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Emotion-focused therapy workshop series (seventh post): internal critic dialogues - background research

I wrote yesterday about the morning session of this EFT training day in the post "Emotion-focused therapy workshop series (sixth post): a method for understanding puzzling reactions".  In the afternoon we explored "Working with self-criticism/depressive splits".  As Greenberg & Angus write in their book "Working with narrative in emotion-focused therapy" (p.9-10) ... "A hallmark of EFT is that therapists' interventions are sensitive to the in-session context of the therapeutic interaction, and particular client states are viewed as opportunities for facilitating specific types of client emotional processes.  To date, six major types of marker-guided interventions have been identified and studied in EFT".  The six problem-markers and accompanying interventions are: "Problematic reactions" which are viewed as opportunities to use "systematic evocative unfolding" (as described in yesterday's post about this seminar's morning session); "Unclear felt sense" typically explored using "focusing"; "Conflict splits" which I already blogged about last month in "EFT workshop series (fifth post): two chair conflict dialogues" and which I'm going to discuss further in today's post; "Self-interruptive splits" with potential accompanying "two chair enactment"; "Unfinished business" markers with possible "empty chair interventions"; and "Vulnerability" with associated therapist "empathic validation".  As an aside, Greenberg & Angus go on to propose a further four kinds of problem marker that can be helpful when integrating EFT and narrative therapy ... "same old stories, empty stories, unstoried emotions, and broken stories" ... but this is a potential future blog subject. 

This afternoon's seminar focused particularly on self-criticism and depressive splits.  Robert Elliott, our course trainer, said something that I found very interesting here.  He pointed out that the results of the first research trial comparing EFT with standard person-centered counselling (PCT) were pretty under-whelming with EFT not really being much more helpful than PCT.  So the relevant research study (York I) - "Experiential therapy of depression: Differential effects of client-centered relationship conditions and process experiential interventions" - reported "This study compared the effectiveness of process-experiential psychotherapy with one of its components, client-centered psychotherapy, in the treatment of (34) adults suffering from major depression. The client-centered treatment emphasized the establishment and maintenance of the Rogerian relationship conditions and empathic responding. The experiential treatment consisted of the client-centered conditions, plus the use of specific process-directive gestalt and experiential interventions at client markers indicating particular cognitive-affective problems. Treatments showed no difference in reducing depressive symptomatology at termination and six month follow-up. The experiential treatment, however, had superior effects at mid-treatment on depression and at termination on the total level of symptoms, self-esteem, and reduction of interpersonal problems. The addition, to the relational conditions, of specific active interventions at appropriate points in the treatment of depression appeared to hasten and enhance improvement."  These aren't results that would make many therapists want to rush out to learn EFT.  Robert however went on to say that the outcomes in York II - "The effects of adding emotion-focused interventions to the client-centered relationship conditions in the treatment of depression" - were a good deal more supportive of EFT and that he thought a key reason for this was improved understanding of how to best work with client "collapse" (agreement with the internal critic) - more on this in the next post.

Having just sat here at my desk reading through the York II research paper, I can understand that EFT supporters would be heartened by the reported client outcomes.  Actually the outcomes for both EFT and for PCT on its own are excellent and stand up very well when compared to results with somewhat similar populations treated with CBT or interpersonal psychotherapy (IPT).  Both York I and York II involved quite small numbers of patients (34 and 38 depression sufferers respectively).  Combining the data from the two studies gives the research more statistical power and, as reported in Greenberg & Watson's fine book "Emotion-focused therapy for depression" (p.12) "Statistically significant differences among treatments were found on all indices of change for the combined sample, with differences maintained at 6- and 18-month follow-up ... In addition, and of great importance, 18-month follow-up showed that the process experiential group (EFT) were doing distinctly better at follow-up.  Survival curves showed that 70% of process experiential clients survived to follow-up - that is, did not relapse - in comparison to a 40% survival rate for those who were in relationship-alone (PCT) treatment."  Exciting results (I wonder if York II follow-up results were better than York I's).  Unpicking this further only increases my respect for these outcomes.  If you look in the "Participants" description (p.104-105) of the 2009 paper, it is stated "None of these clients reported having been diagnosed with more than three previous depressive episodes".  Possibly somewhat counter-intuitively, these clients with few or no previous depressive episodes are the group that CBT and mindfulness-based cognitive therapy (MBCT) struggle to make an impact on when trying to reduce relapse rates - see, for example, Ludgate on "Cognitive behavioral therapy and relapse prevention".  And remember, reductions in relapse achieved with CBT/MBCT typically involve additional treatment on top of acute phase treatment.  In contrast the EFT relapse reduction is achieved (with quite probably a more difficult client population due to fewer previous depressive episodes) simply as a bonus of effective acute phase treatment.  Gosh.  My cautions are the small numbers involved, the current lack of replication, and a probability that the outcomes are somewhat contaminated by treatment allegiance effects - the therapists almost certainly believed more in EFT than in PCT and this is likely to have contributed to the differences found between the two therapies.  However the 18-month follow-up differences are pretty startling - see "Maintenance of gains following experiential therapies for depression".  It's also important to point out that EFT has stood up well when compared head-to-head with CBT - "Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression" - with further details highlighted in the more recent paper "Clients' emotional processing in psychotherapy: a comparison between cognitive-behavioral and process-experiential therapies".

While discussing these research papers, I'll just mention a comment - in the discussion section of the York II report comparing EFT with PCT - that I found particularly helpful as practical advice "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."

In the next post in this series I'll look more at practical issues that come up when working with two-chair internal critic dialogues

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