Dr Melissa Harte Counselling Psychologist Developing an attuned - - PowerPoint PPT Presentation

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Dr Melissa Harte Counselling Psychologist

Developing an attuned therapeutic relationship to enhance healing and transformation for those with complex trauma from an Emotion- Focused Therapy (EFT) perspective

Aims

• Brief introduction to EFT
• Therapist Factors
• Importance of Attunement
• Felt Sense and Felt Shift
• Highly Sensitive Person Phenomenon
• Grounding and Safe Place
• Focusing for processing Traumatic and Painful Events

– case study

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Emotion-Focused Therapy (EFT)

• Developed by Greenberg, Rice and Elliott in 1980’s
• Research

– Task analyses of effective therapy

• Identified “Change Events”

– Problematic reaction points (Rice, 1974) – Conflict splits (Greenberg, 1975)

• Is a marker driven and task/intervention orientated

psychotherapy

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EFT

• Evidenced-based, integrative, manualised and

emotion-focused psychotherapy

• Transforming and restructuring therapy
• Person-centred framework of Rogers
• Empathy, Congruence and Respect
• Self-determination (Self-actualisation)
• Humanistic assumptions and values underpinnings

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Humanistic Assumptions and Values

• Presence / Authenticity. People function best and are best

helped through authentic, person-to-person relationships.

• Experiencing. Immediate experiencing is the basis of human

thought, feeling and action.

• Agency / Self-determination. Human beings are

fundamentally free to choose what to do and how to construct their worlds.

• Holism. People are greater than the sum of their parts, and

cannot be understood by focusing on single aspects.

• Pluralism / Equality. At the same time, differences within

and between people should be recognized, tolerated and even prized.

• Growth. People have a natural tendency toward

psychological growth and development that continues throughout the life

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EFT integrates

• Experiential Perspectives

– Eugene Gendlin – Focusing – Fritz Perls – Gestalt therapy

• Cognitive Science
• Contemporary Emotion Theory
• Existential thought
• Attachment Theory

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EFT

• Develops emotional intelligence
• By systematically and flexibly helping clients

become aware of and make productive use of their emotions

• Facilitating clients to experience and clarify their

emotions

• Make meaning of their emotions
• Strengthen expression of healthy emotions

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Working Alliance (WA)

• Positive WA = best predicator of outcome

– Experiencing the therapist as empathetic and genuinely respectful is viewed as helping clients to free themselves from their constraining internal conditions of worth - Rogers

• Person-centred approach client-therapist

relationship is curative – effective but not efficient

• EFT therapist facilitation is directive of process and

in tune with client – effective and efficient

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Therapist Factors

• Previously overlooked
• According to Hubble, Duncan, Miller and Wampold

(2010) most robust predictor of outcome

• Some therapists are more effective than others

– Better therapist form better alliances

• Assisting therapists to form better alliances has a

direct impact on outcome

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Qualities of Therapist

• Presence

–Fully aware of the moment –Directly encountering the client's experience

• Physically, emotionally, mentally and viscerally

–Being ‘with’ and ‘for’ the other –Intimately engaged whilst maintaining a sense of

centre and grounding within self in that shared space

• Genuineness

–Have integrity, wholeness and congruence –Authentic, self-disclosing, up-front, real,

unpretentious

–Open and transparent

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• Acceptance, prizing and trust

–Non-judgemental, unconditional – set aside

• wn values, expectations

–Value, affirm and honour client as a fellow

human being

–Unconditional confidence in client’s resources

• Collaborative

–Tasks negotiated with client

• Create safety

Qualities of Therapist

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Empathetic Attunement from Therapist – felt-sense

• Tuning into

– Enter the client's internal frame of reference – Client feels therapist is “empathically present” to them whilst they process their pain and/or trauma

• Resonating

– Conveys to client a sense of being really “heard” and being non-judgmentally valued

• Tracking

– Complex internal process – Enables therapist to more accurately determine the intervention required

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The Importance of Attunement

• Blank face experiment

http://www.youtube.com/watch?v=apzXGEbZht0

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Being Attuned and Empathic

• Letting go

– Tolerating ambiguity – Open to experience of the other – Suspend judgement – Flexible – Curious

• Entering

– Enter client’s inner world naturally and easily – Tracking – Understanding cognitively and emotionally

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Therapist-Client Connection

Therapist Client Space of empathic attunement Provides safety Proximal Zone

• Provides safety

Client boundaries porous Therapist boundaries intact

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Therapist-Client Connection

Therapist Client Space of empathic attunement Proximal Zone Advanced empathy and attunement in session

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Therapist-Client Connection

Therapist Client Proximal Zone Client boundaries become more intact and separate

• Individuation process

Therapist boundaries intact

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Felt-sense (Eugene Gendlin, 1978)

• An internal bodily sensed feeling
• Pre-verbal, complex, holistic
• Experienced but often unable to capture into

words

• Symbolic expression of internal world
• An implicit higher-level meaning via symbolic

expression

• Includes thoughts, feelings, perceptions, internal

actions and context

• Accessed by internal attending and experiential

processing

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Attunement through felt-sense

• A skill that can be learnt
• A process of self- and other-awareness
• A kind of “inner listening”

For the client

• Creating an energetic space of “holding”
• To feel “truly known” and “heard”
• Allows opportunity to get to their “inner truth”

Felt Shift

• Useful indicator that a full resolution had been

achieved

• This may take the form of a bodily felt shift or Ah-Ha

experience, or a change in the symbolic representation.

• Such shifts not only indicate that a shift in awareness

has occurred but are quite possibly mechanisms for change.

Felt Shift

• A peak moment when change and growth were

possible.

• The client often seemed to get a direct sense of

authenticity, autonomy, or rightness that could be used to validate choice and responsibility.

• If achieved in the majority of sessions help

strengthen the clients’ sense of self and contribute to a feeling of wellbeing and an unfolding self understanding and meaning.

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Processing Experience

• Change happens in the present
• Cognitive processing of emotion helps

– Make meaning – Aids regulation

• In therapy, facilitate emotional expression in

conjunction with reflective processing

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Why focus on Emotion?

• Emotion influences

–biological and neurochemical levels of system

functioning

–the psychological, cognitive and behavioural

levels

• Interface between body and mind

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Link Between Emotion and Body

• Limbic system is responsible for basic emotional

processes – e.g. fear

• Two paths for producing emotion

– Fast “low” road - amygdala senses danger – survival – Slower “high” road – information carried through the thalamus to neocortex

• Emotions create physiological reactions that can

be interpreted

• Emotion has been clearly identified as being

connected to the immune system and physiology (Pennebaker, 1995)

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Emotions are adaptive

• Efficient automatic signalling system necessary for

survival

• Have neurological primacy
• Are outside of awareness (e.g. snake)
• Prepare us for action
• Involve wishes/needs that lead to action

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Emotion

• Precedes language-based knowing
• With development is fused with cognition
• Has a relational action tendency

– Tell us what is important and whether things are going our way

• An important part of meaning construction

– Integrate experience by giving meaning, value and direction

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Seven discrete primary emotions

• happiness
• anger
• sadness
• fear
• disgust
• interest
• shame

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Action tendency

• Anger
• puff up and thrust forward

+ empowerment and assertiveness

• Sadness
• cry out for lost other - withdrawal

+ adaptive grieving

• Fear
• reaction to danger - withdraw, freeze, vigilance
• Shame
• hide and shrink, deferring to others

+ compassion for self

• Disgust – expulsion of something repulsive
• Happiness – feels good
• Surprise – interest and engagement

Emotional Regulation Difficulties

• Under-regulation

– Overwhelming emotions have a disorganising effect on thought and behaviour and interfere with learning, performance and social relations

• Over-regulation

– Refuse to think about it – suppression, chronic inhibition – Distraction, dissociation, disavowal – Maladaptive anxiety or rage – Fear of emerging emotional experience – Suppression leads to immune system breakdown and negative health outcomes (Pennebaker & Campbell, 2000) – somatic complaints

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Emotion Response Styles

• Adaptive primary emotions

– Immediate feeling – Rapid automatic response to a potentially dangerous

situation

– Resolve quickly – Fear at threat, sadness at loss, anger at violation

• Maladaptive primary emotions

– Arise when emotional system is malfunctioning – Over-learned responses, based on previous, possibly

traumatic experiences

– Debilitating fear, anxiety, shame, humiliation, rage,

unresolved grief

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Emotion Response Styles

• Secondary reactive emotions

–Defensive responses –Tends to be obscure real feeling –Aspects of cognition –Shame about being fearful, guilt about outbursts

• f anger
• Instrumental

–Strategically enacted in order to manipulate or

control others

–Tears aimed to evoke sympathy of others, anger in

• rder to intimidate

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Process

• The unfolding moment-to-moment of client’s inner

experience

• Guide the process, not the content
• Empathic exploration guides the process more

indirectly

• The interaction between client and therapist
• An ongoing organising of experience to create

meaning

– Through the process of reflection on aroused emotions and

bodily felt experience

– Resulting in the person's conscious experience of being-in-the-

world

Dr Melissa Harte Counselling Psychologist

Highly Sensitive Person Phenomenon

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Highly Sensitive Person

• Innate.

– A survival strategy - observing before acting.

• Aware of subtleties.

– Brain processes information and reflects on it more deeply.

• Easily overwhelmed.

– If you notice everything, you are naturally going to be overstimulated when things are too intense, complex, chaotic, or novel for a long time.

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Highly Sensitive Person

• Misunderstood.

– Not necessarily "shy" as shyness is learned. – 30% of HSP are extraverts, although the trait is

• ften mislabelled as introversion.
• Sensitivity not valued.

– Told "don't be so sensitive" so that they feel abnormal.

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Highly Sensitive Person

• Normal.

– 15% to 20% of the population – Too many to be a disorder, but not enough to be well understood by the majority of those around you.

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Arousal levels

• Enough but not too much

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EFT Therapeutic Interventions

Markers and Tasks are organised around five

• rganisational elements:
• Empathy-based tasks

(Exploring the problem, dealing with vulnerability)

• Relational tasks

(Alliance formation and rupture)

• Experiencing tasks

(Gendlin’s focusing task)

• Reprocessing tasks

(Trauma retelling, meaning work, systematic evocative unfolding)

• Enactment tasks

(Empty and two-chair work)

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Goals of EFT

• Restore healthy functioning and functional

affective regulation

• Change clients processing of experiential

information

• Enhance symbolisation of internal experience
• Access dysfunctional emotion schemes
• Promote integration of disavowed and

disassociated parts of self

Babette Rothschild (2004)

• Primary aim: Improve quality of life

–Not always about trauma repossessing especially if client doesn't want to

• Phase I: Stabilisation and safety

–Don’t move to Phase II before Phase I is achieved

• Phase II: Processing Trauma memories

Foundations for Safe Trauma Processing (1)

• Establish safety
• Good contact / WA – may take months or years
• Applying the brakes before the accelerator
• Regard defenses as resources

– Never get rid of strategies/defenses – create more choices

• Always work to reduce the pressure not

increase it

Foundations for Safe Trauma Processing (2)

• Adapt the therapy to the client, rather than client

adapt to the therapy

• Broad knowledge of trauma theory – both

psychological and physiological symptoms

• Regard the client as having individual differences –

don’t judge for non-compliance or failure of an intervention – one shoe doesn’t fit all

• Be prepared to lay aside any of all interventions and

just talk to the client

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Working External Internal Grounding

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Grounding

Check client is grounded in their body often throughout the session Particularly important if client is highly aroused or dissociative – highly traumatised clients may find this very difficult

Invite client to close eyes (optional) and to become comfortable in their chair Relax by taking a few deep breathes – notice the in breath and the out breath Notice back against chair, legs on seat of chair and feet on floor, hands in lap etc

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Safe Place

Encourage client to create an imagined or remember a real place where they felt safe, truly relaxed, no one wanted anything from them Allow then to really experience this fully Highly traumatised clients may not have a safe place and therefore not get past this stage. Build up slowly with grounding Can be used for anxiety/stress reduction Gauge level of anxiety/stress on a scale of 1 to 10 with 10 being very high and 2-3 being within normal levels. Ground the client into their body sitting in the chair Ask them to go to safe place. With each breath slowly reduce the anxiety/stress until within normal ranges Practice regularly and when anxiety or stress increases

Focusing expanded (Harte, 2012)

• Marker

– Unclear felt sense – With the aim to reprocess painful or traumatic events

• Change happens in the present
• Episodic memory can be reprocessed/changed

– Strong evidence from recent neuroscience - reactivation

• f a long-term memory returns it to a labile state,

initiating a restabilisation process termed reconsolidation, allows for updating of the memory

• The body remembers (Rothschild, 2000, 2004)

Episodic Memories

• Memories are malleable and constantly undergoing

revision because of the process of retrieval or recollection.

• Reactivating a previously “stored” memory can lead

to the creation of a new version of that memory

• It is not just laying down a new memory but actually

changing in fundamental ways the original memory

Problems with this….

• Yes of course
• Repressed memory controversy
• Persuasion though Hypnotism or NLP
• Why would you want to change the memories?

Altering Episodic Memory

• Dysfunctional emotional processes arising from

traumatic childhood experiences can be altered by activating the problematic memories, generating new adaptive emotional responses, and then storing the changed memories in stable fashion.

• This according to Greenberg (2011) suggests that

emotion schematic memory can be changed by new emotional experience

• Thus alleviating symptoms and achieving a

greater sense of wellbeing

David

• David is the second child of his mother. David's parents separated when he

was still quite young. His mother had a chronic health condition that would see her often bedbound. He looked after her. The family lived in a country town and David attended an all-boys catholic school. He was choirboy and helped out in the church. On many occasions he was sexually abused by the brothers. He told no one. When he was about 10 his mother remarried but he did not get along with his stepfather. His stepfather was physically abusive towards his mother and the pair argued a great deal.

• David 44, presented with depression which he has suffered with since the

stock market crash in 2010.

• He uses alcohol as a coping mechanism and had anger management

issues.

• He attended counselling regularly.

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Harte, 2012

Thank you Questions

The Emotion Focused Training Centre Level 1, 16a Toorak Rd South Yarra, 3141 mobile: 0407427172 email: melissa@hartefeltcentre.com www.hartefeltcentre.com

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References

Elliott, R. K., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused therapy: The process-experiential approach to change. Washington, DC: American Psychological Association. Gendlin, E. T. (1981). Focusing (2nd ed.). Toronto: Bantum Books. Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings. Washington, DC: American Psychological Association. Greenberg, L. S., Rice, L. N., & Elliott, R. K. (1993). Facilitating emotional change: The moment-by-moment process. New York: Guilford Press.

Pascual-Leone, A., & Greenberg, L.S. (2007). Emotional processing in experiential therapy: Why “the only way out is through.” Journal of Consulting and Clinical Psychology, 75, 875-887. Weiser Cornell, A. (1996). The power of focusing: A practical guide to emotional self-healing. Oakland, Ca: New Harbinger Publications.