I have been writing about Lynne Angus & Les Greenberg's book "Working with narrative in emotion-focused therapy: changing stories, healing lives".  So far, I have put up three posts "Narrative in emotion-focused therapy (1st post): context", "Narrative ... (2nd post): narrative types & modes" and "Narrative ... (3rd post): narrative modes & phases".   Today's post looks at the book's third chapter "Facilitating narrative change processes in emotion-focused therapy".  Somewhat surprisingly to me, they begin "This chapter demonstrates how to use narrative and emotion processes to help the client construct an overall life story that provides both (a) a secure sense of attachment that is sustained by the affect regulation functions of narrative ordering, contextualization, and symbolization of experience and (b) a coherent self-identity.  When applying our dialectical-constructivist model to practice, therapists pursue these two goals to help clients develop new meaning and sense of self.  This chapter discusses these two goals." 

I say "Somewhat surprisingly to me ... ", because this emphasis on "a secure sense of attachment" came a bit out of the blue after what the authors had focused on in the first two chapters of the book.  Having said this, I'm very open to the notion that helping the client develop a securer sense of attachment is a key aspect of the therapy.  It's no surprise that both poor emotion regulation and an unsatisfactory self-identity are routinely entwined with insecure attachment.  This reminds me of Marylene Cloitre's fine, ground-breaking work with child abuse & PTSD.  I wrote about this in a series of three blog posts beginning with "Improving treatments for complex PTSD and for survivors of child abuse (first post)".  Cloitre's 16 session intervention is split into a first 8 that provides STAIR (skills training in affect and regulation) and a second 8 that involves trauma-focused cognitive therapy.  A key point is that this 16 session "sandwich" treatment resulted in better outcomes than a more standard 16 session purely trauma-focused cognitive therapy intervention.  Cloitre discusses attachment issues and the importance of the therapeutic alliance.  See, for example, "Attachment organization, emotion regulation, and expectations of support in a clinical sample of women with childhood abuse histories" and "Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder". The latter paper's abstract reads "This study examined the related contributions of the therapeutic alliance and negative mood regulation to the outcome of a 2-phase treatment for childhood abuse-related posttraumatic stress disorder (PTSD).  Phase 1 focused on stabilization and preparatory skills building, whereas Phase 2 was comprised primarily of imaginal exposure to traumatic memories.  Hierarchical regression analyses indicated the strength of the therapeutic alliance established early in treatment reliably predicted improvement in PTSD symptoms at posttreatment.  Furthermore, this relationship was mediated by participants' improved capacity to regulate negative mood states in the context of Phase 2 exposure therapy.  In the treatment of childhood abuse-related PTSD, the therapeutic alliance and the mediating influence of emotion regulation capacity appear to have significant roles in successful outcome".  So there are indications that a strong therapeutic alliance is helpful through improving patients' capacity to regulate negative mood - to self soothe better. Sounds like attachment territory to me and very much what Angus & Greenberg are discussing in this chapter of their book.

They speak about the "Importance of therapist empathic attunement" and "How to experience and express ... attunement".  They discuss both helping clients identify "narrative context for undifferentiated emotional experiences" and helping clients "access and symbolize previously avoided emotional responses" - so work with both what they call "unstoried emotions" and with what they evocatively call "empty stories".  They write "We believe that therapists need to help clients to disclose their most painful and vulnerable lived stories in order to help them tolerate, reflect on, synthesize, and restory previously avoided primary emotions and feelings."  They talk about Barrett-Lennard's three-stage model of empathic attunement.  "The first stage requires that therapists cognitively and affectively resonate with clients' descriptions of lived experiences.  To achieve this goal, therapists are encouraged to track the unfolding plotlines of the client's told story while processing the affective meanings and impacts of those events - the tacit, lived story - at the same time."  This "double empathy" - both cool cognitive & hot affective - is likely to involve opening our hearts to our clients and truly befriending them.  Meyer et al's recent paper "Empathy for the social suffering of friends and strangers recruits distinct patterns of brain activation" makes this point very clearly - "Humans observe various peoples' social suffering throughout their lives, but it is unknown whether the same brain mechanisms respond to people we are close to and strangers' social suffering.  To address this question, we had participant's complete functional magnetic resonance imaging (fMRI) while observing a friend and stranger experience social exclusion.  Observing a friend's exclusion activated affective pain regions associated with the direct (i.e. firsthand) experience of exclusion [dorsal anterior cingulate cortex (dACC) and insula], and this activation correlated with self-reported self-other overlap with the friend. Alternatively, observing a stranger's exclusion activated regions associated with thinking about the traits, mental states and intentions of others ['mentalizing'; dorsal medial prefrontal cortex (DMPFC), precuneus, and temporal pole].  Comparing activation from observing friend's vs stranger's exclusion showed increased activation in brain regions associated with the firsthand experience of exclusion (dACC and anterior insula) and with thinking about the self [medial prefrontal cortex (MPFC)].  Finally, functional connectivity analyses demonstrated that MPFC and affective pain regions activated in concert during empathy for friends, but not strangers.  These results suggest empathy for friends' social suffering relies on emotion sharing and self-processing mechanisms, whereas empathy for strangers' social suffering may rely more heavily on mentalizing systems."

More to follow ...