Saturday, September 29, 2007

PE-EFT and Motivational Interviewing

Entry for 28 September 2007:

Paper presented to Alcohol Focus Scotland National Alcohol Counsellors Forum, September, 2007.

I. A Bit of Family History…
-Two Main Clans (“Tribes”) of the Person-Centred Approach (PCA)
-Depends on which side of Carl Rogers’ famous “process equation” you focus on:
-Therapist facilitative conditions => Client experiencing

(1) Classical
-From early/middle-period Rogers:
-Focus on therapist relational conditions:
-Empathy, nonpossessive warmth, genuineness
-Person-centred counselling/ therapy
-Various names: “Classical”, “Nondirective”, “Relational”
-Most prevalent in USA, UK
-Also: Pre-therapy (Prouty): Help psychotic clients re-establish psychological contact

(2) Experiential
-From Late Rogers:
-Focus on client experiencing/ process
-Focusing (Gendlin)
-Process-Experiential/Emotion-focused therapy (PE-EFT) (Greenberg, Rice & Elliott)
-German version of person-centered (Sachse: “goal-oriented”)
-Most prevalent in Canada, Belgium, Germany

(3) Integrative PCA
-Existential (Cooper: PC practice + existential theory)
-Expressive (N. Rogers; add play, expressive arts)
-Other Integrative (add other bits to PC base)

(4) Neighboring Peoples (“Cousins”)
-Third Generation CBT: Mindfulness-based CBT (Williams & Teasdale); Acceptance & Commitment Therapy ACT; Hayes); Dialectical Behavior therapy (Linehan); Schema-focused CBT (Young)

II. Contemporary Person-Centred Therapy: PE-EFT
A. History:
-Sources: Humanistic therapy tradition: Person-centered, Gestalt, existential therapies
-Early development, 1970-1985: York University (Canada):
-Early information-processing psychology; Laura Rice; Task analysis
-Late 1980’s: Piloted at University of Toledo
-Early 1990’s: Formalized in Greenberg, Rice & Elliott Facilitating Emotional Change, 1993
-Late 1990’s: Became known as Emotion-Focused Therapy (EFT; Johnson, Greenberg, Paivio)

B. PE-EFT: Distinctive Features
1. Neo-humanistic: Revival/ reformulation of humanistic/ experiential approach to therapy
2. Emotion-focused: Emotional awareness and reprocessing as central to client change
3. Relational stance: Active following of content with some direction of process
4. Exploratory therapist response style: Empathic exploration responses, exploratory questions
5. Marker-guided: Client indicators signal readiness for specific therapeutic tasks
6. Research-informed: Based on research on client change processes; supported by outcome research

C. PE-EFT Therapy Principles
Relationship Principles: Facilitate safe, productive relationship:
1. Empathic Attunement: Enter, track C’s immediate & evolving experiencing
2. Therapeutic Bond: Express empathy, caring and presence to C (bond aspect of alliance)
3. Task Collaboration: Facilitate mutual involvement in goals and tasks of therapy (task/goal aspect of alliance)
Task Principles: Facilitate work on specific therapeutic tasks
4. Experiential Processing: Foster relevant client micro-processes (e.g., attending, experiential search, active expression, interpersonal contact; self-reflection, action planning)
5. Task Completion/Focus: Facilitate client completion of key therapeutic tasks
6. Self-development: Foster client new experiencing, inner strength, agency or empowerment

D. Theory: Emotions are Fundamentally Adaptive
-Emotions tell us what is personally important (information)
-Emotions help us to survive by providing an efficient, automatic way of responding rapidly to important situations
-Emotions prepare us for action: emotions generate wishes/needs, which generate action
-Emotions integrate experience; give it meaning, value & direction
-Three basic concepts: Emotion Schemes; Emotion Response Type; Emotion Regulation

1. Emotion Schemes
-Involved in implicit/automatic processing of experience
-Not available to awareness until activated and reflected upon
-Idiosyncratic and highly variable
-Complexity: Many operate simultaneously
-Empathy, evocative and exploratory work required to foster access, activation & self-reflection
-Complete processing involves all elements

2. Emotion Regulation Necessary for Adaptive Functioning
-Optimal level of emotional arousal or distance
-Varies with situation/task
-Too little & too much both dysfunctional
-Ability to self-regulate emotion derives from early attachment experiences
-Requires both: Ability to access, heighten or tolerate; & Ability to contain or distance

3. Forms of Emotion Response
-Primary adaptive: unlearned, immediate response to situation
-Primary maladaptive: learned, overgeneralized immediate response to situation, no longer fits
-Secondary Reaction: Emotional reaction to a primary emotion response
-Instrumental: Produced for intended effect

4. Change Principles of Emotional Processing (from Greenberg, 2004)
(1) In general, promote emotional awareness/symbolization: (Emotion scheme model)
(2) With overwhelming emotions, promote emotion regulation
(3) With avoided or secondary emotions, help clients deepen and differentiate experience: “You have to arrive at an emotion before you can leave it.”
(4) With maladaptive emotions, change emotion with emotion: Help client find overlooked adaptive emotions and use these transform maladaptive emotions
-E.g., Anger <=> Sadness

E. Therapeutic Tasks
-From research on human problem-solving
-Clients bring specific immediate concerns (tasks) to sessions
-Elements of a therapeutic Task:
1. Marker: observable sign that client may be ready to work on a problem
2. Client steps to resolution
3. Therapist facilitating responses
4. What resolution looks like

A. Examples of PE-EFT Tasks: Marker => Task
-Beginning of Counselling => Alliance Formation
-Unclear feeling => Focusing
-Vulnerability => Empathic Affirmation
-Problematic Reaction => Systematic Evocative Unfolding
-Internal Conflict Split => Two Chair Dialogue
-Unfinished Business => Empty Chair Work

B. Two Chair Work for Internal Conflict Splits
1. Conflict Split Marker: (1) Two wishes or action tendencies; (2) Description of contradiction, conflict between; (3) Expression of struggle, coercion
-Experience: uncomfortable "tornness"
-Types of Conflict Splits: Decisional conflict; Self-Evaluation (self-criticism); Coaching (self-coercion); Externalized splits: over-reaction to others

2. Client Resolution Stages for Internal Conflict Splits:
(1) Marker/Task Initiation: Client describes internal conflict in which one aspect of self is critical of, or coercive toward, another aspect.
(2) Entry: Clearly expresses criticisms, expectations, or "shoulds" to self in concrete, specific manner.
(3) Collapse/Deepening: Experiencing chair agrees with critic (“collapses”); primary underlying feelings/needs begin to emerge in response to the criticisms. Critic differentiates values/standards.
(4) Emerging shift: Clearly expresses needs and wants associated with a newly experienced feeling.
(5) Softening: Genuinely accepts own feelings and needs. May show compassion, concern and respect for self.
(6) Negotiation. Clear understanding of how various feelings, needs and wishes may be accommodated and how previously antagonistic sides of self may be reconciled.

3. Internal Conflict Splits: Therapist Facilitating Responses
-Stage 1: Identify client marker (including pre-marker work); Offer task to client
-Stage 2: Structure (set up) experiment; Encourage separation & contact; Promote owning of experience; Help intensify client emotion
-Stage 3: Help Experiencer access and clarify underlying feelings; Help Critic access, clarify values and standards; Follow deepening forms of the conflict; Facilitate identifying with; expressing; or acting on organismic need; With collapse: Accept/deepen/ differentiate Hopelessness; or Encourage greater specificity in Critic; Without resolution: Bring contact to an appropriate close
-Stage 4: Facilitate emergence of new organismic feelings; Help create a meaning perspective (=processing)
-Stage 5: Facilitate softening in Critic (into fear or compassion)
-Stage 6: Facilitate negotiation between aspects of self re: practical compromises

III. … and What of Motivational Interviewing (MI)?
A. Nature of MI:
-“We define motivational interviewing as a client-centered, directive method for enhancing motivation to change by exploring and resolving ambivalence.” (Miller & Rollnick, 2002)
-Emerged as an alternative to directive/confrontive approaches to substance misuse
-Miller credits Carl Rogers & Tom Gordon as a primary source for MI
-But: commonly combined with information/ feedback = Motivational Enhancement Therapy (MET) (e.g., Project Match)

B. Further Applications of MI
-Extended to other forms of health-related behavior (e.g., over-eating, smoking; Rollnick et al., 2007)
-Being applied to broad range of client presenting problems (e.g., anxiety, depression; Westra, 2004; Arkowitz et al., in press)

C. MI: “Directive” (Guiding) use of Client-centred therapy
-Guide process (not content)
-Help person work with their own ambivalence and access self-motivation
-"Resistance" is generated interpersonally by pressure/control => psychological reactance.
-Avoid confrontation of avoidance & self-damage
-Instead, explore, help person access self-motivation
-Explore both sides of self-damaging behavior
-Miller & Rollnick: If you are acting as a “change advocate”, you are not doing MI!

D. Comparing “Spirit of MI” with PE-EFT Concepts:
Motivational Interviewing || Process-experiential/ Emotion-focused Therapy
-Collaboration || Task Collaboration Principle
-Evocation || Experiential Processing Principle; Task Stage 2
-Autonomy || Self-Development Principle

E. Comparing General Principles of MI & PE-EFT Concepts:
Motivational Interviewing Process-experiential/ Emotion-focused Therapy
1. Express Empathy || Empathic Attunement & Therapeutic Bond Principles
2. Develop discrepancy || Experiential Processing & Task Focus/Completion Principles
3. Roll with Resistance || Relationship Principles (Attunement, Bond, Collaboration)
4. Support Self-Efficacy || Self-Development & Therapeutic Bond Principles

F. MI: Person-Centred or Not?
-Pure MI = Person-centred in contemporary, process-guiding sense
= Member of client process-oriented Experiential Clan
-Cautions: “Change Advocate MI” is not MI, and is not person-centred; Information/feedback element is not “pure MI” (Miller & Rollnick); Zuckoff: Growing dissatisfaction with adding feedback to MI; can be counter-productive

F. The Weird Paradox of MI’s Evidence Base
-Burke et al., 2002, review of MI outcome research:
-No research on MI without feedback or other directive intervention
-Instead: Cite Greenberg, Elliott & Lietaer (1994; update: Elliott et al., 2004) meta-analysis of effectiveness of person-centred & PE-EFT to support effectiveness of pure MI
-But doesn’t include research on substance misuse

IV. A PE-EFT View of Motivational Interviewing
n MI represents an well-developed approach to working with a particular type of internal conflict split
A. Self-Damage Split marker:
-Person is aware that something is harmful to them (e.g., drinking, over-eating)
-They engage in the behavior anyway
-They experience distress over their behavior or its consequences

B. Self-Damage Splits
-Applies to broad range of unhealthy behaviors
-Things we do that aren’t good for us
-food, dangerous behavior, putting ourselves in stressful situations, not sleeping enough, failing to get enough exercise, ignoring health warnings

C. Working with Self-Damage Splits: MI Therapist Facilitating Responses
-MI: Empathic but focused exploration of both sides of the ambivalence about the self-damage split
-Explore: “Reasons to change” vs. “Reasons not to change”
-Help client access, clarify, consolidate, and eventually act upon self-change side of split
-Counsellor must do personal work in order to address critical reactions to client self-damaging processes, avoid becoming “change advocate”

D. Working with Self-Damage Splits: PE-EFT Therapist Facilitating Responses
-Offer Two Chair Work to help client explore both sides of their ambivalence
-Makes the conflict explicit
-More evocative => access emotions attached to each aspect
-Helps counsellor detach from critical reactions
-Strong evidence base for effectiveness of Two Chair Work with depressive splits (Greenberg & Watson, 2006)

E. Engle & Arkowitz (2006): Comparing MI with Two Chair Work
1. Share assumptions and relational stance
2. 2-chair/PE-EFT: Greater access to emotion; Access more complex experiences (Should Self, Reactant Self, Desired Self, Feared Self); Work is more fluid and evolving. But may be too much for some clients, especially early on (< session 3 or 4); Harder to teach to counsellors
3. MI: Use for more highly distressed or self-conscious clients
4. Useful complements to each other

F. Work with Self-Damage Splits: More Research Needed
-No research focused specifically on self-harm splits
-Needs more study to identify nuances in the work, e.g.,
-Strengthening ineffectual coach/self-change parts
-Avoiding internally-generated self-reactance

V. PE-EFT Resources
Recommended books for learning more:
-Elliott, Watson, Goldman & Greenberg, 2004: Learning Emotion-Focused Therapy
-Greenberg & Watson, 2005, Emotion-Focused Therapy for Depression.
-Engle, D.E., & Arkowitz, H. (2006). Ambivalence in Psychotherapy.

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