Managing Emotional Responses in Therapy: An Adapted EFT Supervision Approach

Therapists often encounter experiences in therapy that elicit emotionality, this could be in the form of self-of-the-therapist issues, compassion fatigue, or professional burnout. Whereas approaches to supervision for self-of-the-therapist issues recognize the need for accessing the supervisee’s emotionality, approaches have not focused on how the clinical and professional system could also be part of the cycle. We propose an adapted emotionally focused supervision approach that employs steps one through six of the EFT model. To display how this approach would work, we provide the example of work with longer-term clients. Working with longer-term clients can be a challenge for many therapists, and both the professional and client system come with factors increasing emotional risk to the therapist. Engaging the therapist’s emotionality through supervision has the potential to improve therapeutic outcomes, as well as reduce loss of good therapists in the field to professional burnout.     

Understanding Latina Immigrants Using Relational Cultural Theory

Latina immigrants face a number of challenges as they adapt to their new culture. This article presents Relational Cultural Theory (RCT) as a model for understanding the challenges Latina immigrants may present in psychotherapy. The RCT concepts of mutual empathy and empowerment, connections, condemned isolation, the central relational paradox, and power-over dynamics are used to understand the challenges Latina immigrants experience. Sociopolitical and cultural factors that interact to produce power-over dynamics are identified to show how Latina immigrants are at increased risk for major disconnections. A vignette shows how clinicians can use RCT to provide more culturally relevant treatment in their work with Latina immigrants.     

Emotion Focused Therapy for Avoidant Personality Disorder: Pragmatic Considerations for Working with Experientially Avoidant Clients

Emotion-focused therapy (EFT), an empirically supported treatment for depression and interpersonal difficulties, is now being directed towards clients with personality disorders, such as borderline and avoidant personality disorder. In this paper, both the value of, but also potential difficulties therapists can encounter while engaging in, active EFT chair interventions with clients with avoidant personality disorder (AVPD) are described. While EFT interventions can effectively transform emotion schemes at the heart of both intra and interpersonal difficulties, avoidant clients may have difficulties engaging in EFT interventions that activate core maladaptive emotion schemes related to self and negative/unaccepting representations of ‘others’. Alliance ruptures, intransigent experiential avoidance, or ‘unresolvable stand-offs’ may result. To avoid these problems, the importance of working with a more refined and content based case conceptualization of the particular avoidant client is highlighted. Guidance in optimal emotional processing in order to transform layers of maladaptive emotion schemes present within the client with AVPD is provided. Supporting these clients’ full striving for life, and their capacity to self-soothe is also discussed. A case example illustrates application of the model and principles.     

Addressing power in couples therapy: Integrating socio-emotional relationship therapy and emotionally focused therapy

Romantic relationships are more satisfying and fulfilling when power is balanced relatively equally between partners (Leonhardt et al., Journal of Family Psychology, 34, 2020, and 1). Yet, few couples therapy models explicitly outline how to confront relational power issues (Knudson-Martin & Huenergardt, 2015, Socio-emotional relationship therapy: Bridging emotion, societal context, and couple interaction, Springer). Emotionally Focused Therapy (EFT; Johnson, 2020, The practice of emotionally focused couple therapy, Routledge) is a well-established, evidence-based therapy modality that many therapists use with couple clients, yet despite its effectiveness, it does not provide direction for explicitly addressing and treating power differentials in couple relationships. In this paper, we explore the integration of EFT with Socio-emotional Relationship Therapy (SERT), a model overlay that acknowledges the impact of social discourse on enactments of power in intimate couple relationships. We first address the importance of understanding power in couple relationships, addressing power in couples therapy, and provide a brief overview of SERT and EFT. We then introduce an integration of the models intended to help therapists balance power, increase connection, and secure attachment bonds between romantic partners.     

Treatment for Deliberate Self-Harm: Integrating Emotion-Focused Therapy

This article proposes that Emotion-Focused Therapy (EFT) can be effectively utilized as a treatment modality for deliberate self-harm or integrated with existing treatment approaches. A brief literature review examines evidence suggesting that attachment and emotion regulation are important etiological variables associated with deliberate self-harm. EFT addresses these variables by emphasizing the importance of the therapeutic relationship and assisting clients in the regulation and transformation of negative, maladaptive emotions. The article describes the basic tenets of EFT, comparing and contrasting this approach with therapeutic models most commonly used in the treatment of deliberate self-harm. Finally, it is recommended that future outcome research utilize randomized clinical trials to evaluate the effectiveness of EFT and compare it with other treatment modalities.     

Fat Women’s Experiences in Therapy: “You Can’t See Beyond…Unless I Share It with You”

Abstract

This article reports the results of a qualitative exploration of fat women’s experiences with weight-related microaggressions in psychotherapy. We conducted semi-structured interviews with 15 women about their weight-related experiences as therapy clients and asked for their advice to therapists who work with fat women. We used a general inductive approach to code the data into themes and found that common microaggressions included therapists who overly focused on weight, therapists who appeared to be less interested in clients because of their weight, and dissatisfaction with waiting room seating options. Participants advised therapists to allow their clients to initiate conversations about weight. Results suggest the need for increased awareness of: (a) how clients’ weight may impact therapists’ attitudes and choice of interventions and (b) how weight might influence fat clients’ in-session presentations.     

Emotion-focused Therapy: The Transforming Power of Affect

Emotion-focused therapy (EFT) is an empirically supported humanistic treatment that views emotion as fundamental to experience, as contributing to both adaptive and maladaptive functioning, and as essential to therapeutic change. EFT combines both following and guiding the client’s experiential process, emphasizing the importance of both relationship and intervention skills. Utilizing markers of particular emotional processing difficulties at the core of client problems, therapists intervene with matched interventions aimed to resolve the emotional processing difficulty. This process helps clients access new adaptive emotional resources, transform maladaptive emotional responses, address emotional interruption and regulation, make sense of experience, and construct new meaning and self-narrative.     

A discourse analysis of power in relation to PSYCHLOPS (Psychological outcome profiles) in the context of CBT for psychosis

Aims: Outcome measures (OMs) and routine change measurement have developed dramatically in psychological therapies over the last two decades and some therapists have expressed concerns that this, depending on how it is handled by the parties involved, can markedly affect the therapy. However, little research has investigated this. It therefore seemed timely to explore discourses of OMs drawn upon by both parties in the therapy room. Method: PSYCHLOPS (Psychological Outcome Profiles) is a client‐centred measure which offered an opportunity to explore how therapists and clients receiving CBT for psychosis talked about OMs. A useful contrast was provided by the CORE‐OM (Clinical Outcomes in Routine Evaluation‐Outcome Measure). The discourses drawn upon by clients (n=4) and therapists (n=4) were analysed, informed by a Foucaultian framework. Results: OMs were constructed as empowering or disempowering of clients, as being able to do therapeutic work of engagement and containment, and as part of the apparatus of service power, positioning therapists as relatively powerless to question their use. Discussion: It is suggested that client‐centred measures like PSYCHLOPS, although partly aligned with a recovery framework, may become part of top‐down state and service power, and there is a need for more research into the different ways in which OMs are used in therapy and the impacts on therapists, clients and their relationships.     

Relationship between self‐worrying and self‐critical messages in clients with generalised anxiety engaging in emotion‐focused worry dialogues

Emotion‐focused therapy (EFT) has recently been adapted as a treatment for generalised anxiety disorder (GAD). One intervention used in this adaptation is a worry dialogue, in which the client enacts worry in one chair (“worrier”) and is facilitated to experience the impact of this worry in another chair (“experiencer”). Although not formally studied, anecdotal observations from therapists in the EFT for GAD treatment development study suggested that within worry dialogues there might be a link between client's self‐worrying and self‐critical messages. This study used data from 47 worry dialogues from fourteen study clients who received EFT for GAD. An observation based qualitative analysis of clients' self‐directed messages as present in in‐session worry dialogues was conducted using video/audio recordings of relevant sessions. Results indicate a relationship between self‐worrying and self‐critical messages. A total of 90 paired self‐worry and self‐critic messages across the 47 worry dialogues were logged. Six recurring clusters of themes/relationships were observed: (a) I need to be prepared for future negative events because… I'm weak and a failure; (b) I need to stop worrying… I'm flawed for being a worrier; (c) People will negatively judge me if I engage with them… because I'm not good enough; (d) If I don't worry, there will be negative consequences… and I will be responsible and will be unable to bear it; (e) I worry/ruminate that I cause(d) some damage… because I'm incompetent; and, (f) I must always be prepared against others taking advantage of me… because I'm weak. Given the observed close link between self‐critical and worry processes, it is important that therapists differentiate between these processes and remember to address both in therapy for GAD.     

Using Contextual Therapy to Treat Depression with Couples

Abstract

Though depression is one of the most common presenting problems treated by systemic therapists, there have been relatively few attempts to describe how specific systemic therapy models can be applied to treat couples dealing with depression. In this paper, we discuss how contextual therapy can be used to treat depression in couples therapy. We identify multidirected partiality as an intervention and as a characteristic. We introduce letter writing and internalized other interviewing as contextual interventions that help to facilitate partiality and understanding between clients. A clinical vignette illustrates our discussed concepts.     

Therapists’ and clients’ perceptions of routine outcome measurement in the NHS: A qualitative study

Primary objective: This is the first qualitative study that elicited the perceptions of both psychological therapists and their clients in the use of Clinical Outcomes in Routine Evaluation with computer software (CORE‐Net), where instant visual feedback for session tracking was given on a computer screen in the therapy room at each therapy session. The study also examined how therapists viewed its potential value in supervision and provides suggestions for improving training. Research design: The study adopted a convenience sample of four therapists in a primary care counselling setting (PCC – General Practitioner referrals) who were experienced in using CORE‐Net, and five therapists in an NHS employee/occupational support counselling service (OH) who had just begun to use CORE‐Net for session tracking with 10 of their clients. Method: A qualitative methodology was used and interview data were collected from the therapists via focus groups; the clients were interviewed individually face to face. All data was analysed inductively. Findings: The study identified six overarching themes: (i) therapists were initially anxious and resistant; (ii) therapists adapt ‘creatively’; (iii) outcome measures help the client/therapist relationship; (iv) clients perceive visual measures as helpful; (v) CORE scores inform supervision; and (vi) proper and ongoing training/support of therapists is necessary. The main limitations are comparability of data and the generalisabilty of results. Conclusions: The implementation of routine outcome measurement (ROM) is a challenge but can be made easier with proper training and supervision. Clients appear happier than their therapists when routine outcome measurement is used.     

Fostering Client Creativity in Family Therapy: A Process Research Study

Creativity has been shown to enhance problem solving, and to increase flexibility and adaptability—qualities associated with positive therapeutic outcomes. Literature related to therapist and/or client creativity is primarily anecdotal. Empirical literature addressing how therapists can facilitate the creativity of their clients in family therapy is scarce. In this study, the researchers used process methodology to code the behavior of therapists and clients in 31 videotaped family therapy sessions. Results show a significant positive correlation between interventions that induce positive affect and the creative client behaviors of optimism and playfulness.     

Effective Psychotherapy With Low-income Clients: The Importance of Attending to Social Class

The purpose of this article is to explore some of the issues associated with conducting psychotherapy with low-income clients. Throughout the article, we draw from our specific clinical experiences working with low-income Latina mothers in a depression prevention program. The themes that we address regarding class and psychotherapy are in the areas of assessment of social class, integration of class issues into the therapy process, and managing differences in social class between therapists and clients. As we discuss these themes, we provide concrete recommendations in order to advance awareness and effectiveness in working with economically disadvantaged populations.     

Recording therapy sessions: What do clients and therapists really think?

Aims: Recording therapy sessions has become part of routine practice amongst trainee psychotherapists. To date most research has focused on the benefits of recording sessions to support clinical supervision. There are few data about the benefits or risks for clients. This study aimed to explore the views of clients who had had their therapy sessions recorded and therapists who had recorded sessions. Design: Five clients and 25 therapists completed a qualitative survey, the results of which were analysed using thematic analysis. Findings: All clients and several therapists reported that the recording devices are soon forgotten. Both therapists and clients reported the benefits of recording as being purely for the therapist with none identified for clients. Conclusions: It was observed that clients perhaps did not always understand how recordings were used, suggesting the need for clearer practice guidance.     

Helping construct desirable identities: a self-presentational view of psychotherapy

The author reviews the research demonstrating not only that clients withhold personal information and reactions from their therapists but also that such discretion is associated with positive therapy process ratings and outcomes. These results run counter to traditional approaches to psychotherapy, which demand a high degree of openness from clients. These puzzling findings can be explained by conceptualizing psychotherapy as a self-presentational process, wherein clients come to benefit from therapy by perceiving that their therapists have favorable views of them. Creating these favorable impressions can involve clients' hiding some undesirable aspects of themselves from their therapists. The author offers findings from the psychotherapy and social-psychology literatures in support of this view and makes suggestions concerning what clients and therapists might optimally reveal in therapy.     

DOES "FEMINIST" PLUS "THERAPIST" EQUAL "FEMINIST THERAPIST"?

This research examined the therapy behaviors self-identified feminist therapists engaged in. Practicing therapists (N = 101) were asked to endorse various feminist self-labels and to indicate how often they engaged in a variety of feminist (as assessed by the Feminist Therapy Behaviors-Revised [FTB-R] scale; and other therapy behaviors with both women and men clients. The following results were found. First, incrementally specific feminist self-labeling by therapists improved the prediction of therapy behaviors reflecting the notion that the personal is political. Second, the most strongly identified feminist therapists were distinguished from other therapists by their attention to issues of oppression (e.g., sexism, racism, heterosexism) and socialization. Third, therapists reported engaging in FTB-R behaviors with men clients almost as much as with women clients. And finally, FTB-R and other therapy behaviors emerged as distinct, both in terms of the underlying structure of therapists' responses and in terms of the links to feminist self-labeling.     

“Sharing in people's pain is not an easy thing to do”: Cognitive Behavioural Therapists' understandings of compassion in the workplace

Objectives

Compassion is central to the aim of improving patient care and staff well-being within healthcare systems. To inform service development, explorations of experiences and meanings of compassion are needed. This study explored cognitive behavioural therapists ' understandings of compassion within their work environment.

Design

A qualitative study was conducted using semistructured interviews and interpretative phenomenological analysis (IPA).

Methods

Data were obtained from five practicing cognitive behavioural therapists.

Results

Two superordinate themes were developed, each with two subordinate themes. CBT therapists reported entering the profession with intrinsic motivation to care for others. They further developed an interest in compassion with exposure to clients and ongoing professional development in compassion-focused therapy (CFT). Compassionate work environments helped to facilitate compassionate practice; however, for many, workplaces were perceived to lack compassion. Challenges were encountered when negative workplace interactions left therapists feeling fatigued, distressed and demoralised. There was a desire for recognition and to be seen as more than a “work machine,” the experience of which was a threat to retaining therapists within the profession.

Conclusions

Current recruitment and training processes are producing staff with skills and motivation to deliver compassionate care. However, lack of compassion within workplaces can be a barrier to actioning these skills and motivations. Research needs to focus on how to effectively implement and run systems that are compassionate for both staff and clients. To provide compassionate care, staff need work environments that show compassion to them. These findings provide some insights into and practical suggestions regarding how this can be achieved.     

Therapist perspectives on using silence in therapy: A qualitative study

Twelve experienced therapists were interviewed about their perceptions of why they used silence in therapy. Qualitative analyses revealed that these therapists typically perceived themselves as using silence to convey empathy, facilitate reflection, challenge the client to take responsibility, facilitate expression of feelings, or take time for themselves to think of what to say. Therapists generally indicated that a sound therapeutic alliance was a prerequisite for using silence, and they typically educated their clients about how they used silence in therapy. Therapists typically believed they did not use silence with clients who were psychotic, highly anxious, or angry. They typically thought they now used silence more flexibly, comfortably, and confidently than when they began doing therapy. Therapists typically believed they learned how to use silence from their own experience as a client and from supervision.