Dr Melissa Harte Counselling Psychologist

Dr Melissa Harte Counselling Psychologist
Emotion-Focused Therapy (EFT) and Trauma

Aims Brief introduction to EFT Importance of attunement
Highly Sensitive Person Phenomenon EFT and Trauma Model of Trauma processing Focusing for processing Traumatic and Painful Events

Emotion-Focused Therapy (EFT) (Elliott et al. , 2004; Greenberg et al
Developed by Greenberg, Rice and Elliott Research Task analysis of effective therapy Identified “Change Events” Problematic reaction points (Rice, 1974) Conflict splits (Greenberg, 1975) Marker driven and task/intervention orientated

Task Analysis (Greenberg, 1984, 2007)
It is a method developed to discover and validate client processes of change Evolved out of an event based approach to psychotherapy process research An event was defined as a clinically meaningful client–therapist interactional sequence that involved a beginning point, a working–through process, and an endpoint. The event began with the client statement of the problem (marker), followed by series of therapist responses and the ongoing client performance (task), which, if successful resulted in the client achieving an effective resolution or some therapeutic change.

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

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

EFT integrates Experiential Perspectives Cognitive Science
Eugene Gendlin – Focusing Fritz Perls – Gestalt therapy Cognitive Science Contemporary Emotion Theory Existential thought Attachment Theory

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

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 Person-centred approach client-therapist relationship is curative effective but not efficient PEEFT therapist facilitation is directive of process and in tune with client effective and efficient

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

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

Qualities of Therapist
Acceptance, prizing and trust Non-judgemental, unconditional – set aside own 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

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

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

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”

The Importance of Attunement
Blank face experiment And this is special too

Becoming Empathic Letting go Entering 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

Therapist-Client Connection
Proximal Zone - Provides safety Space of empathic attunement Provides safety Therapist Client Therapist boundaries intact Client boundaries porous

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

Proximal Zone Therapist Client Therapist boundaries intact Client boundaries become more intact and separate - Individuation process

Processing Experience
Change happens in the present EFT intervenes at the emotional level Cognitive processing of emotion helps Make meaning Aids regulation In therapy, facilitate emotional expression in conjunction with reflective processing Catharsis is not the aim – research shows

Levels of Processing Experience
1. Automatic Processing Activated by input Sensory and motor level 2. Affective Processing Emotional level  EFT 3. Executive Processing Conscious Plan of action Conscious choice 4. Conscious Effortful Processing 5. Conscious Performance Processing Final experience

Why focus on Emotion? Emotion influences
biological and neurochemical levels of system functioning the psychological, cognitive and behavioural levels Interface between body and mind

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 Physiological reactions Emotions = body feelings + thoughts Emotion has been clearly connected to the immune system and physiology (Pennebaker, 1995)

Emotions are adaptive Efficient automatic signalling system – necessary for survival Primary signally system Outside of awareness (e.g. snake) Has neurological primacy Prepare us for action Involve wishes/needs – lead to action

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 Is a process of meaning construction Integrate experience – give meaning, value and direction

Primary Emotion (Elliott et al., 2004; Greenberg et al., 1993)
Biologically adaptive response that reflect basic human needs and promote survival-oriented action tendencies Is an immediate and direct response to the environment that is not reducible to or mediated by other cognitive-affective components They are quick to arise and dissipate, with a natural rising and falling in intensity They feel right for the given situation and have adaptive qualities. A number of primary emotions may be experienced for any given experience.

Seven discrete primary emotions (Ekman, 1972).
happiness anger sadness fear disgust interest shame

Emotion Action Tendency
Positive tendency Anger at violation mobilises fight and defence of one’s boundaries empowerment and assertiveness Sadness at loss mobilises reparative grief by either seeking comfort or withdrawal in order to conserve one’s resources adaptive grieving Fear in response to danger mobilises flight, fight or possibly freezing adaptive escape Disgust organises one to evacuate or withdraw from some noxious experience – seen in childhood sexual abuse Shame organises one to hide or withdraw from the scrutiny of others antidoted by compassion for self Joy mobilises satisfaction, creativity and happiness feels good Surprise stimulates curiosity and engagement facilitates openness to further exploration

Emotion Regulation Dysfunction
Emotions become maladaptive because of: past traumas ignored or dismissed Resulting in a failure to self-regulate Over regulated - early abuse and neglect can become internalised as self-abuse or self-neglect Under regulated - a sensitive child who is easily upset may develop an anxious attachment and become emotionally over-aroused Depression, anxiety, substance abuse and anorexia are often attempts to regulate negative emotional states

Emotion Response Styles (Elliott et al., 2004; Greenberg et al., 1993)
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

Emotion Response Styles (Elliott et al., 2004; Greenberg et al., 1993)
Secondary reactive emotions Defensive responses Tends to be obscure real feeling Aspects of cognition Shame about being fearful, guilt about outbursts of anger Instrumental Strategically enacted in order to manipulate or control others Tears aimed to evoke sympathy of others, anger in order to intimidate

Maladaptive Emotions (Elliott et al., 2004; Greenberg et al., 1993)
In therapy primary emotions need to be accessed in awareness for their adaptive information and capacity to organise action. In contrast, maladaptive emotions need to be accessed in order to be transformed, in a process that exposes them to new experience and thereby creates new meaning. Secondary emotions need to be bypassed to get to more primary emotions

Secondary Distress Primary Maladaptive NEED Primary Adaptive
Basic Change Process Secondary Distress Primary Maladaptive NEED Primary Adaptive 34

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

Will to Meaning The search for meaning is a drive within all of us
We are born for meaning Searching for meaning is a form of happiness No lasting pleasure unless it is pleasure steeped in meaning

Highly Sensitive Person Phenomenon Elaine Aron

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.

Misunderstood. Not necessarily "shy" as shyness is learned. 30% of HSP are extraverts, although the trait is often mislabelled as introversion. Sensitivity not valued. Told "don't be so sensitive" so that they feel abnormal. Centre for Emotion Focused Practice

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. Centre for Emotion Focused Practice

Centre for Emotion Focused Practice
Arousal levels Enough but not too much Centre for Emotion Focused Practice

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

Assessment of client for EFT
Ability to form a good working alliance Fairly high functioning Moderate affective disorders Anxiety disorders – GAD, SA, Panic disorder, etc Moderate traumatic life events Interpersonal issues Identity or gender confusion Existential problems

Not suitable for EFT High suicidal risk
Current interpersonal dispute - DV Active or long term substance or alcohol abuse Impulse control disorder Three or more depressive episodes Psychotic Schizoid, schizotypal, antisocial Severe trauma Self not too fragile - borderline ?

Working External Internal Grounding

EFT Therapeutic Interventions
Markers and Tasks are organised around five organisational 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)

Trauma and Emotion Focused Therapy

EFT Theory and Trauma Attachment relationships are crucial to development Unconditional positive regard (Rogers, 1959) Importance of affective experiences in context of attachment relationships Healthy attachment = safety and security → self as worthwhile, competent, others are trustworthy and supportive and emotional regulation Through empathic responsiveness children learn to regulate emotions In absence of empathy children rely on avoidance to cope with maltreatment

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

Two Phase Trauma Model (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) video
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

Dual awareness Video http://www.youtube.com/watch?v=HlM8XV7vIFs
Interoceptor: Responds to stimuli arising within the body Body in space Kinetic sense Sense of balance, walk without looking, identify location Inner reality Internal sense, gives feedback on body, respiration, heart rate, muscle tension Exteroceptor: Reacts to stimuli in external environment Five senses External reality Connects to environment

Flashback protocol (Rothschild, 2000)
Say the following sentences filling in the blanks, following the instructions: Right now I am feeling ______ , (name the current emotion, usually fear) and I am sensing in my body ______ , (describe current bodily sensations in detail), because I am remembering ______ . (name the trauma by title, only — no details). And, at the same time , I am looking around where I am now in ______ (say the year), here ______ , (name the place where you are) and I can see ______ , (describe some of the things that you see right now , in this place), and so I know ______ , (name the trauma again) is not happening now/anymore.

Resilient Trauma Survivors
Secure attachment with a significant other Good affect modulation / positive emotions Ability to “see the bigger picture” of situations Ability to spring back – assertive, autonomous, hardy Lack of personalising bad events/experiences Continuity of identity Mature ego-defences – e.g. altruism Ability to cope with change Healthy self disclosure Sufficient childhood environments for general competence

Focusing Model for Processing Painful or Traumatic Experiences

Emotional Injury (Timulak, 2015).
Occurs when biologically adaptive response of a primary emotion is inhibited or restricted and when this occurs, the fulfilment of basic human needs to be loved, validated and safe are prevented or violated. An injury of this kind has an enduring quality experienced as emotional pain that burdens a person long after the event as though an injury has not healed. Takes various forms as they are events that symbolise the presence of the lack of fulfilment of core human needs e.g. trauma

Emotional Pain (Timulak, 2015).
Emotional pain is the unpleasant, overwhelming, upsetting internal experience or response to an injury that prevents or violates the fulfilment of the basic human needs of being loved, safe and acknowledged

Resolution of Emotional Injury
Some traumatic experiences are encoded primarily in right-brain experiential (non verbal) memory, in the form of emotions, images and bodily sensations and are not processed on the symbolic or verbal level thereby leaving the experiences unintegrated. The SNS can activate the flight-fight response thus making the integration of painful/traumatic experiences less likely. Activation of the ANS can lead to freeze or dissociation at the time of the traumatic event (Polyvagal theory) interfering with making sense of or resolving the experience. Thus painful or traumatic experiences might be recalled only as undifferentiated emotions and body sensations.

Focusing and Felt Sense (Gendlin 1962, 1981, 1996)
Eugene Gendlin’s style of psychotherapy involved directing clients’ attention to their present experience and this then influenced their physiological responses and meaning creation. Gendlin proclaimed that the body holds a particular kind of knowledge that could be accessed by paying attention to bodily felt sensations. He described this special kind of internal sensation that was a vague, hard-to-describe body awareness as felt-sense

Felt Shift / “Aha” moment (Gendlin 1962, 1981, 1996)
The skilful facilitation of process encourages exploration of the edge of the client’s awareness of their experience. Deepening of that experience as it occurs in the present moment can potentially lead to new understanding and change A full resolution manifesting as a result of a felt-shift leads to new thoughts, awareness and feelings Quite possibly a mechanism of change

The Body Remembers (Rothschild, 2000, 2004)
Babette Rothschild asserts that the body has a memory and that trauma memories are stored in the body, which provides an important addition to the model. Other leading trauma therapists agree that body-orientated psychotherapy, or somatic psychotherapy, is effective for dealing with unintegrated trauma experiences

Episodic Memories (Hupbach, Gomez, Hardt, & Nadel, 2007; Hupbach, Hardt, Gomez, & Nadel, 2008; Lane, Ryan, Nadal, & Greenberg, 2015) There is now strong evidence that reactivation of a long-term memory returns the memory to a fragile and labile state, initiating a restabilisation process termed reconsolidation, which allows for updating of the memory Reconsolidation has been suggested as an important mechanism for understanding plasticity, potentially explaining how organisms build on prior experience while incorporating new information Reactivating a previously stored memory can lead to the creation of a new version of that memory

Altering Episodic Memory (Hupbach, Gomez, Hardt, & Nadel, 2007; Hupbach, Hardt, Gomez, & Nadel, 2008; Lane, Ryan, Nadal, & Greenberg, 2015) Change occurs by activating old memories and their associated emotions, and introducing new emotional experiences in therapy that may enable new emotional elements to be incorporated into that memory trace via reconsolidation. This according to Greenberg (2011) suggests that emotion schematic memory can be changed by new emotional experience

Unmet Needs (Elliott et al. , 2004; Greenberg et al
Unmet Needs (Elliott et al., 2004; Greenberg et al., 1993, Timulak, 2015). Accessing an unmet need associated with maladaptive emotions, and providing a sense of rightfully deserving to have the unmet childhood need met, creates a sense of agency Unmet needs embedded in shame-based emotions include needs to be accepted, seen and validated. Fear-related emotions include the need for protection and safety Needs to be loved, connected with and cared for are needs embedded in sadness–related emotions

Neural Clusters or Loops (Rossouw, 2013)
Clusters are formed when neurons fire in a specific sequence which in turn leads to a stronger neural connection and an upregulation of neural activity – “fire together, wire together” New, effective neural pathways can be established using talking therapy of different modalities. When the new patterns are established and regularly activated, the old firing patterns not only will become less preferred patterns but will slowly start to deconstruct thus resulting in less risk of relapse into the default patterns – “fire apart, wire apart” Reprocessing painful/traumatic memories has the potential to untangle these neural clusters which will assist in reducing symptoms.

Emotional Arousal (see Ryan, Nadal, & Greenberg, 2015 and others)
If too intense, the mentalising function mediated by a neural network including the medial prefrontal cortex goes off line, limiting the capacity of reflection and integration therapeutic interventions are unlikely to be effective and integration of emerging understanding won’t occur if arousal levels become too high because the flight-fight or polyvagal systems have become activated Put on the breaks If arousal is too low then cognitive processing of emotions is not likely to occur. Low arousal needs to be increased to achieve sufficient emotion activation and high arousal needs to be decreased

Arousal levels in Reprocessing
Enough but not too much Centre for Emotion Focused Practice

Imagery (Arntz, 2012, 2015) The use of imagery has become incredibly useful in the treatment of anxiety and PTSD Not only as a anxiety reduction process But also for dealing with painful or traumatic events by repossessing the event or events More than a sensitisation process Actually a restructuring process Useful for phobias, OCD, neglect and PTSD symptoms

Imagery and Re-scripting (Arntz, 2012, 2015)
Imagery has been used in psychotherapy for decades. The basic idea of imagery re-scripting is to activate the trauma memory and imagine a different ending that better matches the needs of the client. The therapeutic effects are not based on a simple replacement of the original memory by new memory because the facts of the original trauma memory are not forgotten or overridden by the rescripting. One form of rescripting is asking the client to step into the image as themselves as an adult if there has been childhood abuse as a way of protecting the child.

Things to consider Good working alliance
Client ready, willing and able Client grounded in their bodies and not exhibiting dissociative symptoms Flow of emotion, arousal, memories and body sensations can be contained at will and that they had the ability to move in and out of distressing states Creation of a safe place

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

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 them to really experience this fully and vividly Highly traumatised clients may not have a safe place and therefore not get past this stage. Build up slowly with grounding

Anxiety / Stress Reduction
Gauge level of anxiety/stress on a scale of 1 to 10 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 Typically - unclear felt sense Expanded with the aim to reprocess painful or traumatic events

More Things to Consider
Can’t move into processing until Stage 1 successfully completed The primary emotion emerged first that uncovered the unmet need for that specific event, that in turn led to an action tendency to have that unmet need met. Accessing of the unmet need has its own clear and distinctive role as a transformational element in the task Some clients felt undeserving If the client or the therapist tried to meet the unmet need by going to the action tendency too soon before the primary emotion was fully experienced, the client often could not say what they needed or the process did not deepen sufficiently to activate the core emotional pain

Conclusions The imagery together with activation of the primary emotion, the accessing of the unmet need and the action tendency of that primary emotion created a resolution. The episodic memory was no longer a symbol of that unmet need and the client could leave it, or let it go, as the primary emotion had been discharged and no emotional intensity was reported to remain. The resolution was signified by a felt shift in the felt sense or in some cases a reported “aha” moment. The Felt Shift is quite possibility a mechanism of change

Conclusions The concept of staying with the experience is really relevant when discussing the elements of successful processing. Adaptive primary emotions by the very nature tend to arise and dissipate quickly. Clients need to be able to move through the discomfort and distress of their maladaptive secondary and primary emotions to uncover the primary emotion that is connected with their unmet need. They need to be able to move to an adaptive action tendency necessary for successful processing of their painful/traumatic events.

Conclusions Staying with the experience is the constant.
Emotional pain is an experience. The strength of this model is that it tracks experience and not just emotion. Whilst Gendlin’s Focusing task encouraged people to stay with and talk from their current experience, Greenberg asked clients to talk from their presently felt emotion This Trauma Processing task asks the client to speak intentionally from their emotional and experiential child-self, encouraging them to express their unmet need/s, thus capturing both the processing of their experience and their emotion simultaneously.

Unsuccessful Cases Low levels of experiencing, low level of arousal and low levels of emotional productivity. Episodic memories not fully emerging out of the felt sense Only a partial re-entry into the memory Difficulty connecting with child-self or advocating for child-self Emerging emotion was not differentiated sufficiently or was suppressed and thereby not fully experienced Dissociation and unregulated when touching emotion Talking about feeling rather than feeling it A moving felt sense Difficulty in staying present in experience, or interrupted it with internal avoidance strategies. Inability to develop depth processing.

Thank you and Questions
Centre for Emotion Focused Practice

Dr Melissa Harte Counselling Psychologist

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