Sunday, September 02, 2007

Process-Experiential/ Emotion-Focused Therapy as a Pluralistic Approach

Entry for 3 September 2007:
Presentation at one-day conference of Scottish SPR, "Pluralism in Counselling and Psychotherapy: Practice, Training, Research and Theory". University of Abertay, Dundee, Scotland.

Pluralism vs. Monism: The fox knows many things, but the hedgehog knows one big thing. -Archilochus (7th-century bce)

I. Introduction:
A. Pluralism (American Heritage Dictionary)
• 1. The condition of being multiple or plural.
• 2.a. A condition in which numerous distinct ethnic, religious, or cultural groups are present and tolerated within a society.
– b. The belief that such a condition is desirable or socially beneficial.
• 4. Philosophy
– a. The doctrine that reality is composed of many ultimate substances.
– b. The belief that no single explanatory system or view of reality can account for all the phenomena of life.

B. Pluralism: Etymology
• From plural = Relating to or composed of more than one member, set, or kind
• From Latin pluralis, plus = more
• From Proto-Indoeuropean: pel' = to fill (cf. plus, poly; full, plenty, folk; supply, plethora)
• Root metaphor: Pluralism as hunger (greed?)

C. Pluralism(s) in Therapy
• Multiple causes of client problems
• Multiple people (client & therapist): relational
• Multiple perspectives (client, therapist, observer)
• Multiple client processes (modes of engagement)
– productive & unproductive
• Multiple therapeutic processes (tasks)
• Multiple outcomes

II. Process-Experiential Therapy as a Pluralist Approach
A. Starting point:
- There is more than one form of productive client process
– Classical PCA specified a single form of productive client process
– Exploration and formulation of self-relevant experience
– Client Experiencing Scale (Rogers, Gendlin, Klein, Kiesler, et al.)

B. Process-Experiential/Emotion-Focused Therapy (PE-EFT)
• 1985-1992: Greenberg, Rice & Elliott developed Process-Experiential therapy as an alternative to existing humanistic therapies
– Best for communicating within the PCA/humanistic therapy realm
• 1990’s: Re-branded as Emotion-Focused Therapy for communicating with therapists from other orientations

C. Multiple Forms of Productive Client Process
• Greenberg & Rice (1990): Modes of engagement (micro-processes)
– Attending
– Experiential search
– Active expression of emotion
– Contacting/connecting with therapist
• More recently, expanded to 14 (Elliott, 2006)

D. Multiple Forms of Productive Therapeutic Process
• Different therapeutic processes will facilitate different client modes of engagement:
– Focusing => Attending
– Systematic Evocative Unfolding => Experiential search
– Chairwork => Active expression of emotion
– Empathic Prizing => Contacting/connecting with therapist
• Referred to as “Tasks”
– From research on human problem-solving
– Research method: Task Analysis
– Now expanded to 13 tasks (Elliott et al., 2004)

E. Multiple Client Markers
• How do we know when particular client modes of engagement will be most productive?
• Unclear felt sense => Focusing => Attending
• Problematic reaction point (PRP) => Systematic Evocative Unfolding => Experiential search
• Conflict split or unfinished business => Chairwork => Active expression of emotion
• Vulnerability => Empathic Prizing => Contacting/connecting with therapist

III. Organizing Frameworks:
A. Pluralism Risks Chaos
• Complexity theory: Self-organizing systems emerge at the boundary/ dialectic between order and chaos
• Without some chaos => excessive order kills/stifles/rigidifies
• Without some order => chaos/entropy
• Thus: Need organizing frameworks to contain plurality

B. Organizing Framework 1: Therapeutic Principles
• Formulation of Process-Experiential approach began with a qualitative analysis of principles or guidelines for practice (Elliott, Greenberg & Rice, 1986)
• Organized into 2 broad groups
– Relationship principles: Foster safe, productive relationship (has precedence)
– Task principles: Foster therapeutic work on specific therapeutic tasks
• Operate in tension with each other
• Three main treatment principles within each
• Framework holds the plurality of causes, processes, outcomes
(A) Relationship Principles
• Facilitate safe, productive relationship:
– 1. Empathic Attunement: Enter, attend & track client’s immediate experiencing
• Always start with this
– 2. Therapeutic Bond: Offer empathic, caring presence to client
• = bond aspect of alliance (Bordin)
– 3. Task Collaboration: Offer and facilitate involvement in therapeutic work
• = task/goal aspect of alliance (Bordin)
(B) Task Principles
• Facilitate work on specific therapeutic tasks
– 4. Experiential Processing: Help client work in different ways at different times
• Foster relevant client modes of engagement
– 5. Task Completion/Focus: Facilitate client completion of key therapeutic tasks
– 6. Self-development: Foster client growth, empowerment & choice
C. Organizing Framework 2: Therapeutic Tasks
• Clients bring specific immediate problems (cognitive-affective 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
• Measured by 6-point Degree of resolution scale
– 3. Therapist interventions: What therapist can do to help client resolve
– 4. Resolution state: What resolution looks like

IV. General Empathic Exploration for Problem-Relevant Experience
• Generic/baseline task for PE-EFT
• Client Mode of engagement: Experiential Search

• A. Marker: Problem-relevant experience:
• Any experience that draws client’s attention
– a. Client expresses energy/ interest in the experience
– b. Experience has personal relevance to client
– c. Incompleteness/complexity: Experience is powerful, troubling, incomplete, undifferentiated, global, abstract or external

B. Empathic Exploration Micro-sequence:
• (a) Therapist Initiation: Exploratory question
• (b) Client Response: Answer (description of experience) (may elaborate, initiate new topic)
• (c) Therapist Formulation: Exploratory Reflection (or similar comment showing receipt of answer) (may ask “fit question”)
• (d) Client Confirm/disconfirm (may initiate new topic)

C. Task Model for Empathic Exploration
• Stage 1: Marker
• Stage 2. Task initiation. Help identify particular client experience worth exploring further.
• Stage 3. Deepening: Exploratory manner & responses; Forms of Deepening Exploration
• (1) Redirecting client to internal experiencing:
– When C is external, abstract or intellectual: T:“So what does that feel like inside?”
• (2) Re-experiencing of particular experiences:
– Re-living particular experience(s) in imagination. (episodic memories) (T: “Can you take me through that? So there you were...”)
• (3) Searching edges of awareness:
– Explore unclear, vague, general; troubling, painful; puzzling, confusing; tangled, stuck, blocked; unfinished, missing; or incipient, emerging ("inklings") (T: “So the part that’s not quite clear to you is...”)
• (4) Differentiating experiencing:
– Specifying experience (T: “There are lots of kinds of anger; what is the quality of the anger you’re feeling right now?”)
• (5) Elaborating Experiencing: Filling in missing pieces of emotion schemes
– (a) Missing context or “aboutness”: sources, origins, situations (T: “What it is the sadness about?”) (=situational/perceptual)
– (b) Missing internal/bodily experiencing (T: “What does it feel like inside you?”) (=bodily/expressive)
– (c) Unsymbolized experiencing: global or unverbalizable (T:“How you describe it or picture it to yourself?”) (=verbal/symbolic)
– (d) Missing needs, wants or action tendencies (T: “How would you like it to be?”) (=motivational/behavioral)
• Stage 4: Client experiences some clarification of experience
• Stage 5: Client attains a sense of full understanding, and an appreciation and owning of the experience in its complexity or richness (“Now I know what that’s all about”)
• Stage 6: In addition to the above, client also feels a marked sense of relief (not feeling so distressed about it) or empowerment about the experience (knowing what to do about it)

V. Two Chairwork for Self-Evaluation Splits
• A. Conflict Split Marker
– 1. Two wishes or action tendencies
– 2. Description of contradiction, conflict between
– 3. Expression of struggle, coercion
• Prototypical Split = Decisional conflict
• Experience: uncomfortable "tornness"
• Alternative Forms:
– 1. Self-Evaluation (self-criticism)
– 2. Coaching splits (self-coercion)
– 3. Attribution splits (externalized; over-reaction to others)

B. Two Chair Dialogue for Conflict Splits: Client Resolution Model
1. Marker/Task Initiation: Describes split in which one aspect of self is critical of, or coercive toward, another aspect. Broadly: Describes two aspects, whether attributed or in somatic form.
2. Entry: Clearly expresses criticisms, expectations, or "shoulds" to self in concrete, specific manner.
3. Deepening: Experiencing chair may agree with critic (“collapse”); 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.

C. Therapist Facilitating Responses
•Identify client marker (including pre-marker work)
•Elicit client collaboration in task
•Structure (set up) experiment
•Create separation & contact
•Promote owning of experience
•Intensify client arousal
•Access and differentiate underlying feelings in the experiencing self (including collapsed self process)
•Differentiate values and standards in the critical aspect
•Follow deepening forms of the conflict
•Facilitate identifying with; expressing; or acting on organismic need
•Bring contact to an appropriate close (=closure/ending experiment w/o resolution)
•Facilitate emergence of new organismic feelings
•Create a meaning perspective (=processing)
•Facilitate softening in critic (into fear or compassion)
•Facilitate negotiation between aspects of self re: practical compromises

VI. Conclusions:
A. Task Plurality
• Empathic Exploration and Two Chairwork are clearly different processes:
– Different markers
– Different primary client modes of engagement
– Different facilitating therapist responses
– Different end points/resolutions
…Common Therapeutic Frame
• Yet both can be readily contained within one therapeutic frame:
– Therapeutic relationship: empathic attunement; genuine/caring personal bond; spirit of collaboration
– Way of working: constantly being adjusted to current client mode of engagement; focusing on key client tasks; supporting client growth, choice, empowerment
– Task structure: Six stage model: Marker; Entry; Dialectical Deepening; Emerging Shift; Broader Reflection; Empowerment/Action

• B. Also: Organization Framework 3: PE Emotion Theory
• Multiple aspects of experience connected by emotion
– Emotion Scheme model
– Perceptual, conceptual, bodily, need/action
• All emotions play important roles in human adaptation
– Even so-called negative emotions:
– Fear, shame, disgust, hopelessness etc.
• Multiple types of emotion response
– E.g., different kinds of anger
– Primary adaptive, primary maladaptive, secondary reactive, instrumental
• Multiple forms of emotion regulation:
– Access/approach
– Contain/distance

C. Broader Reflections : Pluralism vs. Integration
• We have consistently referred to PE (and EFT) as an Integrative therapy (primarily Person-centred, Gestalt)
• Tried to argue that this integration of different causes and client/ therapist processes also makes PE therapy pluralistic
• Also: Tried to show how plurality can be usefully organized within integrative frameworks
• But: Can integration be truly pluralistic?
– Is integrative pluralism an oxymoron?

D. Broader Reflections: Limits of Pluralism in PE-EFT?
• Left unanswered: How much can be integrated into Process-Experiential therapy without violating its integrative frameworks?
• What about elements of CBT? E.g.,
– Systematic desensitization
– Thought stopping
– Rational disputation of thinking errors
– Assertiveness training in groups

E. Proposed Test for Integrating New Elements in PE Therapy
1. Apply Therapy Principles:
• 1. Can empathic attunement to client immediate experience be maintained while carrying out this kind of work?
• 2. Can the therapist continue to offer an empathic, caring presence?
• 3. Can task collaboration be established with the client?
• 4. Can key client processes and facilitating therapist responses for this work be identified?
• 5. Is this a key task for clients?
• 6. Most importantly, can this work be pursued without the therapist becoming an expert on the client’s experience, thus interfering with the client’s personal power, responsibility and growth?

F. If a CBT Technique is not Consistent with PE principles?
• Strategy needed for developing parallel PE task models
– Accomplish what CBT techniques do
– Without violating relationship and client autonomy
1 Questions for Developing PE Task Models from CBT Techniques
• 1. What is the client marker for this kind of work?
• 2. What is the desired immediate outcome (resolution) of this kind of work?
• 3. What client modes of engagement does the technique seek to activate in order to reach resolution?
• 4. What therapist responses might facilitate these client modes of engagement without making the therapist into a content expert?
2. Developing PE Task Models from CBT Techniques: Resources
• 1. Empathic, caring, genuine, flexible, task-focused, empowering relationship
– Research evidence supports
• 2. Task analytic approach
– Leads to specificity of CBT without need for theory-driven expertise
• 3. Power of primary adaptive emotion processes to motivate change
– Don’t need therapist expertise/persuasion

VII. Beyond Foxes and Hedgehogs
• What we need most is to be able to integrate many things within a broader pattern
• Integrative pluralism
• Eagle… or homo sapiens?

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