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Emotion-focused therapy workshop series (eighth post): internal critic dialogues - practice points

In the last post on this Emotion-focused therapy workshop series that I wrote, I discussed key background research on using EFT methods to work with people's "internal critics".  In today's post, I'd like to be a bit more practical.  So initially I note some general advice on how to structure EFT interventions.  Quoting from Ellison & colleagues impressive 2009 paper "Maintenance of gains following experiential therapies for depression""The major emotion-focused interventions of EFT are Gendlin's (1996) focusing intervention at a marker of an unclear bodily felt sense; gestalt empty-chair dialogues at markers of unfinished business, in which clients imagine a significant other in an empty chair and communicate unresolved feelings to that person; gestalt two-chair dialogues at conflict split markers, in which clients engage in a dialogue with their critical inner, often introjected, voice; and systematic, evocative unfolding at points of problematic reactions, in which clients are imaginally guided back to the problematic situation so that they may reexperience and make sense of their reactions (Greenberg et al., 1993; Rice, 1974). These specific interventions are hypothesized to facilitate creation of new meaning from bodily felt referents, letting go of anger and hurt in relation to another person, increased acceptance and compassion for oneself, and development of a new view and understanding of oneself (Greenberg, 2002; Watson & Greenberg, 1996).  The first three sessions of the treatment focus on establishing a therapeutic alliance and providing a facilitative therapeutic relationship.  During this phase, only the three CC relationship conditions are implemented. Thereafter, the EFT active interventions are implemented, within the context of the facilitative conditions, when depressogenic affective-cognitive problem markers arise.  The primary aims are facilitating the client's symbolization of particular aspects of subjective emotional experience, facilitating new emotional responses to old situations, and making new meaning of one's experience on the basis of new information that becomes available through the reprocessing of emotional material."

I also note again the York II study - "The effects of adding emotion-focused interventions to the client-centered relationship conditions in the treatment of depression" - discussion section comment that "Findings suggest that a good empathic relationship was present in both treatments. We also know that emotion-focused tasks were performed in about 28% of (EFT) sessions after Session 3.  Previous studies of the EFT treatment process (Goldman et al., 2005) suggest that themes tend to emerge fairly early in treatment (typically around Session 4) and that they center around the two major therapeutic tasks: the two-chair task, which is designed to target the specific problem of self-criticism, and the empty-chair task, which targets unresolved dependence, injury, and loss ... The two-chair task helps clients identify self-criticisms, become aware of the emotional impact on the self of the criticisms, differentiate their feelings and needs, and use these to combat the negative cognitions. The empty-chair task helps clients resolve past losses, hurts, and anger toward significant others by expressing and processing their unresolved feelings. Watson and Greenberg (1996) found that these specific interventions are related to deeper in-session emotional process and stronger outcome."

So in classic EFT for depression, one would typically aim to spend the first 3 or so sessions getting to know the client, clarifying their key issues, and building a good therapeutic alliance.  In York II "The length of treatment ranged from 9 to 20 sessions with a mean of 17.6 sessions."  If we assume a typical EFT depression treatment length to involve say 18 sessions, then the first 3 sessions are likely to be "introductory", and in the subsequent 15 "emotion-focused tasks were performed in about 28% of sessions" - which comes to not much more than 4 sessions where one is using key EFT methods like two-chair or empty-chair dialogues.  Even on these 4 or so occasions where EFT approaches are introduced, one would want to aim for only about 25% of the session to involve relatively highly aroused emotional states - see "Optimal levels of emotional arousal in experiential therapy of depression."  And we're not talking about extreme arousal here.  We're speaking about level 5 of the Client Expressed Emotional Arousal Scale (CEAS).  I quote - "CEAS ratings are based on a 7-point scale, where upper levels indicate higher arousal intensities, lower levels indicate restriction of emotional expression, and Level 3 is considered to be baseline expected emotional expression (e.g., 1  Client does not express emotions. Voice or gestures do not disclose any emotional arousal; 4  Arousal is moderate in voice and body. Emotional voice is present; ordinary speech patterns are moderately disrupted by emotional overflow as represented by changes in accentuation patterns, unevenness of pace, changes in pitch. Although there is some freedom from control and restraints, arousal may still be somewhat restricted; 7  Arousal is extremely intense and full in voice and body. Usual speech patterns are completely disrupted by emotional overflow. Arousal appears uncontrollable and enduring. There is a falling apart quality)."

Putting on my mathematician hat, this suggests that successful Emotion-Focused Therapy for depression probably only involves a total of about an hour actually engaged in the more emotionally aroused sections of two-chair or empty-chair dialogues over the course of about 18 hours of therapy.  Fascinating.  This highlights the fact that EFT can be viewed as Person-Centered Therapy with only rather occasional specific EFT interventions.  It also highlights how important it's likely to be to balance emotionally arousing techniques with plenty of time for emotional processing.  As Whelton put it in his paper "Emotional processes in psychotherapy: evidence across therapeutic modalities""Emotional processing and depth of experiencing, two heavily-researched emotion process categories of the behaviourists and humanists respectively, have been shown to have a robust association with outcome. There is accumulating evidence that both the in-session activation of specific, relevant emotions and the cognitive exploration and elaboration of the significance and meaning of these emotions are important for therapeutic change".  This is narrative therapy territory and links back to the Salman Rushdie quote "Those who do not have the power over the story that dominates their lives - the power to retell it, reexperience it, deconstruct it, joke about it, and change it as times change - truly are powerless because they cannot think new thoughts."  I ran these comments about total time spent in the more emotionally aroused sections of two-chair or empty-chair dialogues past our trainer Robert Elliott.  He commented "That's probably about right; however, the catch is that large sections of chair work are not highly emotionally aroused, but are part of the process of setting it up, introducing the process, deepening and processing.  With many of my social anxiety clients now, we are using chair work for most of the session in most sessions, but the highly emotional bits are not as common."  Interesting stuff ...

And staying just a little longer with practicalities.  See the diagram I've already given in an earlier post: 
Two chair conflict diagram
                                                (This diagram is downloadable both as a PDF file and as a Powerpoint slide).

In today's seminar, Robert highlighted what he feels is a crucially important point - what to do as therapist when the client "collapses" into hopelessness under the internal critic's attack.  "Collapse" implies that the experiencing part of the client "surrenders" and simply agrees that the critic is correct in the harsh comments that they are making.  As therapist we are trying to encourage the emergence of "fight back" from the defeated experiencing self.  We're looking for early signs of some assertiveness and strength - the stirrings of adaptive, growth-orientated primary emotions. So we were offered a couple of therapeutic options here.  One is to get the client to switch straight back to the critic chair after the collapse and then we, as therapist, say to the critic something like "How did you do that (cause the collapse)? ... This is the depression happening right here."  We, as therapist, now aim to increase the pressure on the experiencer by encouraging the critic to be more specific and to focus in on the "worst" aspects of the client.  We're hawk-eyed for any sign of opposition emerging in the experiencing self.  This sometimes occurs while the client is still sitting in the critic's chair and, if it does, we switch them to the experiencer chair.  So, as therapist, one option is to push for emerging experiencer assertiveness by encouraging the critic to be even more oppressive.  Another option is to focus more directly on the experiencer.  Here, after the initial "collapse", one works to "deepen & differentiate" the hopelessness.  This is a therapeutic "empathic prizing" task involving empathic validation, heightening awareness, and empathic conjecture.  Here it's direct caring support and understanding of the experiencer's position that's used to increase the chance of emergence of growth-orientated primary emotion. 

It's interesting and helpful to note that, if one's best attempts to nourish early assertive growth in the experiencer simply don't work, then there are a series of other options.  For example, Arntz & van Genderen in their book "Schema therapy for borderline personality disorder" (p. 79-84) describe a method where the therapist is the one who "fights" the attacking self-critical mode.  Amusingly, the therapist may well end up by physically banishing the critic and putting their chair (now an "empty chair") right outside the room.  Gilbert in his book "The compassionate mind" (p. 344-346) also addresses other ways of working with one's internal critic.  He describes dialogue exercises between the critic mode and a compassionate mode, although he also acknowledges that sometimes he feels it may be important to "fight" internal critic modes that seem engaged in purely destructive attacks rather than misguidededly over-harsh attempts to get the experiencing self to "pull their socks up and try harder".  This variability in therapists' approaches to working with the internal critic parallels the variability in approaches to working with trauma memories.  Here some researchers are active in rescripting past events while others see change typically emerging on its own if clients can be encouraged to stay in touch with the memories through repeated exposure.  See Hackmann et al's "The Oxford guide to imagery in cognitive therapy" for an extended discussion of these issues. 

My personal preference, after working in this field for quite some time, is to use a mix of pre-planned intervention with a respect for surprising, creative responses that may emerge from the client.  It reminds me of something a sculptor friend once told me about how he worked with stone.  He said that he had a pretty clear idea of the final figure he was trying to sculpt as he began chiselling at the stone block; however he also tried to stay respectful and sensitive to the material itself and how it might guide him to take the work in directions that he hadn't initially expected.  An example of this creative parallel is an intervention I used some time ago working with a client on horrid memories of being bullied at school.  What had actually happened in this particular memory was that a bigger, older child had humiliated them in the playground in front of a great crowd of their school fellows.  We re-ran the memory.  My client this time stood up to the bully.  In the evolving "imagery dream", the bully threatened physical violence.  As therapist, I could have intervened in some way here.  Due to earlier conversations with the client and to an intuition during this imaginal re-living, I held off.  In respectful fascination, I listened as the client - with great courage - would not back down under the bully's threats.  The bully then, in front of the big playground crowd, lashed out and hit my client across the face.  My client stood there, looked the bully in the eyes and said something like "Is that all you can do?".  Now it was the bully who didn't know what to say.  The encircling crowd, who initially had been experienced as on the bully's side, now changed into supporters - fellow victims of the bully who now applauded such courageous resistance.  The bully backed away, confused and in retreat.  My client had a deep, healing sense of respect for herself and of respect from those around.  Fascinating and humbling for me as therapist as I considered how close I had got to "leaping in to save" my client when it became apparent that the bully was going to get violent.  How glad I was that I had dropped my script and trusted my experience and intuition in letting the client's process run so creatively.  I certainly don't think this "imagery dream" was pre-scripted by my client.  I think they were in the dream partly making decisions/choices and partly surprised by how the dream events unfolded. 

There will probably never be the research done to compare these differing approaches to the internal critic head-to-head.  In the end, what matters isn't the technique we use, it's the outcomes the client achieves - the reductions in depression or other distress and the ability to go on to lead a more fulfilling life.  Here's where careful monitoring of client response is so important.  One can, of course, track outcomes like level of depression and functioning.  There may also be value in more direct session-by-session tracking of the internal critic's behaviour - for example using the 12-item short form of the "Self-compassion scale" or even more simple measures like this 4-item "Self criticism/self-compassion questionnaire" that I constructed and have used for some years.  It may be valuable, as well, to augment these two-chair self-critic dialogues with other methods.  Implementation intentions are an obvious example as a way of helping changes extend out into relevant situations in day-to-day life - see, for example "Implementation intentions and shielding goal striving from unwanted thoughts and feelings" and "Using implementation intentions to overcome the effects of social anxiety on attention and appraisals of performance".  And also see a variety of other potential augmentation techniques described in the post "Boosting self-compassion & self-encouragement by strengthening attachment security: twelve practical suggestions".  Science and art intertwining - another reason why working as a therapist can be so fulfilling. 

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