Download Working with Emotion in Psychotherapy Alberta Pos York University

All problems are in the end emotional
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The majority of people come into psychotherapy because they
experience significant personal, social or occupational
dysfunction due to emotion or its consequences.
Emotional states such as anxiety, depression, extreme mood
swings, and intense emotional pain can be subjectively intolerable
experiences.
Apathy, flatness, and blocked emotion can also be a concern, as
well as the preponderance of one emotion over others.
The inability to control actions or the opposite problem, the
inability to act because of emotion can be problematic and can
cause unpleasant consequences.
Lack of control and/or faulty reality testing of thoughts that
trigger and maintain emotion may also be problematic.
Basic emotion components
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Stimulus: Emotions are about something
Appraisals: Interpretations of the stimulus
situation and the self
Physiological changes: Arousal
Action tendency-evidence and part of arousal
Phenomenal experience- the subjective experience
in consciousness
Approaches to psychotherapy
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A historical lineage of psychotherapy goes like this:
 Psychoanalytic-Freud
 Behavioral-Skinner
 Cognitive Behavioral-Beck
 Client Centered (Rogers) /Gestalt (Perls)
 Emotion-focused therapies:
 Process/Experiential or EFT (Greenberg)
 Integrative CBT (Segal/Saffran)
 “Neo-analytic” (Sandler)
 Dialectical Behavior Therapy (Linehan)
Psychoanalysis and emotion
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Historical events and family history both thwart and
developed needs that cause conflict neurosis.
Originally problems were viewed as the result of
blocked emotion, once emotion was experienced the
memories relating to emotions would come to
consciousness and could be worked through with
insight. Understanding would regulate and change
emotion.
Emotions seen as part of the id or instinctive process
that were in conflict with super-ego or societal
demands. They had to be tamed with reaso
Behavioral Approaches and emotion
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Learning theory is the heart of this therapy.
Problems result of:
 Skills deficits cause dysfunctional behavior that receives
little positive reinforcement. Teach and learn new
behaviours that can be strengthened with positive
reinforcement.
 Inadvertent reinforcement of undesirable behaviors via
operant conditioning, as in phobia and avoidance.
Extinguish the behaviour by removing the reinforcement.
For example- don’t allow the escape behavior so that it
can’t be rewarded by anxiety reduction, as in exposure
treatment.
 Finding and eliminating the stimulus or associated cues that
elicit inappropriate behavior.
Cognitive-behavioral therapy
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Psychological states are the product of our thoughts,
assumptions and beliefs that function automatically.
People can become aware of these and have some
control over their thoughts.
Bring more controlled awareness to thoughts, in the
form of:
 self-observation
 reality testing/rational thinking- test the validity of
assumptions
Evidence will change beliefs and thinking and impact
mood.
Commonalities in all approaches
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Focused on problematic emotion, the emotion that
should be gotten rid of (i.e., anxiety, depression, anger)
Focused on the power of the rational mind, and the
ability to interrupt emotion with rational thinking or
understanding and distance to regulate and take the
edge off.
Focused on executive powers, the ability to inhibit
responding, that is, de-link the automatic connection
between feeling and behavior.
Did not value emotion as information, did not view the
information value of emotion or see it as a complex
phenomenon.
Client-centered therapy (Rogers)
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The first therapy to value emotion
A model of health. All human beings will grow toward healthy
functioning and reach their potential, given conditions that
foster growth.
Growth needs a safe interpersonal environment.
In early environment where love is conditional. Child learns to
conform to values of others at expense of inner feelings and
needs.
Clients must be brought into stronger contact with their true
feelings and values.
Provide a non-conditional interpersonally safe environment.
Clients will contact who they are and what they need/feel.
This will help them solve problems and act in the service of
their goals.
Experiential therapies assume
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That emotion is a vital regulator of action that provides
awareness to an organism of what is important in terms of
adaptive function in its environment
Experience of emotion is essential to fully accessing the
information value in feeling. Increased emotional awareness is
essential, and experiential psychotherapies can be seen as a
form of training in this awareness (Greenberg & Safran, 1987).
The belief is that once one makes sense of emotional
experience by fully-processing it, emotion can clearly guide
decision making and action.
Information value in emotion
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Several emotion theorists (Frijda, 1986; Izard, 1991; Oatley and
Jenkins, 1992; Tomkins, 1963) have now formulated emotion as
an rapidly-acting meaning system that is activated in response
to events that have significance to our well-being. Emotion also
organizes us for adaptive action in response to these events.
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Emotion provides information about:
 events that are occurring
 our needs, goals, and concerns
 our sense of self
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adaptive actions to take in the service of our needs
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What's happening?
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Discrete emotions naturally occur in response to particular
classes of self-relevant events. They tell us if we have been
violated or treated unfairly (anger), are in danger (fear),
have lost someone important to us (sadness) (Frijda, 1986;
Scherer, 1984).
What do I need?
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Discrete emotions inform of us our needs. They tell us if
we need to assert boundaries (anger), if we need security
and safety (fear) or we need companionship and comfort
(sadness) (Greenberg & Paivio (1997).
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What's going on with me ?
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Emotions inform us about our sense of self in the situation
(Scherer, 1984). When we are angry we experience ourselves
as strong, with resources to deal with the situation. When we
are afraid our sense of self is one of weakness, without the
ability to deal with the event. In shame our sense as
unacceptable.
What should I do?
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Emotion guides action (Frijda, 1986). When we are violated
and angry it is adaptive to hit out and defend oneself. When we
are afraid it is adaptive to freeze or run. When sad and alone it
is adaptive to seek comfort and companionship.
The complex emotional world
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We do not live in worlds in which the only emotional
scenarios we meet are simply and automatically
running away from scary animals, or hitting people
who try to steal our belongings. We live in worlds in
which bosses betray us, parents thwart our choices,
and the media stirs up feelings for which we may
have no target to direct our longings.
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Emotion has been complicated by consciousness,
learning, experience, and memory, as well as our
ability to regulate emotions.
Maladaptive emotions
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Emotional processes can also go wrong.
Emotions are not always adaptive in the
straightforward manner described by emotion
theory.
Individuals can feel fear when approached by
loving others, go into a panic at being successful,
and feel love for abusers.
What is now agreed upon by all approaches
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Emotional is a complex and dynamic integration of
affective programs and cognitive processes like
memory and learning.
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It’s best viewed as a affective/cognitive structure
(Greenberg & Paivio, 1997; Beck, 1996).
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Some affective-cognitive structures are healthy /
adaptive, while others are not.
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How do you identify the healthy from unhealthy
emotions and schemes?
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Greenberg & Safran were the first to suggest emotional
assessment and differential intervention based on such
an assessment (1987; Greenberg & Paivio, 1997)
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Emotions are varied:
 Primary adaptive- normal fear in the face of danger
 Primary maladaptive- fear when shown love
 Secondary or self-protective- anger when really
scared
 Instrumental- acting angry to get what you want
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Primary adaptive emotion
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should be mined for information about needs and
adaptive actions.
Primary maladaptive emotion
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should be explored for the maladaptive meaning
structures that elicit them so that meaning can be
deconstructed and transformed into new
meaning/appraisals that support adaptive emotion in
the situation instead of maladaptive.
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Secondary emotions
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need to be explored for their self protective purpose
resolve the beliefs that interrupt the primary emotion
eventually the primary emotions underlying them
unpacked for their information.
Instrumental emotion
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requires examination and awareness concerning the
manipulative function so that the desired goals can be
achieved in more adaptive ways.
Working with emotion
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Experiences are generated by emotion schemes (programs).
Emotion schemes are triggered automatically, and affect
thoughts and experience automatically (challenge to
Beck/CBT).
Can’t change emotion schemes with thoughts alone, need
emotion ‘on-line’ to change it.
Provide clients with the interpersonal safety needed to
approach emotional experience.
Access emotion schemes by arousing emotional experience in
sessions.
Generate new emotional experiences in therapy.
Support the emergence of adaptive emotion.
Other approaches now concur
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Beck (1996) himself, in a chapter entitled “Beyond Belief”, recently suggested
that certain biologically based modes of functioning determine whether a
belief will be activated.
Samoilov and Goldfried (2000) have called for an “expansion” in Cognitive
Behavioral Therapy toward making use of emotion in therapy and they note
that core affective structures are subject to different change principles than
those involving cognition, as they are not affected by logic.
Foa and Kozak (1986) argued for the importance of arousing emotion in order
to expose it to new input in behavioural treatment of panic and trauma.
Rachman (1981), another behaviourist entertains the possibility that
desynchronies between affect and cognition are possible and has initiated a
discussion of the importance of emotional processing in exposure therapy.
Stein (1991) in a comprehensive review of psychoanalytic theories of affect
remarks that treatment now often consists of helping clients approach and
tolerate emotional experiences such that emotions transform, not through
simple discharge, but by meaningfully connecting emotions to self and
situation.
Experiencing emotion on line
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All approaches are also beginning to concede that
because emotion schemes function automatically, and
are therefore out of awareness, emotion schemes have
to be turned on and brought into awareness in order
for therapy to lead to change. Individuals need to
experience the emotional relevance of what they are
talking about in therapy for therapy to be successful.
When they do they and the therapist both gain access
to all the components more readily.
Emotional arousal
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One possible marker of emotional experience can be
inferred from emotional arousal. When emotion is
aroused to a significant degree the probability that it
will enter awareness increases.
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Research indicates that arousal of emotion in therapy
does relate to good outcome.
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1. In a recent study attempting to match treatment to patient variables in a combined sample of varying
treatments and problems, Beutler, Clarkin and Bongar (2000) found that session emotional intensity was
one of the strongest predictors of outcome.
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2. Jones and Pulos (1993) found that the strategies of, evocation of affect, and, the bringing of troublesome
feelings into awareness, were correlated positively with outcome in both dynamic and cognitive behavioural
therapies in the NIMH collaborative study of depression.
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3. Behavioral treatment of anxiety disorders has long demonstrated that clients who profited most from
systematic desensitization (Borkovec & Stiles, 1979; Lang, Melamed & Hart, 1970) and flooding (Watson
& Marks, 1971) exhibited higher levels of physiological arousal during exposure.
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4. More recently methods that increase arousal have also been found to be effective in treating panic
(Clarke, 1996; Mineka & Thomas, 1999). These and other findings suggest that the arousal of the fearactivated phobic memory structures is important for change.
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5.Mahrer and colleagues (Mahrer, Dessaulles, Nadler, Gervaize & Sterner, 1987) have also shown that
certain good moments in therapy are characterized by emotional arousal and expression and these are
associated with change in personality states in the session (Mahrer, Lawson, Stalikas & Schacter, 1990).
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6.Studies by Beutler and his group have shown significant effects for a treatment involving the arousal and
expression of anger in the treatment of depression and argued for the importance of anger expression in
therapy (Mohr, Shoham-Solomon, Engle & Beutler, 1991).
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7. Greenberg and colleagues also have shown that emotional arousal and expression is significantly related
to outcome in the resolution of unfinished business (Greenberg & Foerster, 1996; Greenberg & Malcolm, in
press; Paivio & Greenberg, 1995). Together these studies provide evidence for the value of emotion
awareness, arousal and expression in individual therapy.
Arousal or Catharsis Sometimes is not Enough
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Although research suggests that the expression and arousal of emotion can
contribute to change, this is true only for some people with some types of
concerns (Pierce, Nichols & DuBrin, 1983),
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This suggests that awareness, arousal and expression of emotion alone may
be inadequate in promoting change.
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Venting has not been found to be effective in reducing laboratory induced
distress (Bushman, Baumeister & Stack, 1999; Kennedy-Moore & Watson,
1999).
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This points to the importance of the further processing of aroused emotion
to make sense of it by symbolizing it in awareness, and by clarifying the
sources of its arousal. Making sense of emotion in new ways also helps to
break cycles of maladaptive automatic emotion processes.
Measuring emotional experience
Segments of psychotherapy are given ratings according to a 7-pt ordinal scale (Klein et al., 1969)
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Level 1: Client talks about external events in impersonal, detached or journalistic way.
Level 2: Client talks about external events with behavioural or intellectual selfdescription, self-as-object style, in an interested personal manner suggesting selfparticipation.
Level 3: Client now talks about personal reactions to external events, limited selfdescriptions, and some reports of feelings appear in reaction to events. Manner is
reactive and emotionally involved.
Level 4: The majority of communication is of feelings and personal experiences told
from the internal and personal perspective. Manner is self-descriptive and associative.
Level 5: Problems and propositions about the self and experiences are explored and
worked through, feelings elaborated and searched.
Level 6: Synthesis of readily accessible feeling and experiences occurs. Feelings vividly
expressed, experienced in an affirmative and conclusive manner.
Level 7: Full and easy presentation of experience, all elements confidently integrated.
Manner is expansive, illuminating, confident and buoyant.
Experiential therapy: Emotional processes
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Make sure the client can regulate and tolerate emotion.
Activate emotion schemes.
Notice which emotion type you are working with
Intervene in the appropriate fashion depending on the
emotion type.
Research on Emotional Experience
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Research on depth of experiencing has been shown consistently to relate to outcome across orientations
(Klein, Mathieu-Couglan & Kiesler, 1986; Orlinsky & Howard 1978).
Foa and Kozak (1986, behaviorists) have argued that the two conditions necessary for the reduction of
pathological fear are the activation of the fear structure, and the introduction of new information incompatible
with the phobic structure. Foa and Jaycox (1998) also have demonstrated that emotional processing of trauma
facilitates recovery. How people make sense of their emotional experience is proving to be important in
predicting both onset of and recovery from phobias and trauma (Ehlers & Clark, 2000).
In a recent review of twenty-seven studies, Hendriks (2001) reports that higher experiencing from averaged
early, middle, and late sessions have all been shown to relate to outcome within a number of different
therapeutic orientations and differing diagnostic categories (cf Greenberg, Korman & Pavio, 2001; and
Hendricks, 2001, for reviews).
Experiencing has been shown to be related to outcome in cognitive behavioural therapy (Castonguay,
Goldfried, & Hayes, 1996)
Reflecting on emotional experience has also been shown to relate to change in dynamic therapy
(Mergenthaler, 1996).
Pos (1999) demonstrated, using a hierarchical regression analysis that while early differences in emotional
experiencing did predict outcome, the level of experiencing reached at the end of therapy was the only
significant independent predictor of change in depression. This demonstrated that experiential therapy did
deepen the experiential process and that it was this increased deepening of emotional experiencing that
predicted change.
Pennebaker (1995) has explained that the disclosure process involved in writing is congruent with the
beneficial aspects of disclosure in psychotherapy. Emotional disclosure may provide structure for emotional
events by translating experience into words. "Through language, individuals are able organise, structure and
ultimately assimilate both their emotional experiences and the events that may have provoked the emotions"
Importance of emotion regulation
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While emotional experience can be a source of useful
information, intense arousal / physiological activation can also
interfere with one’s ability to function.
This often causes individuals to find emotional experiences
stressful in themselves.
Especially troublesome for individuals who are unable to use
emotional information, or for those in whom emotions trigger
dysregulation.
Therefore, before one can experience emotion in awareness (in a
productive manner) one has to be able to first regulate that
experience.
Experiencing may be difficult
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“ I’m afraid if I start
crying I’ll never stop.”
or………worse
Emotion regulation- the first task
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Before arousal and experience of emotion can be of
value an individual must be able to regulate emotion,
that is, have an emotional experience but then be able
to come back to baseline without being seriously
disorganized, shattered, deeply shamed, or negatively
affected by it.
1. Therapeutic alliance: Helps regulate emotion
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Unconditional positive regard, empathy, and
genuineness provide a safe interpersonal environment.
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Secure attachment appears to have an effect on the
ability to regulate / tolerate arousal and distress.
2. Symbolizing: Regulation through language
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Approaching emotion with attention and finding words for
feelings: ‘Containing’ them in language has a regulating effect.
Gottman, Katz, & Hooven, (1996) found that parents who acted
as emotion coaches with their children at age 5 (ability to
approach feelings with awareness and verbal labeling), had
children with better physiological regulation 3 years later.
This may include psychoeducation of the very basic sort, such as
getting to know the basic relationships between body-sensations,
situations and feelings that can help
Help individuals become aware of the meanings of emotion
words and when to apply them to their experience.
3. Creating self-soothing & tolerance skills
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Imagery: Safe place.
Mindfulness and radical acceptance.
Distraction.
Alternate sensation.
Grounding techniques.
Summary
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Not all emotion is problematic, or all good.
There are different types of emotion. Have to know what
you’re working with to know if it should be changed or used
to inform adaptive action.
Change in psychotherapy requires emotion to be activated or
aroused so that the emotion scheme is accessible and
available for editing.
Activation is often not enough. Information from emotion is
also available to be used in adaptive ways. Experience of
emotion, and processing it in awareness, brings the
information value forward, while at the same time allowing
for choices in action, delayed action, planning for action.