Emotion-Focused Therapy: A Clinical Synthesis

A major premise of EFT is that emotion is fundamental to the construction of the self and is a key determinant of self-organization. At the most basic level of functioning, emotions are an adaptive form of information-processing and action readiness that orient people to their environment and promote their well-being (2, 20–22). Emotions are seen by contemporary emotion theorists as significant because they inform people that an important need, value, or goal may be advanced or harmed in a situation. Emotions, then, are involved in setting goal priorities (23) and are biologically based tendencies to act that result from the appraisal of the situation based on these goals, needs, and concerns (2, 22).

Emotion is a brain phenomenon vastly different from thought. It has its own neurochemical and physiological basis and is a unique language in which the brain speaks. The limbic system is fundamentally involved in basic emotional responses (24). It governs many of the body's physiological processes and thereby influences physical health, the immune system, and most major body organs. LeDoux (24) found that there are two different paths for producing emotion: the shorter and faster amygdala pathway which sends automatic emergency signals to the brain and body and produces gut responses, and the longer, slower neocortex pathway, which produces emotion mediated by thought. These developed because clearly it was adaptive to respond quickly in some situations, but at other times better functioning resulted from the integration of cognition into emotional response by reflecting on emotion.

EFT suggests that the developing cortex added the ability for complex learning to the emotional brain's in-wired emotional responses. Internal organizations (neural networks) that produced emotional responses to learned signs of what had previously evoked emotion in a person's own life experience were thus formed. Emotional memories of lived emotional experience are seen as being formed into emotion schemes (5, 21, 25). By means of these internal organizations or neural programs people react automatically from their emotion systems not only to inherited cues, such as looming shadows or comforting touch, but also to cues that they had learned were dangerous, such as fear of one's father's impatient voice, or life enhancing, such as a beloved symphony, and these reactions are rapid and without thought. Emotion schemes are organized response- and experience-producing units stored in memory networks.

Thus, rather than being governed simply by biologically and evolutionarily based affect motor programs, emotional experience is seen as being produced by the synthesis of highly differentiated structures that have been refined through experience and are bound by cultural learning into emotion schemes (5, 26). Emotion schematic processing is the principal source of emotional experience and the target of intervention and therapeutic change in emotion-focused therapy (5, 21).

Emotion schemes are seen as being formed from emotional events such as betrayals or abandonments that result in emotional reactions. The emotion will fade unless it is “burned” into memory. The more highly aroused the emotion the more the experience and the evoking situation will form a memory. An emotion scheme is thus formed by emotions being connected to memories of the self in the situation. As a result, the emotional response can be recreated again and again long after the event. Then a memory of the painful event or a reminder of it stimulates an emotional response.

Changing the emotion schematic memory structures in therapy most likely occurs through the recently investigated process of memory reconsolidation (27, 28). The classic view of memory suggests that immediately after learning there is a period of time during which the memory is fragile and labile, but that after sufficient time has passed, the memory is more or less permanent. During the consolidation period, it is possible to disrupt the formation of the memory; once this time window has passed, the memory may be modified or inhibited, but not eliminated. Recently, however, an alternative view of memory was developed, suggesting that every time a memory is retrieved, the underlying memory trace is once again labile and fragile, requiring another consolidation period, called reconsolidation. This reconsolidation period allows another opportunity to disrupt the memory. The possibility of disrupting a previously acquired emotion schematic memory by blocking reconsolidation has important clinical implications.

EFT intervention is based on two major treatment principles: the provision of a therapeutic relationship and the facilitation of therapeutic work (5). The relational style is person-centered (36), which involves a way of being with patients characterized by entering the client's internal frame of reference and empathically following the client's experience. This is combined with a more guiding, process-directive gestalt therapy style (37) of engaging in experiments to deepen experience. The overall therapeutic style thus combines being with doing and following with leading.

The hallmark of EFT is that in addition to providing an empathic relationship the therapist also guides clients' emotional processing in different ways at different times. In this process certain client in-session states, which are markers of underlying affective/cognitive processing problems, are seen as offering opportunities for differential interventions best suited to help facilitate productive work on that problem state.

A defining feature of EFT is that intervention is marker guided and process directive. Research has demonstrated that clients enter specific problematic emotional-processing states that are identifiable by in-session performances that mark underlying affective problems and that these afford opportunities for particular types of affective intervention (5). Client markers indicate not only the type of intervention to use but also the client's current readiness to work on this problem. EFT therapists are trained to identify markers of different types of problematic emotional processing problems and to intervene in specific ways that best suit these problems. Each of the tasks has been studied both intensively and extensively and the key components of a path to resolution and the specific form that resolution takes has been specified. Thus, models of the actual process of change act as a map to guide the therapist's intervention.

The following main markers and their accompanying interventions have been identified (5).

A number of additional markers and interventions such as trauma and narrative retelling, alliance repair at ruptures, self-compassion at markers of self-contempt, self-soothing at anxious dependence, meaning making at markers of emotional high distress, and clearing a space at markers of confusion, and more, have been added to the original six markers and tasks (12, 39).

EFT theory of both the affective disorders and of eating disorders is discussed briefly below as examples of the application of the general theory to specific types of disorders. We argue that many disorders stem from the same basic underlying processes—core maladaptive emotion schemes, affect avoidance, and problems in affect regulation.

At the assessment interview, the client, a 39-year-old woman, tearfully reports feeling depressed, saying that she has been depressed most of her life, but that the past year has been particularly bad and that she has not been working and has fallen into a pattern of rarely leaving the house or answering the phone or the door. Her relationships with her family of origin members are difficult and often painful. Her mother is an alcoholic with whom she and her three sisters no longer have contact. Her father is a concentration camp survivor. He has always been emotionally removed from the family and is often perceived as being critical and judgmental. There is a history of physical punishment throughout her childhood.

From the exploration of the first session, the therapist has a sense that throughout her childhood and into her adult life she has often experienced herself as alone and unsupported. She has internalized the critical voice of her parents and often judges herself to be a failure. Within the context of a physically and emotionally abusive past she often felt emotionally unsafe and abandoned.

From the first session the therapist observes that the client is able to focus on her internal experience, particularly in response to empathic responses that focus her internally. However, she tends to avoid painful and difficult emotions (as do most people). There seems to be an identifiable maladaptive emotional pattern, wherein she moves into states of helplessness and hopelessness whenever she starts to feel primary emotions of sadness or anger and in response to experiencing needs for closeness and acceptance. She also appeared to have internalized her father's self-criticism, seeing herself as a failure. Unfinished business stemming from her early relationship with her father was also evident. She has unresolved resentment and sadness that have affected her own sense of security and self-worth. The goal of the treatment seemed to be to resolve her self-critical conflict split and to resolve her unresolved feelings toward her father.

In session three, with the help of the therapist's empathic attunement she describes not having gotten approval from her father: “I believe I'm a bad person, but deep down inside I don't think I'm a bad person … yeah, I'm grieving for what I probably didn't have and know I never will have.” The therapist initiates an empty-chair dialogue with her father in this session. In her emotional expression to her imaginary father in the empty chair, she begins to voice the meaning of the painful emotions related to her father. “You destroyed my feelings. You destroyed my life. Not you completely, but you did nothing to nurture me and help me in life. You did nothing at all. You fed me and you clothed me to a certain point. That's about it.” The therapist, drawing on her previous narrative replies; “Tell him what it was like to be called a devil and have to go to church every….” She then continued; “It was horrible. You made me feel that I was always bad, I guess when I was a child. I don't believe that now, but when I was a child I felt that I was going to die and I was going to go to hell because I was a bad person.”

By the end of session three, the thematic intrapersonal and interpersonal issues on which the therapy will focus have emerged clearly. They are embedded in what the client reports as her most painful experience. First, the client has internalized self-criticism related to issues of failure that emerge in the context of her family relationships. This voice of failure and worthlessness initially was identified as coming from her sisters but clearly has roots in earlier relationships with her parents. This becomes more evident later in therapy. Related to her self-criticism and need for approval is a need for love. Love has been hard to come by in her life. She has learned how to interrupt or avoid acknowledging this need as it has made her feel too vulnerable and alone. She has learned how to be self-reliant, but this independence has had a price as it leaves her feeling hopeless, unsupported, and isolated. This need for love is related to her unfinished business stemming from her early relationship with her father (and her alcoholic mother but her father is more central in her experience). She harbors a great deal of resentment toward her father over his maltreatment of her as a child, and she has a tendency to minimize it as “being slapped was just normal.” She has internalized this as a feeling of worthlessness and as being unlovable. These underlying concerns lend themselves very clearly to the emotional processing tasks of both the two-chair dialogue for internal conflict splits and to the empty-chair dialogue for unresolved injuries with a significant other.

In a key dialogue in session 3 she speaks to her father, imagined in front of her in an empty chair and after blaming him for his mistreatment she moves to an expression of primary sadness and anger:

C: It hurts me that you don't love me—yeah—I guess, you know, but … I'm angry at you and I needed love and you weren't there to give me any love.”

Encouraged by the therapist she later tells the image of her father about her fear:

C: I was lonely. I didn't know my father. My father, all I knew you as, was somebody that yelled at me all the time and hit me. That's all—I don't remember you telling me you loved me or that you cared for me or that you thought that I did well in school or anything. All I know you as somebody that I feared.

T: Tell him how you were afraid of being hit.

C: Yes, and you humiliated me. I was very angry with you because you were always hitting me; you were so mean and I heard Hitler was mean, so I called you Hitler.

Later on in the session, she expresses pain and hurt at her father's inability to make her feel loved: “I guess I keep thinking that yeah, you will never be a parent, that you would pick up the phone and just ask me how I'm doing. It hurts me that you don't love me—yeah—I guess, you know.” She ends the session with a recognition that what she had needed was acceptable. “I needed to be hugged once in a while as a child or told that I was OK. I think that's normal.”

By accessing both pride and anger and grieving her loss, her core shame is undone (6). She thereby begins to shift her belief that her father's failure to love her was because she was not worth loving. She says to him in the empty chair. “I'm angry at you because you think you were a good father, you have said that you never hit us and that's the biggest lie on earth, you beat the hell out of us constantly, you never showed any love, you never showed any affection, you never ever acknowledged we were ever there except for us to clean and do things around the house.”

In a dialogue with the critic in session 4 her critical voice begins to soften and both her grief over having not been loved and a sense of worth emerge. “Even though Mom and Dad didn't love me or didn't show me any love, it wasn't because I was unlovable; it was just because they were incapable of those emotions. They don't know how to—they still don't know how to love.” The client does not experience the hopelessness that had been so predominant in her earlier sessions again.

Later in session 7, the client and the therapist work to identify the way in which the client blocks her feeling of wanting to be loved to protect against the pain of having her needs not met. In session 9 enacting her “interrupter” she says to herself “You're wasting your time feeling bad cause you want them; they are not there. So it's best for you to shut your feelings off and not need them. That's what I do in my life. When people hurt me enough I get to that point where I actually can imagine, I literally cut them out of my life like I did with my mother.”

In sessions 7 through 9, the client continues to explore the two different sides to her experience: the critic that attempts to protect her through controlling and shutting off needs and the experiencing self that wants to be loved and accepted. She continues to define and speak from both voices and expresses a range of sadness, anger, and pain/hurt. The hopelessness that was so dominant in the early sessions now is virtually nonexistent. The voice that wants love and acceptance becomes stronger, and the critic softens to express acceptance of this part of her. At the same time she is feeling much better and activation of her negative feelings decrease.

Having processed her anger and her sadness and transformed her shame, she takes a more compassionate and understanding position to her father: a key empirically demonstrated process of change. In an empty-chair dialogue with her father in session 10 she says “I understand that you've gone through a lot of pain in your life and probably because of this pain, because of the things you've seen, you've withdrawn. You're afraid to maybe give love the way it should be given and to get too close to anybody because it means you might lose them. You know and I can understand that now, whereas growing up I couldn't understand.” She is also able to hold him accountable for the ways that he disappointed and hurt her while also allowing her compassion to be central in the development of a new understanding of his inner struggles.

In talking about the dialogue at the end of the session, the client says “I feel relief that I don't have this anger sitting on my chest anymore.” By the end of this 14-session therapy her shame-based core maladaptive belief that “I am not worth loving” has shifted to include the emotional meaning that her father experienced his own pain in his life and that this pain led him to be less available to behave in loving ways toward her or her sisters. Needing to be loved no longer triggers hopelessness, and she is now more able to communicate her needs, to protect herself from feeling inadequate, and to be closer to her sisters.

The effectiveness of short-term EFT for individuals has been demonstrated in several research projects. EFT is an effective treatment for both depression and emotional trauma. EFT activates emotion during treatment to make deep change in automatically functioning emotion schemes that are frequently the sources of problems. EFT combines both following and guiding clients' experiential process, while emphasizing the importance of both relationship and intervention skills.