The effect of therapists' enactment interventions in promoting vulnerability sharing in emotion focused couple therapy.

OBJECTIVE: The primary purported change process in emotion-focused therapy for couples (EFT-C) involves partners accessing and revealing their underlying vulnerable emotions and responding empathically when their partners disclose their vulnerable emotions. One main intervention to facilitate vulnerability sharing is enactment - guiding partners to interact directly with each other. The objective of the current study was to identify interventions therapists can use to help partners share vulnerability in the context of enactment. The primary hypothesis of this study was that promoting these interventions would lead to more vulnerability expressions during enactments. METHOD: One hundred and five vulnerability enactment events were identified from videod therapy sessions of 33 couples dealing with a significant emotional injury who received 12 sessions of EFT-C. Four therapists' interventions were coded: setting a meaningful systemic context, promoting the revealing partner's emotional engagement, preparing the revealing partner for enactment, and promoting the listening partner's emotional engagement in the enactment. In addition, vulnerability expression was coded. RESULTS: Multilevel regression models showed that two interventions were significantly associated with greater levels of expressed vulnerability: setting a meaningful systemic context, and preparing the revealing partner for enactment. CONCLUSION: These findings suggest that therapists can facilitated vulnerability sharing using specific preparatory interventions.

Investigating patient-specific mechanisms of change in SET vs. EFT for depression: study protocol for a mechanistic randomized controlled trial.

BACKGROUND: Major depressive disorder (MDD) is the leading cause of disability worldwide and one of the most heterogeneous mental health disorders. Although there are effective treatments for MDD, about 50% of patients do not respond to treatment. One of the greatest challenges in improving current treatments is identifying the mechanisms responsible for therapeutic change in MDD. The proposed study aims to identify patient-specific mechanisms of change in two treatments for MDD by investigating whether subpopulations of patients differ in the mechanisms of change that operate when receiving a given treatment. Based on theories of targeting weakness and building on strength, we will examine whether the mechanism of change operating when a treatment is provided depends on whether the treatment targets the patient's strength or weakness. METHOD: To test our hypothesis that two treatments, supportive-expressive treatment (SET) and emotion-focused treatment (EFT), differ in their mechanisms of change and to explore whether focusing on the patient's strength or weakness will result in better treatment outcome, we conduct a mechanistic randomized controlled trial. One hundred and twenty-four individuals diagnosed with MDD are randomized to 16 sessions of either SET or EFT. The two treatments are theorized to differ in their main mechanism of change: SET places emphasis on insight as its main mechanism of change, and EFT places emphasis on emotional processing. Both can serve as strength- or weakness-focused treatments, based on the patient's baseline levels of insight and emotional processing. The primary outcome is the Hamilton Rating Scale for Depression. Additional measures include self-report measures and clinical interviews, hormonal, motion, acoustic, physiological, and neuroimaging assessments, performance on cognitive tasks, and narrative material (collected from the sessions and interviews). DISCUSSION: The RCT will expand our understanding of mechanisms of change in psychotherapy, from one-size-fits-all to patient-specific mechanisms of change. By informing therapists about which of the two approaches is most effective with patients based on their baseline characteristics, the RCT will contribute to progress toward personalized treatment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT04576182 submitted on October 1st 2020. FUNDING: The Israel Science Foundation. Trial status: Recruitment is ongoing.

Transforming core emotional pain in a course of emotion-focused therapy for depression: A case study.

OBJECTIVE: To investigate the pattern of change in emotional states over a course of emotion-focused therapy using the model of sequential emotional processing as an initial framework for analysis. METHOD: This was a single case study observational design examining 15 sessions of therapy with one client. A qualitative analysis of moment-to-moment shifts in client emotional events was conducted. This conceptualised the interplay between experienced emotions using the sequential emotional processing model as an interpretative framework. The analysis was triangulated by using existing observer-based rating scales and reliability assessed with an independent rater. RESULTS: The sequential emotional processing model was found to be an effective means to explain the sequence of expressed emotional events, although some emotional events and emotion scheme change processes pertaining to this particular case required additional explanation than provided in the original model descriptions. CONCLUSIONS: Observed nuances in this specific case included highlighting triggers to emotional experience and avoidance processes fuelled by anticipatory fear. The observations included a process of change through accessing core feelings of shame, fear, and loneliness and their transformation through the generation of self-compassion and assertive anger. Implications for practice are discussed in terms of case conceptualisation and therapeutic strategy.

Emotion-focused therapy for generalized anxiety disorder: An exploratory study.

Among psychological therapies for generalized anxiety disorder (GAD), cognitive-behavioral therapy has a dominant position as the most studied therapy. However, some researchers have recommended that to increase treatment options and broaden choice for clients, non-cognitive-behavioral therapy models for GAD should be examined. The present study was an exploratory study, assessing pre-post outcomes and 6-month follow-up of emotion-focused therapy for GAD, supplemented by qualitative posttherapy client accounts of helpful and unhelpful aspects of therapy and changes reported since therapy started. Fourteen clients were assessed on several measures focusing on GAD symptoms, depressive symptoms, and general psychological functioning. Quantitative pre-post and 6-month follow-up data indicated large effect sizes. Qualitative data captured changes in emotional functioning, anxiety, self-acceptance, self-confidence, and self-understanding. Clients reported as helpful both relational aspects of the work and in-depth experiential tasks, although some found the experiential aspect of the work difficult. The findings suggest that there may be value in assessing emotion-focused therapy as a treatment for GAD in a randomized controlled trial. (PsycINFO Database Record

Vulnerable Emotional Expression In Emotion Focused Couples Therapy: Relating Interactional Processes To Outcome.

This study examined whether interactions characterized by high expression of emotional vulnerability in one partner followed by a highly supportive response style by the other partner predicted greater improvement on domains of forgiveness, unfinished business, trust, and relationship satisfaction in a sample of 32 couples presenting for Emotion Focused Couples Therapy with unresolved emotional injuries. For each outcome measure, two separate hierarchical regression models were tested (injured partner vulnerability and offending partner supportiveness; offending partner vulnerability and injured partner supportiveness). Both models significantly predicted improvement on the majority of outcome measures. Practice suggestions for working with emotionally injured couples are provided in light of the findings.

Self-narrative reconstruction in emotion-focused therapy: A preliminary task analysis.

OBJECTIVE: This research explored the consolidation phase of emotion-focused therapy (EFT) for depression and studies-through a task-analysis method-how client-therapist dyads evolved from the exploration of the problem to self-narrative reconstruction. METHOD: Innovative moments (IMs) were used to situate the process of self-narrative reconstruction within sessions, particularly through reconceptualization and performing change IMs. We contrasted the observation of these occurrences with a rational model of self-narrative reconstruction, previously built. RESULTS: This study presents the rational model and the revised rational-empirical model of the self-narrative reconstruction task in three EFT dyads, suggesting nine steps necessary for task resolution: (1) Explicit recognition of differences in the present and steps in the path of change; (2) Development of a meta-perspective contrast between present self and past self; (3) Amplification of contrast in the self; (4) A positive appreciation of changes is conveyed; (5) Occurrence of feelings of empowerment, competence, and mastery; (6) Reference to difficulties still present; (7) Emphasis on the loss of centrality of the problem; (8) Perception of change as a gradual, developing process; and (9) Reference to projects, experiences of change, or elaboration of new plans. CONCLUSIONS: Central aspects of therapist activity in facilitating the client's progression along these nine steps are also elaborated.

Affective Change in Psychodynamic Psychotherapy: Theoretical Models and Clinical Approaches to Changing Emotions.

OBJECTIVES: Affective change has been considered the hallmark of therapeutic change in psychoanalysis. Psychoanalytic writers have begun to incorporate theoretically the advanced understanding of emotional processing and transformation of the affective neurosciences. We ask if this theoretical advancement is reflected in treatment techniques addressing the processing of emotion. METHODS: We review psychoanalytic models and treatment recommendations of maladaptive affect processing in the light of a neuroscientifically informed model of achieving psychotherapeutic change by activation and reconsolidation of emotional memory. RESULTS: Emotions tend to be treated as other mental contents, resulting in a lack of specific psychodynamic techniques to work with emotions. Manualized technical modifications addressing affect regulation have been successfully tested in patients with personality pathology, but not for psychodynamic treatments of axis I disorders. CONCLUSIONS: Emotional memories need to be activated in order to be modified, therefore, we propose to include techniques into psychodynamic therapy that stimulate emotional experience.

Emotion categories and patterns of change in experiential therapy for depression.

OBJECTIVE: This investigation examined the relationship between in-session types of emotional experience operationalized by the emotion category coding system and the reduction of depressive symptoms in emotion-focused therapy (EFT). METHOD: Segments of videotaped sessions were coded and the different emotion categories were related to reduction in depressive symptoms in a sample of 30 clients who received EFT for depression. RESULTS: Both fewer secondary and more primary adaptive emotions, in the working phases of therapy, were found to significantly predict outcome. Moderate levels of primary maladaptive emotion in the middle working session were associated with outcome and the frequency with which clients moved from primary maladaptive to primary adaptive emotions in this session-predicted outcome. CONCLUSIONS: Results of this study support a transformational model of changing emotion with emotion.

Interpersonal forgiveness in emotion-focused couples' therapy: relating process to outcome.

The objective of this study was to relate the in-session processes involved in interpersonal forgiveness to outcome. The sample consisted of 33 couples who received 10-12 sessions of Emotion-focused couple therapy with the aim of resolving various forms of emotional injuries (i.e., transgression that violates the expectations of a close relationship, which leaves one partner feeling hurt and angry). The results of the present study were based on the analyses of 205 video-taped segments from 33 couples' therapies. Hypotheses relating the role of three in-session components of resolution, the injurer's "expression of shame"; the injured partner's "accepting response" to the shame, and the injured partner's "in-session expression of forgiveness", to outcome were tested using hierarchical linear regression analyses. Outcome measures included the Enright Forgiveness Inventory (The Enright Forgiveness Inventory user's manual. Madison: The International Forgiveness Institute, 2000), the Dyadic Adjustment Scale (Journal of Marriage and Family, 1976; 13: 723) and the The Interpersonal Trust Scale (Trust; Journal of Personality and Social Psychology, 1985; 49: 95).

Narrative and emotion process in psychotherapy: an empirical test of the Narrative-Emotion Process Coding System (NEPCS).

OBJECTIVE: While the individual contributions of narrative and emotion processes to psychotherapy outcome have been the focus of recent interest in psychotherapy research literature, the empirical analysis of narrative and emotion integration has rarely been addressed. The Narrative-Emotion Processes Coding System (NEPCS) was developed to provide researchers with a systematic method for identifying specific narrative and emotion process markers, for application to therapy session videos. METHOD: The present study examined the relationship between NEPCS-derived problem markers (same old storytelling, empty storytelling, unstoried emotion, abstract storytelling) and change markers (competing plotlines storytelling, inchoate storytelling, unexpected outcome storytelling, and discovery storytelling), and treatment outcome (recovered versus unchanged at therapy termination) and stage of therapy (early, middle, late) in brief emotion-focused (EFT), client-centred (CCT), and cognitive (CT) therapies for depression. RESULTS: Hierarchical linear modelling analyses demonstrated a significant Outcome effect for inchoate storytelling (p = .037) and discovery storytelling (p = .002), a Stage × Outcome effect for abstract storytelling (p = .05), and a Stage × Outcome × Treatment effect for competing plotlines storytelling (p = .001). There was also a significant Stage × Outcome effect for NEPCS problem markers (p = .007) and change markers (p = .03). CONCLUSION: The results provide preliminary support for the importance of assessing the contribution of narrative-emotion processes to efficacious treatment outcomes in EFT, CCT, and CT treatments of depression.

Client emotional productivity-optimal client in-session emotional processing in experiential therapy.

OBJECTIVE: The goal of this investigation was to examine the predictive validity of Client Emotional Productivity (CEP), an operationalization of optimal client in-session emotional processing, possessing seven features: Attending, symbolization, congruence, acceptance, regulation, agency and differentiation. METHOD: CEP was related to improvement in depressive and general symptoms, in 74 clients (66% female, 34% male) who received experiential therapy of depression and this was compared to the relationship between client high expressed emotional (CHEEA) arousal and the working alliance (WAI) and outcome. RESULTS: Hierarchical regression analyses revealed that working phase CEP predicted significant reduction of depressive and general symptoms over and above that predicted by beginning phase CEP, the working alliance and working phase CHEEA. Working phase CEP emerged as the sole, independent predictor of outcome for both depressive and general symptoms. CONCLUSION: Productive emotional processing, thus, mediates the relationship between the alliance and outcome and seems to go beyond mere activation and expression of emotional experience. It rather seems to involve an increase in the ability to process activated primary emotion in a productive manner specified by CEP.

Emotions, the great captains of our lives: their role in the process of change in psychotherapy.

A view of human functioning is presented in which functioning is seen as integrating head and heart, emotion and reason, in a process by which people are constantly making sense of their lived emotional experience to form narratives of told experience. Because much of the processing involved in the generation of emotional experience occurs independently of and prior to conscious thought, therapeutic work on a purely cognitive level of processing is unlikely to produce enduring emotional change. The questions especially relevant to psychotherapy are how we can best facilitate change in emotions rather than only changes in cognition or behavior. A theory of emotional change is presented in which change in emotion is seen as requiring that first emotions be felt and then they both be exposed to new emotional experience and be reflected on to create new meaning. The process of emotional change thus involves both new experience and new understanding. At times, people also need to protect themselves from being overwhelmed by emotions. They need to be helped to tolerate and regulate them so that emotions inform their lives rather than control them. The importance of both emotion awareness and emotion regulation in therapeutic change is thus highlighted. The article ends by reviewing research on the role of emotional processing in therapeutic change and presents six empirically based principles of emotional processing that will help move the field toward psychotherapy integration in a manner that clearly recognizes emotion as a key component of functioning and change.

Therapist interventions and client innovative moments in emotion-focused therapy for depression.

According to the narrative approach, change in self-narratives is an important part of successful psychotherapy. In this view, several authors have highlighted the usefulness of narrating new experiences (like actions, thoughts, and stories) during therapy in contrast with maladaptive client self-narratives. These new experiences are termed here innovative moments (IMs), and different types can be specified: action, reflection, protest, reconceptualization, and performing change. With the aim of understanding which therapist skills are related to client IMs, we analyzed the association between exploration, insight, and action skills and IMs in two initial, two middle, and two final sessions of three good outcome (GO) and three poor outcome (PO) cases of emotion-focused therapy (EFT) for depression. IMs occurred more often in GO than PO cases. Furthermore, in GO more than PO cases, exploration and insight skills more often preceded action, reflection, and protest IMs in the initial and middle phases of EFT, but more often preceded reconceptualization and performing change IMs in the final phase. Action skills were more often associated with action, reflection, and protest IMs across all phases, especially in the final phase, of GO EFT.

Innovative moments and change in client-centered therapy.

Previous studies have used the Innovative Moments Coding System (IMCS) to describe the process of change in Narrative Therapy (NT) and in Emotion-Focused Therapy (EFT). This study aims to extend this research program to a sample of Client-Centered Therapy (CCT). The IMCS was applied to six cases of CCT for depression to track the Innovative Moments (IMs) which are exceptions to the problematic self-narrative in therapeutic conversation. Results suggest that IMCS can be applied to CCT, allowing the tracking of IMs' emergence. The analysis based on a generalized linear model revealed that the overall amount of IMs is significantly associated with symptom improvement, which is congruent with former studies done with the IMCS.

Organizing awareness and increasing emotion regulation: revising chair work in emotion-focused therapy for borderline personality disorder.

Emotion-focused therapy (EFT) is an empirically supported treatment that may have potential as a stage-two treatment for borderline personality disorder (BPD). Specific aspects of BPD--the tendency to experience fluctuating self-states; weakness in meta-cognitive or reflective functioning; and the tendency for self-states to be organized by presently occurring interpersonal processes--present challenges to applying some EFT interventions with this population. In particular, even within a highly attuned, validating and accepting empathic relationship, clients with BPD may have difficulty with the usual manualizations of chair work interventions. This is because these interventions often employ polarization and intensification of experience in order to activate adaptive alternate emotional resources and self organizations. For the client with borderline personality disorder, these interventions may be counter-productive, emotionally dysregulating and disorganizing. EFT chair work, however, also has the potential to provide structure to the borderline clients experience of self, to stimulate metacognitive awareness, provide an alive experience of the process of polarization, attenuate emotional activation, and increase the experience of self-coherence. This article describes the development of stepwise approximations of EFT two-chair intervention for self-critical splits. It outlines potential stages of two-chair work as well as intervention principles important for productive chair work with this population. The EFT change principles of awareness, expression regulation, reflection, transformation, and corrective experience still centrally apply. However, several additional strategies are discussed to scaffold clients' capacity to both experience and regulate emotion.

The construction of a model of the process of couples' forgiveness in emotion-focused therapy for couples.

This study explored how forgiveness unfolds in the context of emotion-focused couples therapy (EFT-C) in eight cases of women betrayed by their partners. Forgiveness was defined as a process involving the reduction in negative feelings and the giving out of undeserved compassion. This was measured by changes in the pre- and posttreatment scores on the Enright Forgiveness Inventory, the Unfinished Business Resolution Scale, and a single item directly asking respondents to indicate their degree of forgiveness. A task analysis was performed to rigorously track the steps leading to forgiveness using videotapes of therapy sessions for eight couples. The performance of the four couples who forgave were compared with each other and then contrasted with the performance of another four couples who did not reach forgiveness at the end of therapy. Based on these observations, a model of the process of forgiveness in EFT-C and a process rating system were developed.

Narrative change in emotion-focused psychotherapy: a study on the evolution of reflection and protest innovative moments.

Innovative moments (IMs) are exceptions to a client's problematic self-narrative in the therapeutic dialogue. The innovative moments coding system is a tool which tracks five different types of IMs-action, reflection, protest, reconceptualization and performing change. An in-depth qualitative analysis of six therapeutic cases of emotion-focused therapy (EFT) investigated the role of two of the most common IMs-reflection and protest-in both good and poor outcome cases. Through this analysis two subtypes (I and II) of reflection and protest IMs were identified, revealing different evolution patterns. Subtype II of both reflection and protest IMs is significantly higher in the good outcome group, while subtype I of both IMs types does not present statistically significant differences between groups. The evolution from subtype I to subtype II across the therapeutic process seems to reflect a relevant developmental progression in the change process.

Empathy.

After defining empathy, discussing its measurement, and offering an example of empathy in practice, we present the results of an updated meta-analysis of the relation between empathy and psychotherapy outcome. Results indicated that empathy is a moderately strong predictor of therapy outcome: mean weighted r = .31 (p < .001; 95% confidence interval: .28-.34), for 59 independent samples and 3599 clients. Although the empathy-outcome relation held equally for different theoretical orientations, there was considerable nonrandom variability. Client and observer perceptions of therapist empathy predicted outcomes better than therapist perceptions of empathic accuracy measures, and the relation was strongest for less experienced therapists. We conclude with practice recommendations, including endorsing the different forms that empathy may take in therapy.

Narrative change in emotion-focused therapy: how is change constructed through the lens of the innovative moments coding system?

The aim of this study was to advance understanding of how clients construct their own process of change in effective therapy sessions. Toward this end, the authors applied a narrative methodological tool for the study of the change process in emotion-focused therapy (EFT), replicating a previous study done with narrative therapy (NT). The Innovative Moments Coding System (IMCS) was applied to three good-outcome and three poor-outcome cases in EFT for depression to track the innovative moments (IMs), or exceptions to the problematic self-narrative, in the therapeutic conversation. IMCS allows tracking of five types of IMs events: action, reflection, protest, reconceptualization, and performing change. The analysis revealed significant differences between the good-outcome and poor-outcome groups regarding reconceptualization and performing change IMs, replicating the findings from a previous study. Reconceptualization and performing change IMs seem to be vital in the change process.

Therapist and client perceptions of therapeutic presence: the development of a measure.

The authors developed two versions of a therapeutic presence measure, based on an earlier model of presence (Geller & Greenberg, 2002)-Therapeutic Presence Inventory-therapist (TPI-T) and client (TPI-C) versions-to measure in-session therapeutic presence. They explored their reliability and validity in two studies. In the first, items generated from the previously established model were subjected to analyses and expert ratings. In the second study, therapists and clients rated therapists' presence postsession. Therapists also completed the Relationship Inventory, and clients assessed two additional factors: session outcome, using the Client Task Specific Measure-Revised, and therapeutic alliance, using the Working Alliance Inventory. Findings revealed that both versions of the TPI had good reliability and construct validity. However, TPI-T had low predictive validity and the TPI-C showed good predictive validity. In particular, clients reported positive therapeutic alliance and change following sessions when they felt their therapist was present with them.