2. Overview Current views of Emotion Emotion -focused Therapy (EFT) Research on EFT Future of Psychotherapy

3. Shift in View of Emotion Views of emotion have varied greatly over the history of emotion in psychology & particularly in psychotherapy theory. Emotions initially were seen as discharge products of drives (Freud), as epiphenomena (Skinner), and then during the recent cognitive revolution as post-cognitive phenomena (Beck) There however has been a marked shift in the last decades from a cognitive to an adaptive view of emotional functioning. Due in large part to compelling findings in the affective and cognitive neurosciences in the past two decades (Damasio, 1994, 2003; LeDoux, 1996, 2002) emotions have clearly been shown to be an independent and an adaptive component of human functioning and not simply secondary to cognition.

4. Evolutionary Function As many emotion researchers have pointed out primary emotional responses have been evolutionarily preserved because they serve an adaptive function (Lane 2008, Panksepp 2008, Frijda 1988). Emotions provide an assessment of the degree to which goals or needs have been met in interaction with the environment. They also reset the organism physiologically, behaviourally and cognitively to adjust to changing circumstances. From birth on, emotion also is a primary signalling system that communicates intentions and regulates interaction

5. Rapid and Automatic Response Emotional processing of simple sensory features occurs extremely early in the processing sequence (Whalen et al 2001) This initial "pre-cognitive", perceptual, emotional processing of the “low” road, fundamentally, is highly adaptive because it allows people to respond quickly to important events before complex and time-consuming processing has taken place by the prefrontal cortex “high” road to emotion (LeDoux 1996) Because the shorter amygdala pathway transmits signals more than twice as fast as the neocortex route, the thinking brain often can’t intervene in time to stop emotional responses. Automatic emotional responses occur, before one can stop them, be it jumping back from a snake, snapping at a spouse, crying at a sad ending or feeling joy at a baby’s smile.

6. Emotion Cognition Interaction Neuro and psychological research on emotion thus shows that emotion is pre-cognitive but it also shows that emotion interacts with cognition to form complex affective cognitive structures termed emotion schemes (Oatley 1992,Greenberg 2002) These are a primary meaning system in that they automatically evaluate what is significant for our well being and are carriers of personal meanings for the self. Emotions also include automatic attentional and evaluative processes, and are themselves cognitive in the broad sense of cognition but are more than computational or propositional forms of knowledge. Emotion and conscious thought interact in language to create meaning

7. New Agenda This ‘ new look ’ in emotion research has begun to set a new agenda for psychological research – to determine under what conditions emotions play a determining role in human experience and how this occurs. The question does emotion precede cognition or vice versa has been superseded by one asking “under which conditions do emotions influence thought or vice versa?”. The questions especially relevant to psychotherapy are how can we best facilitate a) emotion awareness b) overcoming the avoidance of emotion to promote access to its adaptive benefits. c) emotion transformation.

8. Four Key Research Findings Awareness and symbolization of bodily felt emotional experience down regulates emotional (Lieberman, Eisenberger, Crockett, et al 2004, Pennebaker,1995) Emotion influences memory, thought, decisions and narrative construction (Bower,1981, Damasio 1999, Forgas, (2000) Emotion changes emotion (Davidson 2000, Fredrickson, Mancuso, Branigan, & Tugade, 2000) Emotion changes memory during its reconsolidation period. (Nadel, & Moscovitch, 1997, Nader, Schafe& Le Doux, J. E. 2000;Schiller D Monfils, Raio, Johnson, LeDoux & Phelps 2010)

9. Emotion Awareness Research has shown that emotions rather than sitting fully formed in the unconscious exist in an undifferentiated form consisting of sensori - motor schemes that are pre-ideational and pre-verbal (Lane 2008). Implicit emotion, or bodily felt sensations, can be turned into conscious experiences of specific emotions by putting the felt sensations into words (Lane 2008; Barrett et al. 2007). Through this process an individual can feel specific emotions and “ know ” what it is that they are feeling. This suggests a dialectically constructivist view of emotion in which we construct what we feel by attending to a bodily felt sense and symbolising it in awareness.

10. Clinical Implications Because much emotional processing occurs independently of and prior to conscious, deliberate cognitive operations, therapeutic work on a purely cognitive level of processing is unlikely to produce enduring emotional change in “low” road emotion. Emotion needs to be activated if we want to change emotion. Low road emotions can be changed by opposing emotions Emotion memories need to be activated to add new experience for reconsolidation. Bodily felt experience needs to be symbolized in awareness to create new thoughts, meanings and narratives

11. The Duality of Emotion An important duality however occurs in working with emotion We need to activate it to make sense of it but we also need to protect ourselves from it and regulate it Emotions serve a unique combination of epistemological and hedonic functions - as both carriers of knowledge and givers of pleasure-pain. Feelings provide us with immediate, intimate, personally meaningful knowledge about ourselves and others Feelings also are carriers of suffering and pain at intensities that cannot be tolerated (or of pleasure) and can become a source of threat and a danger to psychological existence.

12. Working With the Duality of Emotion Feelings thus inform us about ourselves, and our surrounding in an unmediated and personally specific manner. These feelings need articulation and this sharpens and clarifies what is felt and promotes But there comes a point when feelings change their function. Given their powerful dimension as pain/pleasure feelings can loose their meaning giving function and become overwhelming or destructive. In this instance they need regulation to preserve a sense of self-coherence

13. Emotional problems from the “low” road need to be dealt with in a different manner than “high” road emotions Low road processing as we have seen is rapid, automatic and wholistic and is a source of adaptive information that needs to be in awareness to orient to the environment. When dysfunctional and under-regulated, however it is a source of distress and needs to be regulated and transformed using emotion change principles. High road processing is cognitively derived and culturally influenced by higher level goals/plans. Reason is involved in its generation, dysfunction is based on cognitive error, and change involves cognitive change principles. The Second Duality

14. Overview of EFT EFT views emotions as centrally important in both adaptive and maladaptive functioning, and in therapeutic change. EFT takes emotion as the fundamental datum of human experience while recognizing the importance of meaning making, and views emotion and cognition as inextricably intertwined. EFT offers a dialectical constructivist model of functioning in which optimal adaptation is seen as involving an integration of reason and emotion by symbolizing bodily felt experience to make sense of it.

15. In EFT therapists are empathically attuned to emotion and work to enhance clients’ emotion-focused coping by helping them arrive at their core emotional experience by 1.approaching and becoming aware of it 2.regulating, tolerating and accepting it and, having experienced it, help them to leave it by 3.transforming that which is maladaptive by generating alternate adaptive emotional responses 4.and by constructing new narratives

16. Characteristics of the Therapeutic Relationship Therapeutic Presence (Geller & Greenberg, 2011). 1.Being completely in the moment 2.Bringing one’s whole self into the encounter with the client, physically, emotionally, cognitively, and spiritually 3.Being grounded in one’s own body 4.Receptively taking in the verbal and bodily expression of the client’s moment by moment emotional experience 5.Extending to meet the other in an empathic and congruent manner

17. Assessment 1. Primary 2. Secondary 3. Instrumental Biologically adaptive Maladaptive

18. Principles of Emotional Change Based on six empirically supported principles of change that guide differential intervention; Emotion Awareness, Expression, Regulation, Reflection Transformation Corrective Experience A major premise guiding intervention is that one cannot leave a place until one has arrived at it.

19. Experiencing Tasks Task Marker Intervention Process End State

20. Enactment tasks Task Marker Intervention Process End State

21. Model of Resolution of Self Criticism Role Play Critic Harsh criticism Specific criticisms Values standards Softening Role play Experiencer Affective reaction Differentiated feelings Emerging experiences Wants and needs Negotiation Integration SecondaryMaladaptive Adaptive Self Critical Marker

22. Research Evidence of Effectiveness of Emotion-focused Treatments Evidence Based Treatment of Depression  Goldman,Greenberg, Angus,(2006).PsychotherapyResearch,16,536-546.  Watson, Gordon, Stermac, Kalogerakos, & Steckley(2003). Journal of Consulting and Clinical Psychology, 71, 773-781).  Greenberg, & Watson, (2006). Emotion-focused therapy for depression. Washington D.C.: American Psychological Association  Ellison,J., Greenberg, L., Goldman, R.N., & Angus, L. (2009). Maintenance of gains in Experiential therapy of depression. Journal of Consulting and Clinical Psychology, 77, 103-112. Trauma Paivio & Nieuwenhuis (2001).Journal of Traumatic Stress,14, 115-133. Pavio & Pascual-Leone(2010) Emotion-focused Therapy for Complex Trauma. Washington D.C.: American Psychological Association Greenberg, Warwar, & Malcolm, (2008). Differential Effects of Emotion -focused therapy and psycho-education in facilitating forgiveness. Journal of Counseling Psychology,55, 456-464

23. To become a true applied science psychotherapy research needs not only to provide evidence of effectiveness but also to specify the processes of change that lead to the effects Change Process Research

24. Relating Process to Outcome

25. Correlation between the working alliance and outcome in York 1

26. Relationship Conditions, Working Alliance in OISE Study Watson Geller 2005 JCCP Relationship conditions( E, P.R & C) predicted outcome in both treatments This relationship was mediated by alliance

27. Depth of Experience Does Depth of Experience(EXP) predict outcome Does increase in EXP over treatment predict outcome

28. T P O TherapistPatient Outcome T.EXP EXP Symptom Reduction Relating Process to Outcome

29. Experiencing Scale 1. Objective and intellectual, giving no evidence of the personal significance of events they describe. 2. Personal but detached; no explicit reference to feelings, reactions, or internal states. 3. Reactions to external events begin to appear. 4. Marked shift inward with a focus on exploration of feelings and internal experiences. Clients are in direct contact with their fluid experience and speak 'from' it as opposed to 'about' it.

30. 5. Questions about experience and the self are raised and explored from an internal perspective. 6. Newly realized feelings and experiences are integrated and explored to produce personally meaningful constructions and resolve issues. 7. Shifts and new understandings in one particular area of experience are broadened to a wider range of experiences giving clarity and meaning.

31. Experiencing and increase in EXP on Core Themes predicted reduction in depression in Experiential Therapy over and above WAI (Goldman & Greenberg &Pos, 2005) Experiencing and increase in EXP on Emotion Episodes predicted reduction in depression in Experiential Therapy over and above WAI (Pos, Greenberg &Warwar 2003) Experiencing has also predicted reduction of depression in CBT (Castonguay, Goldfried, & Hayes, 1996). Experiencing in Therapy of Depression

32. Depth of Experiential focus of therapist predicts improvement in BDI, RSE ( T O 1, O 2 ) Therapist’s Depth of Experiential Focus Depth of Experiential Focus of therapist responses relates to moment-by-moment level of patient experiencing and increases the probability that the client will focus inward, by a factor of eight (T P)

33. EXP in EFT(YORK) & CBT (NIMH) Signif. interaction between therapy type and session p<.01 (ES=.17) Signif. increase in depth of EXP over time in EFT, p<.01

34. Hierarchical Regression: Peak Emotional Experiencing on Outcome Therapy Predictor Total R square F df Beta Type Variable R square change change EFTPeak EXP BDI Early.16.16 4.24* 1,23 -.40* Working.31.15 4.83* 1,22 -.51* Peak EXP SCL Early.20.20 5.59* 1,23 -.44* Working.42.22 8.46** 1,22 -.62** CBTPeak EXP BDI Early.15.15 4.29* 1,24 -.39* Working.32.16 5.47* 1,23 -.47* p <.05, ** p <.01; N = 25 in all cells; EXP = Experiencing; BDI = Beck Depression Inventory; SCL-90R = Symptom Checklist R. * Note: There was a unique significant contribution of peak EXP in the working-phase on the BDI and SCL-90R measures for EFT; and significant only on the BDI for CBT.

35. EXP in EFT & CBT(OISE) (Watson & Bedard, 2006) Mean modal EXP significantly higher in the good outcome group regardless of treatment Mean modal EXP ratings increased from early to mid therapy EFT significantly higher mean modal EXP than CBT

36. Deepening experiencing may be a core ingredients of change for many therapy approaches BUT Does emotional arousal predict outcome?. Relating Emotional Arousal to Outcome

37. Client Emotional Arousal Scale-III 1.Person does not express emotions. Voice or gestures do not disclose any emotional arousal 2. Acknowledgement but very little arousal in voice or body. Almost completely restricted 3. Person acknowledges emotions. Arousal is mild in voice and body 4. Arousal is moderate in voice and body Emotional voice is present, arousal still somewhat restricted 5. Arousal is fairly intense in voice and body Speech patterns deviate markedly from the client’s baseline 6. Arousal is very intense and extremely full Freely expressing emotion, with voice and body. 7. Arousal is extremely intense and full Complete disruption of speech, uncontrollable

38. Central EFT Hypothesis: Making sense of aroused emotion leads to good outcome 1)Emotional arousal in the middle phase of therapy predicted final outcome( added14% of outcome variance). 2)High levels of Experiencing in late phase of therapy substantially increased the outcome variance predicted (13%) (Warwar 2003).

39. Peak Emotional Arousal and Experiencing for the BDI (N=32) Variable Total R 2 Change in R 2 F Change Dfs Beta Block One Early EXP.19.19 6.86* 1,30.08 Block Two Mid Arousal.33.14 6.15* 1,29.26 Block Three Mid EXP -.30 Late EXP.46.13 3.16 1 2,27.29 Note: Overall F (4,27)=5.65** *p<.05, **p<.01, 1 p<.06

40. Peak Emotional Arousal and Experiencing for the SCL-90R (N=32) VariableTotal R 2 Change inR 2 FChange Dfs Beta Block One Early EXP.12.12 4.25* 1,30.30 Block Two Mid Arousal.37.25 11.42** 1,29 -.36* Block Three Mid EXP -.30 Late EXP.58.21 6.75** 2,27 -.44* Note: Overall F(4,27)=9.36*** *p<.05, **p<.01, ***p<.001

41. Clients’ emotional arousal and perceptual processing strategies during Emotion episodes (EEs) were examined in relation to treatment outcome (21%). Emotional arousal in conjunction with perceptual processing during mid-therapy predicted reductions in depressive and psychopathological symptomatology better than either of these variables alone (10%). Emotional Arousal and Perceptual Processing

42. Variable R Total R Change R 2 Total R 2 Change F Change dfβ Step 1 BDI (pre).093-.093.009.2531, 29-.093 Step 2 BDI (pre) Mid Arousal.550 -.026 -.542.303.29411.8091, 28 -.026 -.546** Step 3 BDI (pre) Mid Arousal Mid LCPP.637 -.101 -.289 -.321.406.1034.6861, 27 -.105 -.343 a -.383* Step 4 BDI (pre) Mid arousal Mid LCPP Mid WAI.642 -.100 -.235 -.297 -.077.412.006.2601, 26 -.104 -.304 -.363 b -.093 Note. BDI = Beck Depression Inventory; LCPP = Levels of High Client Perceptual Processing; WAI = Working Alliance Inventory. * p <.05.** p <.01.a =.062.b =.059. Hierarchical Regression Analysis for Mid Therapy Variables Predicting Depression at Outcome

43. Emotional arousal What is an Optimal Level?

44. Frequency of Emotional Arousal Hypothesis: Moderate level of frequency will relate to good outcome and account for significantly more outcome variance than the alliance alone. Given that the idea of a non-linear relationship between general arousal and performance has been an accepted psychological premise since at least the turn of the century (Yerkes & Dodson, 1908), it is surprising that it has not been applied to psychotherapy.

45. Being too emotionally aroused interferes with the ability to think clearly, and distress reduction has been shown to entail moving from states of hi arousal and lo meaning to lo arousal and hi meaning (Pascual-Leone & Greenberg 2008). Maintaining a level of expressed emotional arousal that is otherwise beneficial to emotional processing for too long might have a similar detrimental effect. Extended periods of highly aroused emotional expression might produce mental fatigue, or some process that interferes with the processes that lead to beneficial outcome. Too-frequent activation is probably a sign of repeated lack of resolution rather than signalling a working through of material

46. Ratings Emotional Arousal Raters viewed videotape of three sessions, one minute at a time noting the highest arousal level on the CEAS within that minute. The highest peak arousal rating for five-minute blocks was used.

47. Scatter Plot of FHEA against BDI

48. Results Hierarchical regressions showed that a nonlinear pattern of expressed emotional arousal predicted outcome significantly above the alliance. The working alliance was found to predict 14% of outcome variance on the Beck Depression Inventory Moderate frequency (25%) of heightened emotional arousal added significantly to the prediction of outcome variance (15%). The combination predicted 30% of outcome variance on the BDI. An optimal frequency (25%) of highly aroused emotional expression was found to relate to outcome, with deviation from this optimal frequency predicting poorer outcome.

49. Conclusions Too much or too little emotion was found to be not as helpful as a moderate amount. Intense and full level of emotional expression is seen as being predictive of good outcome, as long as the client does not maintain this level of emotional expression for too long or too often.

50. Is All Emotional Arousal Equally Productive?

51. Emotional Productivity An emotional expression is considered therapeutically productive if a client experiences a primary emotion in such a way that... a.A client can extract the useful information inherent in an adaptive emotion (Emotion Utilization) b.A maladaptive emotion has the potential to be transformed into a more adaptive emotional experience (EmotionTransformation)

52. Measure of Productive/Unproductive Emotion I No Yes II Unproductive Is the emotion experienced in the present? Is the emotion primary? Yes Unproductive No

53. Is the activated primary emotion adaptive Does the person take the stance of a victim? Is the emotion overwhelming ? Is the emotion stuck or blocked? Unproductive No Yes All No Productive

54. Productive Emotions Overall vs Arousal 4 or Above 100- 80- 20 - 0- 40- 60- PoorGood 78e440e423c407c418e412e413c415c Client number % of productive emotions % of productive emotions 4 or above % of total amount of emotions

55. © Auszra, Greenberg, Herrmann, 2008 Manner of Processing Contactfully Aware AttendingSymbolization CongruenceAcceptance AgencyRegulation Differentiation

56. © Auszra, Greenberg, Herrmann, 2008 Hypotheses 1. Emotional Productivity will increase from the beginning phase towards the working phase and the termination phase. 2. Working phase emotional productivity will predict outcome over and above; beginning phase emotional productivity; high expressed emotional arousal; and the working alliance. Clients: –Total N of 74 drawn from the York 1 and York 2 depression studies.

57. © Auszra, Greenberg, Herrmann, 2008 Results – Reliability A random sample of 2/3 of all sessions was rated by a second coder ScaleReliability Client Emotional Arousal Scale - III (Warwar, S. & Greenberg, L.S., 1999) Cohen’s Weighted Kappa = 0.90 Client Emotional Productivity Scale (Auszra, L.; Greenberg, L.S. & Herrmann, I.R., 2006) Cohen’s Kappa = 0.85

58. © Auszra, Greenberg, 2011 Process variable Total R 2 Changes in R 2 Beta Step 0: WAI.114*-.356** Step 1: WAI Beginning CEP.190*.076 -.309* -.297* Step 2: WAI Beginning CEP Beginning CEE.204.014 -.281* -.279* -.160 WAI Beginning CEP Beginning CEE Working CEP.546**.342 -.068 -.156 -.114 -.641**

59. Summary of Results Emotional productivity increases towards the working and the termination phase Working phase emotional productivity predicts outcome over and above beginning phase emotional productivity, high expressed emotional arousal and the working alliance CEP is the sole independent predictor of outcome, explaining independently 34.2 % of the variance for the BDI

60. Tests of the Basic Change Process Secondary Distress Primary Maladaptive NEED Primary Adaptive

61. Types of Emotion Hypotheses In samples of chair dialogue across treatment: 1-3) Proportion of, and increase in Secondary, Primary Adaptive and Primary Maladaptive Emotions will relate to outcome

62. Emotional Sequences Hypotheses 4.The Sequence of Primary Maladaptive Emotion followed by Primary Adaptive Emotion will predict good outcome. 5.The Sequence of Secondary Emotion followed Primary Maladaptive followed by Primary Adaptive Emotion will predict good outcome.

63.  N = 30 of EFT Clients  3 sessions were coded: First chair work session; (approx. 4th session) Best chair work session according to the degrees of resolution scale (DRS); Better of two sessions preceeding the best chair work session (according to DRS); Sampling

64. Summary of Results © Herrmann, Greenberg & Auszra, 2011 1.Proportion of Secondary Emotions in the Working Phase negatively predicts Outcome over and above Emotion Activation. 2.Moderate Levels of Primary Maladaptive Emotions in the Middle Working Session are significantly associated with outcome. 3.The Frequency of the Emotion Sequence Primary Maladaptive Emotion to Primary Adaptive Emotion in the Middle Working Session predicts Outcome over and above Emotion Activation. The Sequence also significantly predicts Outcome independently of the Proportion of Secondary Emotions.

65. Summary of Results © Herrmann, Greenberg & Auszra, 2011 4.Proportion of Primary Adaptive Emotions is the best Predictor of Outcome. It predicts outcome over and above Emotion Activation. It mediates the effect of Secondary Emotions on outcome. For Better Outcome Clients, the Proportion of Primary Adaptive Emotions increases significantly across the Sessions in Comparison to Poorer Outcome Clients.

66. Conclusion © Herrmann, Greenberg & Auszra, 2011 What seems central for good therapy outcome: With regard to Primary Maldadaptive Emotions moderate levels seem to be beneficial; there is no “the less the better” or “the more the better”. Moving through and leaving Primary Maldaptive Emotions towards Primary Adaptive Emotions seems to be important. Not only reduction of symptomatic Secondary Emotions but also the increase of Primary Adaptive Emotions over the course of Treatment seems to be central to successful therapeutic process.

67. Percentage of Negative, Anger-, and Positive Primary Adaptive Emotions © Herrmann, Greenberg & Auszra, 2011

68. Basic Change Process Secondary Distress Primary Maladaptive NEED Primary Adaptive

69. Degree of Resolution Scale Rejecting Anger Acceptance, letting go Grief / Hurt Global Distress Negative Evaluation Assertive Anger / Self- Soothing Fear / Shame Need Start 2 3 4 5 6 8 7 9 1 The model is flattened into a 9-point ordinal scale Secondary Distress Primary Maladaptive Need Adaptive

70. Regression of the model against time Average Good in-session outcome Average Poor in-session outcome Degrees of Resolution Scale Time n Looking at the regression slope for each of the 34 cases n Good outcomes have a significantly steeper slope (p=.01; Wilcox signed rank test)

71. Landscape of Action : what is happening? Landscape of Consciousness : what does it mean ? *Landscape of Feeling: what does it feel like? Narrative modes of Processing (Angus et al 1999)

72. Narrative Processes Model and Coding System (NPCS) (Angus et al 1999;1996) External Narrative Mode : what happened ? Personal Storytelling/Information Internal Narrative Mode : what did I feel ? Emotional Differentiation Reflexive Narrative Mode : what does it mean? Meaning exploration in relation to stories & emotions

73. Narrative Process Modes Over Time (Angus et al 1999) Poor Outcome Good Outcome hi lo

74. Narrative Process Mode Patterns E-R + R-E = storytelling & meaning-making E-I + I-E = storytelling & emotions R-I + I-R = emotions & meaning-making

75. Narrative Processes in Psychotherapy York I Depression Study : Emotion-focused Therapy Dyads Narrative Mode Shifts x Outcome E -I/ I - E I - R/ R to I R - E /E -R Outcome Good 06.0 % 42.0% 52.0% Poor 20.6 % 21.4% 58.0 %

76. Schematic Model of Narrative Process Modes (Angus et al 1999) Poor Outcomes Client Personal Storytelling : External Narrative Mode (Landscape of Action) Therapist shift to meaning-making : Reflexive Narrative Mode (Landscape of Consciousness) Good Outcomes Client meaning making: Reflexive Narrative Mode (Landscape of Consciousness) Therapist shift to emotional differentiation : Internal Narrative Mode ( Landscape of feeling)

77. Schematic Model of Narrative Process Modes (Angus et al 1999) Personal Storytelling : External Narrative Mode (Landscape of Action) Poor Outcomes Client story Telling Meaning-making : Reflexive Narrative Mode (Landscape of Consciousness) Good Outcomes Therapist shift to Emotional Differentiation : Internal Narrative Mode

78. In a Chair Dialogue with her Father Reflexive C: I don’t know why you were so unable to stop (gambling). It was so bad for us all (sighs and tears) Internal T : stay with the sadness, I know that might be hard to stay there, but it seems important … can you tell him about sadness, is that what it is, sadness, is that what if feels like? C : uh, kind of anger T : okay, so tell him about the anger / C I’m so angry at what you did to us T Uh huh

79. Reflexive C : um, why don’t you ever do anything about it ? (the gambling) you’re a responsible adult and it’s your own problem T : alright, tell him that, it’s real important …your responsible, I hold you responsible for your actions as an adult C: you’re responsible for your own – actions, you’re an adult – why did, me and mom and the rest of my brothers have to be um, (sniff) affected by it? Internal T : mmhm tell him how you were affected by it

80. C: Not to bring up how we felt, it was to be kept a secret T: I had to push everything down, I had to pretend it wasn’t happening, right? C: yeah… not to be real T: can you tell him, I resented having to pretend ? C: I resented to pretend living that way, it makes me angry T: that really makes me so angry Reflexive C: it wasn’t fair to be brought up that way. I think you’re selfish

81. Conclusion Making narrative sense of moderately aroused emotions that are deeply experienced and reflected on in the context of an empathically attuned relationship predicts therapeutic outcome

82. Toward the Future In this talk a number of principles for working with emotion have been suggested in order to promote the inclusion of emotion focused work into all treatment approaches. In the future “school” wars will end and the therapeutic relationship, emotion/ motivation, the cognitive, and the behavioral systems will all be valued as important in therapeutic work. Privileging one system for therapeutic attention over the others leads to a narrowing of perspective. We will develop a true understanding of the conditions under which it is optimal to intervene therapeutically with which system.

83. There currently are proposals for Emotion-focused experiential therapies( Greenberg 2002) Emotion-focused Cognitive and Cognitive Behavioral approaches, (Kendall 2008, Powers 2010). Experiential Dynamic approaches (Fosha 2002 McCullough 2005) and Emotion-focused Systemic approaches (Greenberg &Goldman 2008, Diamond and Diamond 2004) This indicates the move towards integrative approaches for the new millennium that all will include emotion. A key question for the future is under what conditions cognition is governed by emotion processes and vice versa and under what conditions both are governed by social cultural and biological processes.

84. THE END

85. Emotion Process in Depression Perceive Loss, humiliation, entrapment Feel Disappointed/sad Primary emotion Feel Fear and shame “I’m weak/bad” Maladaptive emotion Feel Depressed/hopeless Secondary emotion Act Inactive/low energy Secondary critical /coercive thoughts Think “Should get moving” Think Automatic thought Im worthless/ unloved Fast Automatic Slow Automatic Disclaimed/disowned

86. Results © Herrmann, Greenberg & Auszra, 2011 Reliability  on Identification of Emotion Activation (Cohen‘s kappa 0.887) on Emotion Categorization (Cohen‘s kappa 0.825)

87. Correlation Matrix Emotion Categories and Outcome © Herrmann, Greenberg & Auszra, 2011 Emotion CategoryBDI (standardized residual gain) SEC/INST First Working Session (fws)-.020 SEC/INST Middle Working Session (mws).431* SEC/INST Best Working Session (bws).580** PMA First Working Session (fws).286 PMA Middle Working Session (mws)-.009 PMA Best Working Session (bws).256 PA First Working Session (fws)-.227 PA Middle Working Session (mws)-.577** PA Best Working Session (bws)-.732** *p <.05, ** p <.001 Pearson R correlations between ECs and outcome

88. Secondary Emotions Independent Variables Total adjusted R 2 Adjusted R 2 change F changedfStandardized β weights Step 1: Activation.0943.9961, 28-.353 Step 2: Activation SEC/INS.442.34812.4722, 27 -.283 -.600** © Herrmann, Greenberg & Auszra, 2011 *p <. 05, ** p <.001 Results of Hierarchical Regression Analysis: BDI on Working Phase Activation and Working Phase Secondary Emotion

89. Primary Maladaptive Emotions Independent Variables Total adjusted R 2 F changedfStandardized β weights PMA PMA squared.2726.4102, 27 -1.973* 2.044* © Herrmann, Greenberg & Auszra, 2011 Results of Regression Model Including a Quadratic Term for PMA in the Middle Working Session in Predicting Change on BDI *p <.05

90. Primary Maladaptive Emotions © Herrmann, Greenberg & Auszra, 2011

91. Sequence Primary Maladaptive to Primary Adaptive Emotion © Herrmann, Greenberg & Auszra, 2011 SEQ PMA-PABDI in First Working Session-.123 in Middle Working Session-.532 ** in Best Working Session-.150 Pearson R correlations between Sequence PMA to PA and BDI in the sessions ** p <.001

92. Hierarchical Regression Analysis © Herrmann, Greenberg & Auszra, 2011 Independent Variables Total adjusted R 2 Adjusted R 2 change F changedfStandardized β weights Step 1: SEC/INS.38018.7821, 28.634** Step 2: SEC/INS SEQ PMA-PA.488.10812.8482, 27.498* -.323* SEC/INS SEQ PMA-PA.211 -.239 PA.655.16716.4703, 26-.527* *p <.05, ** p <.001 Results of Hierarchical Regression Analysis: BDI on Working Phase Primary Adaptive Emotion including potential confounding variables

93. Longitudinal Multilevel Modeling © Herrmann, Greenberg & Auszra, 2011 *p <.05, ** p <.001 Results from Multilevel Modeling of Primary Adaptive over Sessions as a Function of the BDI Equation: Primary Adapative it = β oi + β 1i Session t + β 2i BDI.rg + β 4 i BDI.rg 2 + β 5i Session t × BDI.rg + ε it­­ CoefficientSt. Err.dft-valuep-value Intercept0.1370.086561.6020.115 Session0.0460.034561.3830.172 BDI.rg-0.0070.01027-0.7030.488 BDI.rg 2 0.001 273.3880.002* Session × BDI.rg-0.0100.00456-2.4470.018*

94. Average proportion of Primary Adaptive Emotions for various levels of treatment success (BDI.rg) at best working session (session 1), middle working session (session 2) and best working session (session 3) © Herrmann, Greenberg & Auszra, 2011

95. A 3-Dimensional visualization for the expected trajectory in Primary Adaptive emotions over the three therapy sessions for various treatment outcomes as measured by the residual gain score on BDI

96. Sequential hypothesis Newly emerging emotions occur in ordered patterns (Pascual Leone & Greenberg 2007).