journal of Family Therapy. 31, 345-355. doi: 080/01926180390232266.

Durand, M.V. & Barlow, D.H. (2003). Essentials of abnormal psychology. California: Wadsorth.

Elliott, R. & Greenberg, L.S. (2007). The essence of process-experiential/emotion focused therapy. American Journal of Psychotherapy, 63(3), 241-254. Retrieved from http://strathprints.strath.ac.uk/27735/.

Elliott, R. (2012). Emotion-focused therapy. In: The tribes of the person-centred nation. PCCS Books, 103-130.

Emmerling, M.E. (2013). Dialectical constructivism: the integration of emotion, autobiographical memory, and narrative identity in anorexia nervosa. University of Alberta, Alberta.

Greenberg, L.S. (2004). Emotion-focused therapy. Clinical Psychology and Psychotherapy, 11, 3-16. doi: 10.1002/cpp.388.

Greenberg, L. (2006). Emotion-focused therapy: a synopsis. Journal of Contemporary Psychotherapy, 36, 87-93. doi: 10.1007/s10879-0069011-3.

Greenberg, L.S. & Pascual-Leone, J. (2001). A dialectical constructivist view of the creation of personal meaning. Journal of Constructivist Psychology, 14(3), 165-186. doi: 10.1080/10720530125970.

Paivio, S.C. & Nieuwenhuis, J.A. (2001). Efficacy of emotion-focused therapy for adult survivors of child abuse: a preliminary study. Journal of Traumatic Stress, 14(1), 115-133. doi: 10.1023/A:1007891716593.

Pos, A.E. & Greenberg, L.S. (2007). Emotion-focused therapy: The transforming power of affect. Journal of Contemporary Psychotherapy. 37, 25-31. doi:0.1007/s10879-006-9031-z

Weiten, W. (2007). Psychology: themes & variations. California: Wadsworth.

Wnuk, S.M., Greenberg, L. & Dolhanty, S.J. (2015). Emotion-focused group therapy for women with symptoms of bulimia nervosa. Eating Disorders: the Journal of Treatment and Prevention, 23(3), 253-261. doi: 10.1080/10640266.2014.964612.