Integrating “Being” and “Doing” in Emotion-Focused Therapy
Emotion-Focused Therapy (EFT), also known as process-experiential psychotherapy, integrates person-centered, gestalt, and existential therapies. Apart from its neo-humanistic perspective, what is most distinctive about EFT is its person-centered but process-guiding relational stance with its marker-guided task strategy.
It is a therapy that emphasizes the collaboration between the therapist and the client. The therapist integrates “being” and “doing” with the client, and balances between “following” and “leading” the client (Greenberg, 2007). Apart from empathically attuning to the client’s immediate inner experience, the therapist is also an active leader of the therapeutic process. It is perceived as a kind of dialectic (i.e. a creative tension) between two vitally important aspects of therapy (Elliott et al, 2004).
This paper is an attempt, firstly, to review the essence of the three therapies mentioned above and, secondly, to see how Emotion-Focused Therapy integrates them to form its basic treatment principles and carry them forwards through different therapeutic tasks. Thirdly, it is to highlight how the “being” of the therapist should guide the “doing” of the therapist in Emotion-Focused Therapy through a demonstration of three pieces of therapeutic process. It is also a reflection of the writer’s own learning process of integrating her “being” and “doing” parts.
Person-Centered Therapy
The therapeutic approach originated by Carl Rogers (1951) is based on a humanistic and egalitarian philosophy. There is a strong belief and faith in the client’s capacity for self-discovery and self-direction. Individuals are seen as basically rational, responsible, realistic and inclined to grow. When Rogers first formulated his client-centered therapy in 1951, he emphasized that the therapist’s primary role is to enter into the client’s frame of reference and provide an atmosphere of empathy, unconditional positive regard, and congruence. Establishing these conditions in therapy, which are necessary and sufficient, will tap the vast resources for self-understanding and growth that individuals have within them. As client-centered therapy developed through three decades into person-centered therapy, there is an increased emphasis on the therapist’s congruence or genuineness as “the most basic of the attitudinal conditions that foster therapeutic growth” (Rogers, 1980). The therapist inevitably influences the process of therapy as a whole person and the therapeutic process is centered on the interaction between the client and the therapist.
Emotion-Focused Therapy builds on this foundation and develops its own treatment principles. The relationship principles of EFT are empathic attunement, therapeutic bond and task collaboration. The task principles include experiential processing, task completion and focus, and self-development. The first two of the relationship principles are basically very person-centered, while the third relationship and the task principles go beyond the “being” of the therapist and add the “doing” element of the therapeutic process. The major discrepancy between PCT and EFT is their theoretical assumptions. For Rogers, the three core therapeutic conditions are necessary and sufficient, whereas the stance of EFT is that the three therapeutic conditions are necessary but the therapeutic process can be more efficient and effective with appropriate implementation of therapeutic tasks.
Gestalt Therapy
The three cornerstones of theoretical framework in Gestalt therapy are field theory, phenomenology, and dialogue (Yontef, 1998). The first provides a way of thinking, the second offers a way of defining and working with awareness, and the third defines the therapeutic relationship. Gestalt therapy, similar to PCT, also experiences its own evolution over the past few decades. It evolves from the classical Gestalt therapy of a bunch of more cathartic, confrontation techniques to a more relational, supportive, dialogic Gestalt therapy.
Due to the more observable methodology of Gestalt therapy, it is often mistakenly assumed that its essence is the “Gestalt therapy techniques” and that catharsis and breaking down defenses are the aim of the techniques. In essence, the primary goal in dialogic Gestalt therapy is to “meet” the client existentially, to “start where the client is” and to make contact empathically. It is very much person-centered in this sense. In a dialogic relationship, the contact is emerging moment-by-moment without aiming for a pre-intended outcome. It includes the elements of inclusion, confirmation, therapist’s presence and commitment to dialogue (Yontef, 1998). It corresponds very nicely with the core therapeutic elements in PCT, i.e. empathic understanding, unconditional positive regard, therapist’s congruence and the therapeutic alliance.
The theory of change in Gestalt therapy is paradoxical. It is to “change to be who you are, not who you are not”. The more one claim who one is, the more one can grow. Real growth is: knowing and identifying with one’s self. It echoes what Rogers has said, “the more I can accept myself as I am, the more I cannot help but change”. Healing is making oneself whole, to integrate one’s internal conflicting parts. The phenomenological attitude supports self-identification by validating the client’s subjective experience. Hence, focused awareness and acceptance of the different parts of the client helps the inner self emerge and come alive. The changing process requires the therapist and the client work collaboratively in focusing, understanding, and experimenting with new experience in the process of experiential discovery.
Emotion-Focused Therapy shares the same notion with Gestalt therapy that an effective therapeutic relationship includes but not limited to the stance of Person-Centered Therapy of presence, empathy and acceptance. An effective therapeutic relationship also embraces a vision of active methodology, which is based on the collaboration between the therapist and the client, and the experiential understanding of the client’s inner experience.
In view of the above, it can see that PCT puts a heavy emphasis on the “being” of the therapist, while the classical Gestalt therapy may give an impression of over-emphasizing active techniques. The point is: the “doing” of active techniques would not sacrifice or diminish the essence of the therapeutic relationship on one hand, while the therapist has to use effective means to convey the “being” part on the other hand.
Existential Therapy
The aim of existential therapy is to “set clients free”. Freedom, in the existential sense, refers to the absence of external structure. The individual is entirely responsible for his/her own world, life design, choices, and actions (Yalom, 1980). Within these freedoms, there is a great capacity to create meaning in one’s lives. The healing conditions of existential liberation include presence, invoking the actual, vivifying and confronting resistance, and meaning creation (Schneider, 1998).
Presence refers to being with the client, making space for the client, and inviting the coming out of the client. It also includes the client’s own presence for his/her inner self. Invoking the actual means bringing attention to what is present, what is alive, and what is activated. It is a revelation of what actually is, but is not focused or attended to, to an extent that it is overlooked. Resistances are blockages to awareness of what is present and actual. A respectful and genuine acceptance of client’s resistances is crucial in the process of helping the client to aware, to understand, and to accept these blockages. With acceptance, change follows. Meaning creation is the integral part of the whole therapeutic process.
An Integrated Process-Experiential Approach
After reviewing the essence of Person-Centered Therapy, Gestalt Therapy and Existential Therapy, it is notable that Emotion-Focused Therapy has integrated the essence of the three therapies and formed a basic foundation of the essentials of the therapeutic process i.e. the therapist’s presence, empathy, acceptance and therapeutic alliance.
The Importance of the Therapist’s Presence
The therapist’s congruence means that he/she is fully focusing on the present moment. He/She is able to flow with the moment-to-moment experience of the client, that is, fully present with the client. The therapist is able to get in touch with his/her inner experience and is courageous enough to disclose the here-and-now experience if it is therapeutic to the client. The transparence and spontaneity of the therapist is also a therapeutic agent in the process of therapy. Rogers has commented in his late years that when he was “intensely focused on a client, just my presence seems to be healing” and “simply my presence is releasing and helpful” (Rogers, 1986, p.130).
Therapeutic Presence includes the elements of immersion, expansion, grounding and being with and for the client. Immersion includes a kind of absorption, experiencing deeply with non-attachment, present-centered and focused. Expansion means timelessness, inner spaciousness, being energized and enhanced inner experiencing. Grounding is centered, steady, holistic and at ease with one’s self. Being with and for the client is a sense of compassion for others and a sense of self-compassion for oneself (Geller & Greenberg, 2002).
The Importance of Empathy
It is the empathic attitude that is essential and not the behaviors such as the techniques of reflection of feelings, paraphrasing or worst of all parroting. Rogers (1986) rejected the idea that empathy was to be equated with reflection. In his later writing, he emphasized the idea that what he was doing was “checking” his understanding of the client. It is a deep and sustained psychological contact. Yet, it is not a kind of emotional diffusion or emotional identification. It is an ability to “perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as an ability if one were the person, but without ever losing the ‘as if’ condition” (Rogers, 1951, p.210). It encourages the client to hold or stay with his/her experience so as to stimulate a deep re-working of personal life issues. It is a powerful “curative agent” in itself and thus a major component of the healing process. It creates a secure therapeutic relationship and strengthens a working alliance between the client and the therapist. It dissolves the sense of alienation in the client. However, empathy without sympathy (or compassion), without understanding, and without wisdom, can be harmful.
While an empathic attitude is cultivated and maintained, the next clinical question is how to convey empathic understanding to the client and how to enhance the quality of empathy. In EFT, the intentions for therapeutic responding are differentiated and as a result, a wide spectrum of empathic intervention skills is developed. These include empathic reflection, empathic exploration, empathic evocative responding, empathic conjecture, and empathic refocusing (Elliot et al., 2004). All these micro empathic intervention skills are actually the “doing” part of therapy. A skillful implementation of these skills balances between leading the client by empathic exploration and evocative responding, and following the client by empathic listening and reflection.
The Importance of Acceptance
There is no point to talk about acceptance if there is no accurate understanding of the client. With an in-depth empathic understanding, the acceptance and non-evaluative prizing of the client is very nourishing and affirming. It encourages the client’s risk-taking of contacting his/her vulnerable self. It also conveys a faith and respect in the client as a person and in his/her ability to heal. The unconditional positive regard of Rogers conveys an egalitarian attitude, which strengthens the client’s autonomy, responsibility and mutuality. It is not only a caring presence but also a non-manipulative and non-intrusive caring that would not reinforce the client’s dependency. It is also a deep therapeutic trust in the healing powers of the client, which requires the steadiness, patience, and supportiveness of the therapist (Schneider, 1998).
The intervention skill of empathic affirmation and validation in EFT is a way of doing in conveying the therapist’s acceptance of the client.
The Importance of the Therapeutic Relationship
It is a true encounter between two human beings attempting to make contact in a helping context. It provides an interpersonal support, a sense of togetherness, hope and courage for the client to face his/her conflicting and disorganized selves, and his/her denied negativities. It is a kind of non-exploitative inclusion without losing the differentiation of boundary between the client and the therapist. The therapeutic exchanges give way to the process of the dialectical formation of new wholes. The dialogical and interpersonal nature of the change process is becoming more important through the process of the development of the therapy itself.
Therapeutic Process
The therapist’s congruence can help the therapist to have an emotional resonance or empathic echoing with the client so that the therapist can have an accurate understanding of the client. With a non-judgment and non-evaluative attitude, there is a genuine acceptance and prizing of the client. With such conditions established, the client begins to increase his/her self-awareness, to unfold a new self-understanding and to cultivate a sense of self-acceptance. Therapeutic changes would then take place, which finally resulted in the client’s self-empathy. Self-empathy is a kind of respectful inner listening, with readiness to take seriously whatever signals arise internally. It is a kind of experiential knowing and an inner echo of recognition. It enables an inner communication and an integration of different selves, which may be conflicting to each other before therapy. A conceptualization of the therapeutic process based on the above four essential elements can be summarized and illustrated in Figure 1.
Figure 1
A Conceptualization of Therapeutic Process
Therapist’s Congruence
↓
Emotional Resonance i.e. Empathy with the Client
↓
<--------- Empathic Skills
Understanding the Client
↓
<---------- Empathic Affirmation
Acceptance and Prizing of the Client
↓
<----------- Therapeutic Tasks of EFT
Client’s Self-Awareness
↓
Client’s Self-Understanding
↓
Client’s Self-Acceptance (congruence)
↓
Changes in Client: Self-Empathy
↓
Interpersonal Empathy
In summary, Emotion-Focused Therapy is built on the foundation of a therapeutic presence, attitude and relationship, which is person-centered and existential. Based on this foundation and go further beyond this, a series of in-session therapeutic markers and tasks are identified and differentiated to guide the therapeutic process, which would be discussed in the following.
Therapeutic Tasks in Emotion-Focused Therapy
Emotion-focused therapy has incorporated a variety of experiential tasks drawn from person-centered, gestalt, existential, and interpersonal therapy traditions (Elliot et al., 2004). Table 1 shows a summary of the major therapeutic tasks with its corresponding markers used in EFT.
Table 1 Therapeutic Tasks in EFT
Markers
Unclear Felt Sense
Problematic Reaction Point
Conflict Split
Self-Interruption
Unfinished Business
Trauma Event
Meaning Protests
Intense Vulnerability
Emotional Distress
Therapeutic Tasks
Focusing
Systematic Evocative Unfolding
Two-Chair Dialogue
Two-Chair Enactment
Empty Chair Work
Trauma Retelling
Meaning Creation
Empathic Affirmation
Self-soothing
The emotion-focused therapist is an experiential guide who knows about the subjective terrain and emotional processes of the client. The therapist is engaging in “process guiding”, always actively working towards an objective with the client, aiming at achieving an immediate response intention, a within-session task and an overall treatment goal (Mahrer, 1983). Whatever the therapeutic task the therapist is engaging with the client, it is still of paramount importance to maintain the therapeutic presence, attitude and relationship bonding in the implementation of the above tasks in a respectful, accepting and flexible manner, instead of following a manual of procedures in its own right. It is proposed as an experiment with the mentality of “try something new and see what you experience” (Yontef, 1998). These experiments are means of phenomenological exploration (Yontef, 1995).
Examples of Therapeutic Process
Three pieces of therapeutic process were illustrated to highlight how the “being” of the therapist should guide the “doing” of the therapist in Emotion-Focused Therapy.
Example 1: Annie – Use of Systematic Evocative Unfolding
Annie was recalling an experience when she went to a mindfulness retreat where she knew nobody. On the first day, she tried to greet a person who caught her eyes. Her response made her feel very uncomfortable and she later identified her feeling as anger. This feeling kept on bothering her for the rest of the retreat and it lingered on for the past week. She was quite confused about her emotional reaction. With this marker of problematic reaction point, I suggested using systematic evocative unfolding to help her differentiate the trigger point of her reaction and to make sense in terms of her characteristic style.
Initially, I conveyed my interested curiosity in her experience and maintained a supportive bonding with her while using a lot of empathic conjectures to access her emotional experience. The following is an excerpt on how she gained new awareness on her emotional reaction.
T: What made you so angry at that moment? Her way of looking at you? Or her body gesture? (Identifying the trigger point)
C: I can remember the moment very vividly. She lifted up her head, looked at me. This picture seems to have printed in my mind. It was the facial expression and her tone that has striken me. (Pause)
T: How did the facial expression strike you? (Empathic exploration)
C: The facial expression means something.
T: What is it?
C: “What are you doing?”
T: Sort of “you are out of place”. (Empathic conjecture)
C: I am not certain. (Pause)
C: “Don’t you know what you are doing?” (Pause) I felt that I was stupid.
T: Aha. Stupid. (Empathic affirmation)
C: I think it was me who blamed myself. “You should watch more carefully. You should assess the environment better before you make any response.”
(She finally got it. From projection of her anger to owning her anger.)
T: Aha. You are angry with yourself for making a wrong decision.
(Empathic Validation: I put her discovery in a more direct and firm statement, giving a sense of emphasis ‘That’s it.’)
C: Yeh...
T: You have searched for a long time. You have pondered for a long time. You have looked at her for several times. And finally, you decided to greet her.
(Elaborate her decision-making process)
C: Yes, I think I made a wrong decision. I made the decision too quickly and eventually I suffered. (New meaning making)
T: You made yourself fall in the trap.
C: Yes. I made myself fall in the trap. I should be more careful.
T: You blame yourself for being too hasty.
C: Mm…I am angry with myself for making a wrong decision.
T: You felt that you were being blamed. You felt she blamed you or you blamed yourself. Which feeling is stronger? (Help her to differentiate her projection from her owning)
C: The feeling of blaming myself is stronger. (Pause) In fact, her facial expression could be neutral or just a little surprised. I did not assess the environment well before I made the decision.
T: You blame yourself.
C: Just now, you asked me if the feeling of rejection was familiar to me. I often make decision very quickly. I am …I am angry with myself for being too hasty. When I do so, I would say to myself “You see. You make the same old mistake again.” (She was broadening the meaning of her experience)
T: I repeat again. (Empathic resonance: use of first person)
C: I get myself into trouble (Laugh). You should slow down and don’t be too hasty.
T: Do you have clearer idea about why you had such response at that moment? It reflects part of your personal style of making decision. And you still cannot accommodate and accept this part of you at the present moment i.e. making a decision and then getting into trouble. (Meaning making for her puzzle towards her emotional reaction.)
C: I am quick in pace. I am ambivalent. I love and hate this part of me. I know that I gain opportunity cost when I make quick decision. I have gain and I have loss. I always try to sooth myself after I make a decision. (Another marker (self-split) emerges for another therapeutic task.)
T: This episode is another opportunity to tell you something about yourself. And this part of you has not yet comfortably integrated.
(Reconfirm her discovery and awareness for this session. Put a bookmark here indicating a place where she can work on next time.)
Initially, I kept track on Annie’s internal emotional experience as she re-visited the scene in a much slower pace. I maintained an attitude of “not knowing” curiosity and acceptance of whatever she was experiencing and what she would discover. A sense of therapeutic security was created and Annie was able to discover her experience layer by layer. Even when she criticized herself as stupid at 29C, I affirmed her experience that it was okay to feel stupid. At 34C, she said she was angry with herself for making a wrong decision, I still maintained a non-judgmental attitude to her anger and self-blaming. It is believed that the therapist’s acceptance can help client’s self-acceptance and change would follow.
I learnt from this experience about empathy as a major component of the healing process. It helps to make a deep and sustained therapeutic contact. It leads to deep sustained empathic enquiry and sensitive conjectures. Finally, it results in a resonant grasping of the “edges” of the client’s experience to help create new meaning.
Example 2: Bonnie – Use of Two-Chair Dialogue
Bonnie came to therapy as she suffered from depression and overwhelming ups and downs of emotions. She understood that her depressive symptoms owned much to her past childhood experience, especially the relationship with her mother. As described by Bonnie, her mother was abusive and controlling. She felt that she was not being loved as a child and was very much emotionally deprived. She experienced a damaged self-image, a lot of guilt and shame in her childhood. She carried a heavy burden of emotional wounds when she moved out to live on her own and she has completely cut off any contact with her mother since then.
I recalled a session with Bonnie in which I suggested using two chairs to work with her conflict split. She felt that her mother prohibited her from being a creative self. On her chair, she felt very bored, freeze and had no freedom to act on her own. She was not allowed to eat or to drink or to go to the toilet. The other chair represented her lively and creative self. She encountered a great disapproval from her mother (resistance) to sit over the other chair. She felt that there was glue sticking her on her present position. Dialogue was kept going with her to enhance her awareness of the presence and the power of her resistance.
After this session, she reported that she was more aware of the moment when she felt bored, frozen and fixated. She was not so afraid of these feelings and she understood the reason and origin of such feelings. She could elicit her creative self to help her cope with these feelings. She could observe herself from a distance and allowed her feelings of discomfort to be with her for a moment. Her tolerance of her negative emotions was enhanced and her capacity to stay with them was increased. She was also able to sooth herself. In this way, she developed a more accurate appraisal both of her strengths and her contributions to her relationship difficulties, especially with her mother, without being filled with shame.
I learnt from this experience about the importance of being with the process and keeping track the client's experiential world. I also learnt that it is important to:
be aware of the interruption process (the resistance)
make contact with the resistance
stay with the resistance
focus on the resistance: emotional, sensory and mental
respect the existence, the meaning and the functions of the resistance
accept the presence of the resistance
allow the resistance to change, to transform and to complete itself
Although I intended to use two-chair dialogue work to facilitate the client to aware of her conflict split initially, I maintained the attitude of “not knowing” and “radical acceptance” (Cornell, 2005) in the process moment-by-moment. The active focusing on her resistance helped to make the therapeutic process more effective and also enhanced the quality of the therapeutic relationship. Hence, it is not a necessarily must to follow the chair work procedures with her at that moment given that I tried to work with the here-and-now process (as the figure) against her background of history and characteristic style.
Example 3: Connie –Use of Empty Chair Work
Connie came to therapy as she still had unfinished emotions due to the separation with her ex-boyfriend. She felt that this was a traumatic experience for her to discover that her ex-boyfriend has been unfaithful to her for a long time.
In the fifth session, empty chair dialogue with her ex-boyfriend was facilitated. Initially, she expressed her helpless sadness. She had a lot of self-blaming and believed that she must be “not good enough” so as to cause the breakdown of the relationship. Her primary feeling of anger was then accessed and evoked. She was able to express her anger towards her ex-boyfriend, and to differentiate her part of responsibility from his. She was able to condemn him in a congruent way for his losing of commitment in the relationship and his change of value in intimate relationship. She felt very much empowered after this session.
In the fifteenth session, she brought up her residual feelings towards her ex-boyfriend again. She felt that she was able to set a boundary between her and her ex-boyfriend and she no longer blamed herself for the separation after the last empty chair dialogue. However, she was in a depressive mood after she heard the news on Sichuen earthquake. The only one she wanted to share her feelings was her ex-boyfriend. She felt that she should not still be emotionally attached to him. Connie was then helped to review the whole process of the relationship. She came to realize that the first year of their relationship was very genuine and they shared similar value and life goal. The most impressive experience for their togetherness was the time when they were having a field study in a village in Mainland China. That’s why when she watched the news on Sichuen earthquake, he was the first person she thought of. Through empathic exploration and validation, Connie was helped to accept this episode with him as something memorable for her and to transform this experience as her internal resource for self-soothing and self-support.
From this experience, I learnt that by delineating the boundary between Connie and her ex-boyfriend, she had totally denied all experiences with him. With a trusting and supportive relationship, Connie was facilitated to have a focused awareness on the nature of relationship with him in the first year of their courtship. I experienced the importance of including and accepting all sorts of inner experiences of the client. Her own acceptance and empathy towards her inner parts created an inner spaciousness for transformation to take place.
Conclusion
In the process of learning EFT, I find that self-reflection of the therapist on his/her use of skills is of paramount importance. To what extent can my “doing” in the therapy session really convey the necessary therapeutic attitudes? How can my “being” and “doing” facilitate my client’s change in his/her direction? Besides, I believe that there should be a much wider possibilities and alternatives of therapeutic tasks awaiting our experimentation, apart from those listed in Table 1. Therapy should be a “permission to be creative” (Zinker, 1977, p. 3ff, quoted by Yontef, 1998).
Emotion-Focused Therapy is a dialectic approach in which there is a tension between the “being” part of the therapist and the “doing” part of the therapist. The therapist is maintaining the balance moment-by-moment to make it an integrated whole. Without the “being” part, the mere “doing” part loses its spirit and direction, and can be detrimental to the healing of the client. With only the “being” part, therapy would remain in an abstract realm leading to nowhere.
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