EFT Effectiveness and Training - part III,IV

Robert Elliott é co-autor com L. Greenberg e outros, da Terapia Processual-experiencial, focada nas emoções. Colabora com a Sociedade na Especialização em Psicoterapia, através do treino em TPE/EF. Nesta entrevista, tida em Lisboa a 11 de Fev 2010, aborda, entre outros tópicos, as características distintivas da P-E/EFT.

Robert Elliott is, with Leslie Greenberg and others, co-originator of Emotion-focused Therapy.  He is intervening in the Society’s Psychotherapy Specialization, offering EFT training, as Les Greenberg does. This 50 minutes conversation took place the 11th February 2010, at Lisbon. The distinctive features of P-E/EFT were among other topics discussed.

A.H.: Given your clinical experience, how many sessions are needed for EFT to improve client’s life quality or to solve the main clinical problems of a client?

R.E.: Yeah, I mean, it really depends on the client group, right? You know? And even with something like social anxiety we’ve got a protocol which is 16 to 20 sessions and that seems to work for most clients, but some of our clients get done in 7 sessions or 12 sessions, and they’re done, right? Other clients it turns out they need more than 20 sessions and then we have to figure out how to work with that, because underneath the social anxiety is trauma, often deep trauma, and the trauma is what’s driving the social anxiety so you have to go work with that and sometimes that’s quite complicated. And particularly when the client comes in without good access to the inner world so that they then need to spend some period of time in therapy learning to develop that access, and that can take 10 or 15 sessions before a client can actually learn to move around in their internal world and get access. And then the therapy can start, right? So if you spend 10 or 15 sessions helping the client to learn how to focus essentially… Now we’ve got, there’s the social anxiety and we work with that we go to another level, get to the trauma work, you know? So it can easily take much much longer, right? It just depends on the client group you’re working with and the nature of that client particular issues and problems. Yeah? So it’s like asking how long is a piece of string, it depends upon… right?

A.H.: Yeah, right, of course. Besides depression you have already talk on other populations, the effectiveness studies with other populations are there relevant results you want to talk some, a little bit about results?

R.E.: Certainly with depression the therapy is highly effective. You know, I think we’ve got a sense that is that in working with that critic process, a lot of what EFT’s has got in depression is really helping the person see the inner critic process and bring it out - there’s something really powerful about that. So, so we’ve got now a body of evidence, where recognizes as an evidence based therapy by the American Psychological Association. Unfortunately in the UK the center of review bodies are ignoring the evidence, they just kind of pretend it doesn’t exist. But, you know, certainly depression, and post trauma, I just said there’s a line of research mostly by Paivio, but also by other people, that does meet the criteria for being evidenced based therapy to use the American Psychological Association criteria. But that’s not PTSD, that’s people having difficulties with trauma, having been traumatized, right? And the couples, you know? The Sue Johnson’s group and Leslie Greenberg have done some research on couples therapy too. EFT for couples is a really really effective therapy; it has got some of the best results in the field, that’s very powerful therapy. So that’s, those are the areas where EFT is strongest in.

A.H.: Ok, that’s clear. From the point of view of someone who believes in affect primacy, who believes that only emotions can change emotions, how do you understand or explain the so called success of cognitive and behavioral focused techniques, still dominant today?

R.E.: Well, CBT folks are really good at marketing with what they do. And they are really good at disseminating, you know? Aaron Beck once said that if it works it’s CBT, so… by definition it must be CBT if it works, right? So, I mean, there’s a process of sort of Borg like assimilation - if I can make a Star Trek analogy - and, so that’s that. But there are other questions, how is it that clients in all kinds of therapies are able to use those therapies to change themselves, no matter if those are behavioral therapies or cognitive therapies or family systemic therapies or constructivist therapies or person-centered therapies or whatever. Clients use, in general, are able to use most practically any kind of therapy to change themselves and that’s because…

J.S.: Although the therapists…

A.H.: In spite of the therapist.

R.E.: Yeah, that’s right, in spite of the therapist, often in spite of the therapist. So that’s because the client is the active change agent in the therapy, you know. We, like as therapists we like to believe that we’re doing the heavy lifting, but actually it’s our clients that are the active change agents and we are to facilitate their process. We are really there for them to use us to change themselves. And but, of course, we feel as we were the center of the universe, because each person is the center of their universe anyway, so. If I’m a therapist I’m going to feel as I’m the center of my universe but the client is also the center of their universe too and they’re the person who came in to change, so. Anyway, so, I think clients take whatever they’re offered and they run it through their own processes. I work with a team of research who is studying dynamic, psychodynamic and cognitive therapy in the nineteen-eighties in the UK - David Shapiro’s team - and no matter what the therapy was, if it was psychodynamic therapy the clients would be trying cognitive therapy and if it was cognitive therapy they would be trying to look at their childhoods. So the clients were doing their own thing and they were just using what was offered to them in their own change process, you know? So they’re accessing their emotions, I mean, and they’re using their emotions to change their cognitions and they’re using their emotions to change emotions and they’re following the action tendency to behavior change…

A.H.: There’s a common factor?

R.E.: I think emotion is the common factor, personally. But that’s my view.

A.H.: How do EFT [therapists] copes with difficult clients, such as the severe personality issues, avoidant or borderline? Is there room in EFT for this kind of problems?

R.E.: Yes, yes I think so. It has to be room, we make room for it. And in the Learning book, for example, we have a section were we talk about working with borderline processes, because inevitably as a therapist you end up having to work with clients with borderline processes. Now, when you work with this sort of more difficult or fragile client processes, it takes more time and you spend more time in the relationship, you know, because there are more relational ruptures and… so relational rupture work becomes a more central part of the therapy, but relational rupture work is a task also. Right? So it’s pretty good kind of task. I do do empty chair and two chair work with my clients with borderline processes and they can handle that, they don’t have a problem with that. I mean often, clients with borderline processes often, are often so incredible split over themselves already that the conflict splits just jump out at you and the self-criticism splits…

A.H.: Can they get in touch with their emotions?

R.E.: Yeah, I mean the issue with borderline, with some of the fragile or the borderline processes is not can they get in touch with their emotions, it’s are they going to get overwhelmed by their emotions and go to a flooded overwhelmed state? Will they lose their emotion regulation? That’s the issue and that’s what you got to be really careful with. And so, when I work with borderline processes I make sure early in the therapy that we work with the task called clearing a space - which is an emotion regulation task - and I’m going to use more of balance, and now I’m using self-soothing. I think self-soothing it’s really really important task for working with clients with borderline processes. So basically it’s the same thing I was saying before, you know? It’s really important for us to work with these various client populations because… Well it’s important for us to be able to meet these clients and it stretches the therapy and helps it develop.

A.H.: These leads us maybe to the therapeutic failures or unsuccess in EFT. Which are in your opinion the main reasons for an occasional therapeutic failure?

R.E.: You mean when the therapy doesn’t work how do we understand why it didn’t work. Well in the book that, I think it’s Watson, Greenberg and Goldman, the 6 cases - cases in Emotion Focused Therapy - they have 3 success cases and 3 less success cases, and basically their feeling is that the clients who were not as successful ran out of time, they need more therapy. That 16 to 20 sessions was too short for some of these folks and I think a lot of this stuff I was saying before, if it takes 10 or 15 sessions for a client to develop a better relationship with their inner world and ability to look inside, then they’re going to have trouble fitting into a 16 to 20 sessions treatment protocol, right? Almost need… I think it was Reiner Sachse the German person-centered therapist who proposed that (he’s working with clients with psychosomatic difficulties or alexithymia) he proposed that we actually had a protocol for that, you know? That the first 15 sessions of the therapy was about just teaching them focusing and then you go on and do the work with the other problems. So that’s a big thing. But also difficult life circumstances, you know, the clients got hostile others or is very socially isolated, there’s things in their lives that are eating away at them, undermining their change process, undermining things that might start to happen, and that makes it really difficult. We all know clients with such difficult lives that all we can do is accompany them and keep them from deteriorating, I think.

A.H.: Is there an ideal client for EFT?

R.E.: I mean… with YAVIS clients, you know young, attractive, verbal, intelligent, successful? Right, yes? Remember that? I mean… folks like us… I don’t know… Yes, so these are clients that we find more easier to work with…

A.H.: More emotional conscious?

R.E.: Yeah, I mean more emotional intelligence, but of course, those clients need us less, right? I mean a lot of those clients basically just need a little bit of… you know?... or they can do it themselves with a little bit of help or something. So is there an ideal client… so… I’d like to say that the ideal client is the one in front of me, right? Because every client is a challenge and it’s my job try to figure how to help them help themselves, what is it that going to be the that’s…

A.H.: The one that is there to be helped…

R.E.: Yeah, exactly…

A.H.: Can we turn into training?

R.E.: Sure.


Part IV

A.H.: Empathy, again, it used to be part of the clinical training programs, but not so much since the dominance of CBT as an empirically-supported treatment. And rapport is what is talked about in CBT. How do you see this turn?

R.E.: Well as I said at the beginning empathy I see as foundational for, not just for EFT, but actually for all therapies and Arthur Bohart and Leslie Greenberg and Jeanne Watson and I did a meta-analyses of the literature on the relationship of the empathy and the outcome several years ago and, you know, empathy is one of the strongest predictors of outcome, there is… Is even stronger than therapeutic alliance. And, you know, so, yeah, I think that it’s a shame that empathy isn’t emphasized as much. If you look at really really skillful CBT therapists, people like Robert DeRubeis or Steve Hollon, the big names, they all have person-centered training, they got taught empathy in the seventies in their graduate training and underneath the CBT there’s solid empathic skill, right? So, I think it’s a shame that it’s not emphasized as much as it used to be. My friend Carmen Mateu in Spain in the University of Valencia is developing an empathy training curriculum. This is a CBT course she teaches in but she’s developing an Empathy training. She came and spent a year with us in Glasgow to see how we taught our students empathy and I think there’s place for that.

A.H.: A variety of Empathy and listening skills, of emotional attunement and listening, appears as main abilities of EFT therapist (in EFT terms). Which are the major difficulties that a beginning psychotherapist will find when learning how to be empathic, how to listen for emotions?

R.E.: Right, this is the kind of thing, right, that what gets in the way on our ability to be empathic, you know. And in the training we do in Glasgow we use a lot of processes. I mean the students are in active and professional development groups, we have large group processes, we have… but anyway the point of all this is that there is lots of places where we get stuck. And one of the places we get stuck is, for example, we’re afraid of strong emotions or particular emotions – we’re afraid of our anger, or we’re afraid of any kind of intense feeling or fear, something like that.

J.S.: Or our sadness…

R.E.: Or our sadness, absolutely, right for a man and men don’t cry… and then that becomes a block to our empathy because when our client becomes sad then we get scared of their sadness and, then we can’t connect with it, we can’t empathically attune to it. So that’s a huge one. I think the other thing, the other place where people get stuck is when they’re attacked and, you know, when the client is unhappy with us or is challenging us or is making demands of us that we’re afraid we can’t meet, then lots of therapists get, really get their empathy blocked and some of those therapists turn on those clients and attack them and harm them, right? And so, that’s really really important in training courses to address that, otherwise we turn out harmful therapists. Right. So for me that’s a core aspect of Empathy training - is teaching therapists how to hear a potential attack and criticism and how to bear strong emotions. But that requires personal development work.

A.H.: To them to regulate themselves.

R.E.: Exactly, their own emotion regulation, own self-exploration in terms of where those emotion phobias have come from. yeah, Those are some of the ones, there are other ones too but…

A.H.: Ok. So what makes a good EFT therapist? What kind of skills or profile would you say he or she needs in order to be a Good Therapist?

R.E.: Right, let’s see… It helps to be curious about people, it helps to be in touch with your own emotional life. I once said at a conference “it helps to be somewhat insecurely attached - you know if I’m too securely attached, in other words I trust that you like me and I trust that our relationship with each other, I’m not going to be curious, I’m not going to be, you know, I’m not going to be that curious. I’m just going to assume that you are who I think you are and I can rely on that and that’s going to make me actually not as good as a therapist. So I think that a little of insecure attachment actually goes a long way to driving us as therapists to be curious about other people. I don’t know if that makes sense but…

A.H.: That makes sense, yes. Would you recommend personal therapy as an important part of training?

R.E.: Yeah, I think so, yeah…

A.H.: No doubt on that.

R.E.: Yeah, for me it’s a question of when is the personal therapy and what other things are equivalent to a personal therapy, but you know, personal growth work of some kind is essential. At some point it’s essential the person experiences therapy as the client. We have a sort of ongoing discussion in the course I teach on about whether to make personal therapy mandatory part of the training. Right now it’s not, it’s not mandatory and the argument is that if you force people as part of their training to go into therapy, they’re maybe unwilling and it’s kind of… It kind of undermines the therapy, right? So the question is whether it actually makes sense requiring it but absolutely I think it’s essential for a therapist to be competent … and even something like 2 chair work, you know? You can’t really facilitate a 2 chair work process unless you’ve been a client and experience it from the inside, because you don’t really know what it feels like, you don’t know what you’re asking the person to do, you don’t know how embarrassing it is, you don’t know how scary it can be when all of a sudden you access something you didn’t know it was there. You have to, you know. Part of, an essential aspect of being competent in 2 chair work is having experience as the client. Now, we do that in skill practice because clients take turns, the clients and therapists role each other. But you know, within the therapy it’s also important.

A.H.: So we are close to the end, do you want to add something of your own on this issues.

R.E.: Well, let’s see, what could I say…

J.S.: What kind of recommendation would you make for beginning therapists for example…

R.E.: You mean a person who’s beginning to study therapy and is interest in EFT.

J.S.: Hum hum.

R.E.: I would say first to get yourself some really good empathy training, basically, first get some solid background in being present with the other person in an empathic and caring way. Then look at your own issues and then start an EFT training and work your way through the training in both therapist and client roll. Get involved in research on EFT. Several years ago we did focus groups with our students and we asked them what did help them learning EFT and we developed a kind of a stage model, a stage students go through the learning EFT, and one of which is feeling totally overwhelmed and lost. But one of the things they told us was that taking part in research was invaluable to them. And I thought back to my own experience as a graduate student where I persuaded a bunch of my friends to let me tape sessions they did with clients and I learned huge amount from doing that research, studying what my friends did, studying how clients experienced that, reading tapes, all those things. So, basically, and practice, supervised practice. You have to learn by doing, you can’t,… like everything…

A.H.: Wonderful, thank you so much.

R.E.: It was a pleasure.