Introduction Emotion Special Issue Leslie S

Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 11, 1–2 (2004) Introduction Emotion Special Issue Leslie S. Greenberg* Department of Psychology, York University, Toronto, Canada

In this issue on an emotion-focused approach to unconscious, preverbal or perceptual. Modes of therapy, emotion is seen as a special form of infor- processing based on fear or loss have been called mation processing crucial to survival and adapta- cognitive. Complex states such as worthlessness or tion. It is now clear that emotion influences modes hopelessness, which are based as much on emotion of processing, guides attention, enhances memory as they are on cognition and are more feelings than and that much behaviour is in the service of beliefs, have been treated as cognitions. Different emotion regulation and attachment. People do not personality disorders have been seen as being only do things because of their views of things but based on a different cognitive content. Now that because it feels good or bad. People attempt to cognition is so all encompassing, the thesis that regulate affect—to minimize unpleasant and max- cognition produces emotion and disorder and that imize pleasant affect—and this is a driving force in therapy should be aimed at changing cognition is human motivation and action. much less testable and much less interesting than Emotions, as well as influencing information when cognition meant automatic thought. The processing and providing action dispositions, also cognitive hypothesis has essentially become un- provide evaluations of goal attainment. These testable and non-refutable. The important question evaluations are not necessarily in language or for the field now is ‘When is it important that reflexively self-conscious. In addition emotions emotion is mediated by cognition and when is it have more to do with evaluation of the significance important that cognition is mediated by emotion of things to one’s well-being than with their truth and what are the best forms of intervention for the or rationality. From an emotion-focused perspec- different instances?’ tive, disorder is seen as resulting more from fail- Another problem with the dominant cognitive ures in the dyadic regulation of affect, avoidance paradigm is that the cognitive therapy proposal of affect, traumatic learning and lack of processing that people need to bring troublesome emotion into of emotion than from logical error, irrationality or line with reason’s dictates simply is not humanly fea- lack of insight. sible. It denies human complexity. In fact a desire The clarification of the nature and functioning of to be totally rational can itself produce emotional emotion over the last decade is especially impor- distress. If reason ruled, people would not do any- tant in light of the proposed relationship between thing simply because they enjoy it. Passion is emotion and cognition in the cognitive revolution. an important part of life, giving it colour and In its original form the post-cognitive hypothesis— meaning. We do things for the emotional effects. that emotion was caused by automatic thoughts Emotion therefore needs to be treated as an independent accessible to consciousness—was interesting and variable that interacts with and influences cognition testable but the meaning of cognitive by now has and behaviour. It is the thesis of this issue that in become so all encompassing as to become almost therapy emotion needs to be validated and worked with meaningless. So many phenomena are now viewed directly to promote emotional change and that a com- as cognitive, irrespective of whether they are prehensive approach to treatment needs to incor- porate a focus on emotion. Greenberg in the first paper on Emotion-focused *Correspondence to: Professor L. S. Greenberg, Department therapy (EFT) offers Awareness, Regulation and of Psychology, York University, 4700 Keele St., Toronto, Ontario, Canada M3J 1P3. Tel: +416 736 5115 ext. 66111. Transformation as three empirically supported Fax: +416 736 5814. principles of emotional change and argues that a E-mail: [email protected] deepening of client’s core emotions in therapy, for

Copyright © 2004 John Wiley & Sons, Ltd. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.387 2 L. S. Greenberg suitable clients produces more enduring change. routes to emotion and that intervention should He suggests that clients have to arrive at an vary according to the emotion generation route. emotion before they can leave it and that emotion This view is applied to working with individuals often is best changed by an alternate emotion. with unipolar depression and suggestions are Menin in the second paper presents Emotion Reg- made as to how Cognitive Behavioural approaches ulation Therapy (ERT) as an integrative approach need to be adapted for the treatment of mood dis- to treating GAD. ERT starts with psycho-education orders. An account of working in an emotion- but moves to skill training in somatic awareness focused manner with coupled emotions in bipolar and in emotion, knowledge, utilization and regu- disorder is also presented. lation. These skills are then used to confront core Whelton in a concluding paper reviews research thematic issues using experiential exposure exer- on emotion in therapy and concludes that there is cises. Fosha in the next paper shows how, in an mounting evidence to support the hypothesis that emotionally engaged therapeutic relationship, the the acceptance of emotional experience is generally moment-to-moment processing of emotion to beneficial and that its avoidance is generally completion produces therapeutic transformation. harmful, even when the emotions are painful and She also points out that positive emotions are sen- negative. He also finds that processing information sitive affective markers of important transforma- in an experiential manner predicts successful out- tional processes. She describes several types of comes, that emotional arousal and expression can positive emotion that arise spontaneously during lead to constructive change for some clients and moment-to-moment experiential therapeutic work some problems but that this occurs most when and the transformation processes they represent. arousal is coupled with reflection. Finally he finds Power, in the penultimate paper, presents an evidence to support that exposure to difficult and outline of the SPAARS approach to emotion and fearful stimuli while emotionally aroused, restruc- emotional disorder. This multi-level theory of tures expectancies and reduces anxiety and symp- emotion demonstrates that there are two different toms of trauma.

Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 1–2 (2004) Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 11, 3–16 (2004) Emotion–focused Therapy L.S. Greenberg* Department of Psychology, York University, Toronto, Canada

In an Emotion-focused approach emotion is seen as foundational in the construction of the self and is a key determinant of self- organization. As well as having emotion people also live in a constant process of making sense of our emotions. Personal meaning is seen as emerging by the self-organization and explication of one’s own emotional experience and optimal adaptation involves an integration of reason and emotion. In this framework therapists are viewed as Emotion coaches who work to enhance emotion-focused coping by helping people become aware of, accept and make sense of their emotional experience. Emotion coaching in therapy is based on two phases: Arriving and Leaving. A major premise is that one cannot leave a place until one has arrived at it. Three major empirically- supported principles of Emotion Awareness, Emotion Regulation and Emotion Transformation that guide emotion coaching are discussed. Copyright © 2004 John Wiley & Sons, Ltd.

EMOTION IN HUMAN FUNCTIONING harmed in a situation (Frijda, 1986) and they indicate how individuals appraise themselves and A major premise of Emotion-focused therapy (EFT) their worlds (Greenberg & Korman, 1993; Lazarus, is that emotion is foundational in the construction 1991). Emotions then are involved in setting of the self and is a key determinant of self- goal priorities (Oatley & Jenkins, 1992) and are organization. At the most basic level of functioning biologically-based relational action tendencies that emotions are an adaptive form of information- result from the appraisal of the situation based on processing and action readiness that orients people these goals/needs/concerns (Arnold, 1960; Frijda, to their environment and promotes their well- 1986; Greenberg & Korman, 1993; Greenberg & being (Frijda, 1986; Greenberg & Paivio, 1997; Safran, 1987, 1989; Oatley & Jenkins, 1992). Differ- Greenberg & Safran, 1987; Lang, 1995). EFT sug- ent action tendencies correspond to different emo- gests that emotional intelligence involves honing tions. For example, fear is associated with the the capacity to use emotions as a guide, without mobilization for ﬂight, while anger involves the being a slave to emotions. urge to attack, repel, or break free. According to a number of emotion theories, an As well as involving a primary meaning system, important although not the only source of emotion that informs people of the signiﬁcance of events to production at the psychological level is the tacit their well-being and a rapid adaptive action ten- appraisal of a situation in terms of personal goals, dency (Frijda, 1986) emotion also is a primary sig- concerns or needs (Frijda, 1986; Izard, 1991; Oatley nalling system that communicates intentions and & Jenkins, 1992; Tomkins, 1986). Thus, emotions regulates interaction (Sroufe, 1996). Emotion thus are important because they inform people that an regulates self and other, and gives life much of its important need, value, or goal may be advanced or meaning. Recent research has shown that a common earlier view, that emotion is post cognitive, is inadequate *Correspondence to: Professor L. S. Greenberg, Department (LeDoux, 1996; Zajonc, 1980). Emotion can and of Psychology, York University, 4700 Keele St., Toronto, Ontario, Canada M3J 1P3. Tel: +416 736 545 ext. 66111. often does precede cognition, but, more impor- Fax: +416 736 5814. tantly, it makes an integral contribution to infor- E-mail: [email protected] mation processing in its own right (Forgas, 1995,

2000; Greenberg, 2002; Greenberg & Safran, 1987). to depression whereas a stable positive affective Neuroscience has shown emotion to be an in- style builds psychological resilience. The ability dispensable foundation for many cognitive pro- to recruit positive emotions in the face of stress cesses, particularly for making decisions (Bechera, appears to be a crucial component of resilience Damasio, Tranel, & Damasio, 1997; Damasio, 1994) (Davidson, 2000). and changing emotions as we will see leads to Evolution however has blessed humanity with change in modes of cognitive processing. more negative basic emotions than positive ones, The amygdala, at the centre of the emotional in order to aid survival. An important conclusion brain, serves as the ‘smoke detector’ that pre- to be drawn from an evolutionary point of view is consciously interprets whether incoming sensory that negative emotions are often useful. Anxiety, information is a threat. The amygdala forms emo- anger, sorrows and regret are useful or they would tional memories in response to particular sensa- not exist. Unpleasant feelings draw people’s atten- tions such as sounds and images that have become tion to matters important to their well-being. associated with physical threats. These emotional However when unpleasant emotions endure even interpretations appear to be extraordinarily diffi- when the circumstances that evoked them have cult to change (LeDoux, 1996). Therefore, the changed, or are so intense that they overwhelm, or challenge of any effective psychotherapy, be it evoke past loss or trauma they can become dys- of trauma, anxiety or depression is to transform functional. Healthy adaptation thus necessitates amygdala reactions so that innocuous reminders of learning to be aware of, to tolerate, and to regulate past experience are not seen as a return of past loss, negative emotionality (Frijda, 1986; Tomkins, 1963) failure or trauma. as well as to enjoy positive emotionality for the Forgas (2000), in his affect infusion model, has benefits it endows (Frederickson, 1998). Dysfunc- recently shown that the infusion of affect into cog- tion in the ability to access and process emotional nition depends on the type of processing that is information, both positive and negative, thus dis- occurring. It is when processing is substantive in connects people from one of their most adaptive ambiguous, open situations, like most interper- orientation and meaning production systems sonal experiences, that affect is most likely to influ- (Frijda, 1986; Izard, 1984, 1991). ence the construction of beliefs. By contrast more controlled processing in explicit problem-solving situations is most impervious to affect infusion A DIALECTICAL–CONSTRUCTIVIST effects. Cognition and memory clearly have been VIEW: INTEGRATING BIOLOGY found to be mood dependent (Blaney, 1986; Forgas, AND CULTURE 2000; Palfia & Salovey, 1993). Ultimately it is important to understand the independent contri- As well as having emotion we also live in a con- bution of both emotion and cognition and their stant process of making sense of our emotions. We interaction in the production of human distress. have proposed a dialectical–constructivist view Significant new findings have also emerged of human functioning to explain this process about the relationship between positive emotion (Greenberg, Rice, & Elliott, 1993; Greenberg & and psychological resilience. Fredrickson (2001), Pascual-Leone, 1995, 2001; Guidano, 1991; for example, has helped to identify the adaptive Mahoney, 1991; Neimeyer & Mahoney, 1995; function of positive emotions. Positive emotion Pascual-Leone, 1987, 1990a, 1990b, 1991; Watson & improves problem solving by making thought Greenberg, 1997). In this view personal meaning processes more flexible, creative and efficient. The emerges by the self-organization and explication of playful creativity associated with emotions like joy one’s own emotional experience and optimal and interest motivate people to learn and achieve adaptation involves an integration of reason and more than they otherwise would, which helps emotion. This integration is achieved by an them to accrue future personal and social ongoing circular process of making sense of experi- resources. Fredrickson (2001) also found that posi- ence by symbolizing bodily-felt sensations in tive emotion builds resilience by undoing the awareness and articulating them in language, effects of negative emotion, a finding which may thereby constructing new experience. have important relevance for recovery from the In a dialectical–constructivist view the person is effects of self-criticism. Furthermore, in the neuro- seen as an agent who is in a constant process of psychological research of Davidson (2000) a ten- symbolizing bodily-felt referents to create new dency to low positive affect confers a vulnerability meaning, and who creates new experience by the

Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 3–16 (2004) Emotion-focused Therapy 5 ways in which bodily-felt experience is organized. autonomy are met with criticism and rejection Attending to, and discovery of, pre-conceptual, from parents. As a consequence, the child is likely elements of experience, influences the process to develop schemes in which intimacy or auton- of meaning construction while the process of omy is associated with fear and shame. Later in meaning construction influences what is experi- life, when the individual is criticized or rejected, enced. There are in this view essentially two these schemes may be activated out of awareness, important streams of experience and knowing, an and patterns of physiological arousal and response embodied experiential stream and a more social, tendencies associated with the original lack of conceptual linguistic stream. support and associated negative beliefs or expec- With development, emotional experience, rather tations formed by this experience will be evoked. than being governed simply by biologically- and The person may feel afraid and physically shrink evolutionarily-based affect motor programmes, is away from closeness or risk taking and tacitly produced by highly differentiated structures, that appraise intimacy or assertion as threatening and have been refined through experience and bound likely to meet with failure. Even though the indi- by culture into what have been called emotion vidual may consciously know that this defeatist schemes (Greenberg et al., 1993; Oatley, 1992; pessimistic stance may be unfounded in any given Pascual-Leone, 1991). These are organized situation, the emotional response endures. response- and experience-producing units stored Change in emotional experience is brought about in memory networks. Much adult emotional expe- in therapy first by activating the maladaptive experience is of this higher order, generated by idio- rience of fear and shame underlying the hopeless- syncratic schemes based on biology and learning ness and then by accessing adaptive feelings of that serve to help the individual to tacitly antici- sadness at what is missed and the yearning for pate future outcomes. Thus for example over time closeness, and the anger at the maltreatment. These the innate response of joy at a human facial con- adaptive emotions are attended to and validated, figuration becomes differentiated into feelings of are used to vitalize a more resilient sense of self to pleasure with a specific caretaker and contributes help transform the person’s maladaptive affects to the development of basic trust. Feeling an and to explicitly challenge maladaptive beliefs. In emotion involves experiencing body changes in this way the new self-experience and views are relation to, and integrated with the evoking object integrated with the existing negative experience or situation and one’s past emotional learning. It is and views to consolidate a new self-organization. the feeling of the emotion that allows for the for- Thus a process of accessing the adaptive and bring- mation of emotion networks or schemes, because ing it into contact with the maladaptive helps consciously feeling something involves higher transform or undo the maladaptive schemes levels of the brain, and entails a synthesis of (Greenberg, 2002; Greenberg & Paivio, 1997). emotion–cognition–motivation and action into In this view, in order to change, clients need to internal organizations. Emotion schematic pro- activate new adaptive experience in therapy in cessing is the principal target of intervention order to change maladaptive experience, and they and therapeutic change in emotion-focused need to develop new narratives that assimilate therapy (Greenberg & Paivio, 1997; Greenberg experience into existing cognitive structures and et al., 1993). generate new ones. Therapy thus involves chang- Although it is important to recognize the adap- ing both emotional experience and the narratives tive function of emotion it is clear that given that in which they are embedded (Greenberg & Angus, emotions reflect experience they can become mal- 2003). adaptive responses to situations. Emotions become In a dialectical–constructivist view people are maladaptive through learning and socialization thus viewed as constantly striving towards making and especially to failures early on in the dyadic sense of their pre-conceptual experience by sym- regulation of affect (Fosha, 2000). In addition affect bolizing it, explaining it and putting it into narra- repertoires show individual differences. Some tive form. Pre-conceptual tacit meaning carries people are more easily triggered into anxiety, rage implications and acts to constrain but does not or joy and some people may be born with damaged fully determine meaning. Rather it is synthesized emotional systems. with conceptual, explicit meaning to form expla- An example of the development of a maladap- nations constrained by experiencing (Greenberg & tive depressogenic emotion scheme is seen in a Pascual-Leone, 1995, 2001). This provides the child whose initiatives either for closeness or ongoing narrative of a person’s life.

The brain thus can be seen to possess two impor- EMOTION COACHING tant meaning systems, one based on a symbolic conceptual language and the other based on a Emotion coaching is aimed at enhancing emotion- sensory motor affective language. Body talk then focused coping by helping people become aware of, is intelligent brain talk and people need to pay accept and make sense of their emotional experi- attention to ‘feeling knowledge’ and to make sense ence. Coaching is defined in general as involving a of it with their linguistic conceptual abilities in mutually accountable relationship in which both order to be able to benefit consciously from its evo- client (trainee) and therapist (coach) collaborate lutionarily adaptive offerings. actively in the creation of an educational experience It is likely that in traditional, more cognitive and for the client who is an active participant in the insight-oriented psychotherapy, people learn to process. Emotion coaching entails a highly collab- understand that certain emotional or somatic orative relationship involving both acceptance and reactions are erroneous interpretations of what is change (Linehan, 1993). The goals of emotion occurring or belong to the past and are now irrel- coaching are acceptance, utilization and transfor- evant. This may help them override automatic mation of emotional experience. This involves physiological responses to reminders of past expe- awareness and deepening of experience, process- rience but not abolish them. Although re-appraisal ing of emotion as well as the generation of alterna- or insight provides people with a new way of tive emotional responses. In emotion coaching thinking or deeper understanding of the reasons a safe, empathic and validating relationship is they feel the way they do, cognitive change of this offered throughout to promote acceptance of nature is unlikely to reconfigure the alarm systems emotional experience. An accepting, empathic of the brain, or the emotion schematic networks relational environment provides safety leading to that have been organized from them. More con- greater openness and provides people with the new ceptually oriented or instructional forms of inter- interpersonal experience of emotional soothing and vention rely on top-down techniques to manage support that over time becomes internalized disruptive emotions and sensations. Emotions are (Fosha, 2000; Greenberg & Johnson, 1988). As well often approached as unwanted disruptions of as providing interpersonal validation this type of ‘normal’ functioning that need to be harnessed safe relational environment reduces interpersonal by reason rather than as adaptive information anxiety and thereby frees up clients’ processing or as reactivated associations and unintegrated capacities enabling them to pay attention to their fragments of prior emotional states. Top-down bodily-felt experience. In this type of relational processing generally promotes problem-focused environment people sort out their feelings, develop coping and focuses on inhibiting unpleasant sen- self-empathy and gain access to alternate resilient sations and emotions rather than on promoting responses based on their internal resources. emotion-focused coping which focuses on pro- Emotion coaching is a collaborative effort to help cessing emotion to completion, transforming clients use their emotions intelligently to solve emotion and integrating emotion into ongoing problems in living by accepting emotion rather narratives. than avoiding it, utilizing both the information and Emotion-focused therapy views bottom-up pro- response tendency information provided by it, and cessing as essential in changing automatic emo- transforming it when it is maladaptive. tional responding. In bottom-up processing clients In addition to following where the client is are asked to become aware of and track sensori- moment by moment the therapist also coaches the motor processes (the sequence of physical sensa- client in new ways of processing experiential infor- tions and impulses) as they progress through the mation. Change and novelty can be introduced body (Perls, Hefferline, & Goodman, 1951) and to into the emotional domain by guiding people’s be mindful of their internal experience (Kabat-Zin, attention and meaning construction processes and 1993). They are asked to disregard thoughts that also by helping people to become aware of their arise until the bodily sensations and impulses emotional processes. Although difficult, it is possi- resolve or crystallize into a clear meaning and to ble to enter into the highly subjective domain of symbolize the bodily-felt sense in words (Gendlin, unformulated personal experience, a place beyond 1996). The bottom-up element of the process con- reason and often beyond words, and have a posi- sists of people learning to observe and follow the tive influence. The steps involved in coaching unattended to or avoided sensori-motor reactions people to experience their emotions skilfully are that are activated in the present. elaborated below.

Emotion coaching (Greenberg, 2002) in therapy provides direction for the exploration not by sug- is based on two phases: Arriving and Leaving. A gesting what content clients should focus on, nor major premise is that one cannot leave a place until by interpreting the meaning of their experience, one has arrived at it. The first phase of arriving at but rather by guiding the type of processing in one’s emotions, involves the following four steps. which they engage. Each therapist response is These are focused on awareness and acceptance of viewed as a processing proposal that guides the emotion. type of emotion in which the client engages. The types of proposals used in emotion coaching are • First, it is important to help people become those that help people symbolize their internal aware of their emotions. experience and make sense of them. Coaching in • Second, people need to be coached to welcome the emotional domain involves helping verbally their emotional experience and allow it (this label emotions being felt, helping people accept the does not necessarily mean they must express emotion, talking with the client about what it is like everything they feel to other people but rather to experience the emotion, facilitating new ways of acknowledge it themselves). People also need to processing the emotion, and teaching ways of be coached in skills of regulation if needed to soothing or regulating the emotion. It is important help them tolerate their emotions. to note that people often cannot simply be explic- • Third, people need to be helped to describe their itly taught new strategies for dealing with difficult feelings in words in order to aid them in solving emotion but often have to be facilitated experien- problems. tially to engage in the new process. For example • Fourth, they need to be helped to become aware accessing a need or goal may be very helpful in of whether their emotional reactions are their overcoming a sense of passivity or defeat or to help primary feelings in this situation. If not, they move out of a painful feeling. However, explicitly need help in discovering what their primary teaching people that this is what they should feel feelings are. is not nearly as helpful as interpersonally facilitat- The second phase focuses on emotion utilization or ing this by asking them at the right time, in the transformation to promote leaving the place arrived right way, when they are feeling hopeless and have at. This stage involves moving on or transforming processed the feeling, what it is they need. It is for core feelings. It is here that the coaching aspect is example, by experiencing a process of shifting more central. states by accessing needs that the experiential links between states are best forged. This then is consol- • Fifth, once the person has been helped to expe- idated only later by explicit knowledge of the rience a primary emotion, the coach and person process. together need to evaluate if the emotion is a healthy or unhealthy response to the current situation. If it is healthy it should be used as a PRINCIPLES OF WORKING guide to action. If it is unhealthy it needs to be WITH EMOTION changed. • Sixth, when the person’s accessed primary emo- Emotion Assessment tions are unhealthy, the person has to be helped In working with the emotions it is important to to identify the negative voice associated with make distinctions between different types of emo- these emotions. tional experiences and expression that require • Seventh, the person is helped to find and rely different types of in-session intervention. We on alternate healthy emotional responses and have emphasized the importance of differentiating needs. between both primary and secondary emotions, • Eighth, people need to be coached to challenge and between emotional experience that is adaptive the destructive thoughts, in their unhealthy or maladaptive (Fosha, 2000; Greenberg & Paivio, emotions, from a new inner voice based on their 1997; Greenberg & Safran, 1987; Greenberg et al., healthy primary emotions and needs, and to 1993). Primary emotions are the person’s most learn to regulate when necessary. fundamental direct initial reactions to a situation The dialectic of acceptance and change, is like being sad at a loss. Secondary emotions are embodied in a style of following and leading. those responses that are secondary to other more Following provides acceptance and leading intro- primary internal processes and may be defences duces novelty and the possibility of change. This against these such as feeling hopeless when angry.

Secondary emotions are responses to prior within an overarching framework that emphasizes thoughts or feelings or to complex sequences of emotional/social support as important in the these. Sequences such as, feeling angry in response promotion of change. In therapy emotional/social to feeling hurt or feeling afraid or guilty about support is operationalized as the provision of a feeling angry. Secondary emotions need to be relationship characterized by attunement to affect, explored in order to get at their more primary gen- validation of experience and empathic responsive- erators. Although the skills of awareness and ness. Outside therapy it involves encouraging the understanding apply to most emotions, it is only acquisition of interpersonal emotional support awareness of some primary emotions that provides characterized by listening, validating relationships access to adaptive information that promotes ori- as well as instrumental support when needed. entation and problem solving. Thus accessing the Emotional support inside therapy is the founda- healthy anger at unfairness, that underlies power- tion for the therapeutic effectiveness of the follow- lessness, promotes adaptation, while accessing the ing three emotion processing principles: (1) shame at loss of esteem, that underlies rage, can increasing awareness of emotion, (2) enhancing promote attachment in place of destructiveness. emotion regulation, (3) transforming emotion. The next crucial distinction to be made is These three principles act as a general guide for between those primary states that are adaptive, working with emotion. They help understand the and are accessed for their useful information, and different goals of emotion-focused intervention those primary states that are maladaptive, and and explain how to work with different types of need to be transformed. Maladaptive emotions are emotion at different times. those old familiar feelings that occur repeatedly and do not change. They are feelings such as, a core Emotion Awareness sense of lonely, sad, abandonment, of wretched worthlessness, or recurrent feelings of shameful The ﬁrst and most general goal in Emotion-focused inadequacy that plague one all one’s life. These therapy is the promotion of emotional awareness. feelings do not change in response to changing The goal in EFT treatment is for clients to become circumstance nor when expressed, nor do they aware of their primary emotions and more specif- provide adaptive directions for solving problems. ically their primary adaptive emotions. Increased Rather they just leave the person feeling stuck, emotional awareness is therapeutic in a variety of often hopeless, helpless and in despair. It does not ways. Becoming aware of and symbolizing core help simply to get in touch with these emotions emotional experience in words provides access they need to be replaced or transformed. both to the adaptive information and action ten- Distinctions between different types of emotion- dency in the emotion. Awareness helps people provide clinicians with a map for differential inter- make sense of their experience and promotes vention with emotion. Primary emotions need to assimilation of it into their ongoing self-narratives. be accessed for their adaptive information and It is important to note that emotional awareness is capacity to organize action, whereas maladaptive not thinking about feeling, it involves feeling the emotions need to be regulated and transformed. feeling in awareness. Only once emotion is felt Secondary maladaptive emotions need to be does its articulation in language become an impor- reduced by exploring them to access their more tant component of its awareness. primary cognitive or emotional generators. The therapist works with clients to help the client Emotion-focused work therefore involves access- approach, tolerate and regulate as well as accept ing primary adaptive emotions in order to sym- their emotions. Acceptance of emotional experi- bolize their adaptive information and evoking ence as opposed to its avoidance is the ﬁrst step in maladaptive emotions in order to make them awareness work. Having accepted the emotion amenable to change by exposing them to new rather than avoided it the therapist then helps the information and experience. client in the utilization of emotion. Here the client learns how to utilize the emotion that they have become aware of and accepted to improve coping. Clients are helped to make sense of what their Goals of Emotion-focused Intervention emotion is telling them and to identify the Emotion-focused therapy relies on three major goal/need /concern that it is organizing them to empirically-supported principles for enhancing attain. Emotion is thus used both to inform and to emotion-processing. The principles are embedded move.

Emotion awareness has now been grounded in a Emotional expression has recently been shown to measure of levels of emotional awareness (LEAS) be a unique aspect of emotional processing that developed by Lane and associates (Lane, Quinlan, predicts adjustment to breast cancer (Stanton et al., Schwartz, Walker & Zeitlin, 1990; Lane & 2000). Women who coped with cancer through Schwartz, 1987). Five levels of emotional aware- expressing emotion had fewer medical appoint- ness are measured. In ascending order these are ments, enhanced physical health and vigour and physical sensations, action tendencies, single emo- decreased distress compared to those low in tions, blends of emotion, and blends of blends of expression. Expressive coping was also related to emotional experience (the capacity to appreciate increased quality of life for those who perceived complexity in the experiences of self and other). their social environment to be highly receptive. The dynamic interaction between phenomenal Analyses suggested that expressive coping experience, establishing a representation of it, enhanced the pursuit of goals, but that this was elaborating that representation (e.g. identifying the mediated by hope. Emotional arousal, awareness source of the emotional response) and integrating and in some situations its expression therefore it with other cognitive processes are the funda- appears to be therapeutic aspects of emotional pro- mental processes involved in the cognitive elabo- cessing. Expressing emotion in therapy does not ration of emotion addressed by the levels of this involve the venting of emotion but rather express- measure. LEAS has been found to correlate sig- ing strongly experienced emotions in therapeutic nificantly with self-restraint and impulse control. environments rather than constricting them. This finding, replicated in independent samples, In addition to the informational value of emotion indicates that greater emotional awareness is asso- awareness, symbolizing emotion in awareness ciated with greater self-reported impulse control. promotes reflection on experience to create new Individual differences in emotional awareness meaning and this helps people develop new narra- have also been found to predict recovery of posi- tives to explain their experience (Greenberg & tive mood and decrements in ruminative thoughts Pascual-Leone, 1995; Guidano, 1995; Pennebaker, following a distressing stimulus (Salovey, Mayer, 1990; Watson & Greenberg, 1996; Whelton & Golman, Turvey, & Palfai, 1995). Greenberg, 2000). For example, symbolizing trau- Awareness of emotion also involves overcoming matic emotion memories in words helps promote avoidance of emotional arousal and the promotion their assimilation into a person’s ongoing self- of emotional processing (Foa & Kozak, 1986; narrative (Van der Kolk, 1995). Putting emotion Greenberg & Safran, 1987). There is a strong human into words thus allows previously unsymbolized tendency to avoid painful emotions. Normal cogni- experience in emotion memory to be assimilated tive processes often distort or interrupt emotion and into people’s conscious, conceptual understand- transform adaptive unpleasant emotions into dys- ings of self and world where it can be organized functional behaviour designed to avoid feeling. To into a coherent story. In addition, once emotions overcome emotion avoidance clients must first be are in words they allow people to reflect on what helped to approach emotion by attending to their they are feeling, create new meanings and evalu- emotional experience. This often involves changing ate their own emotional experience. the cognitions governing their avoidance. Then clients must allow and tolerate being in live contact with their emotions. These two steps are consistent EMOTION REGULATION with notions of exposure. There is a long line of evidence on the effectiveness of exposure to previously The second principle of emotional processing avoided feelings (Foa & Jaycox, 1998). From involves the regulation of emotion. Important issues the experiential perspective, however, approach, in any treatment are what emotions are to be reg- arousal and tolerance of emotional experience is ulated and how these emotions are to be regulated. necessary but not sufficient. Optimum emotional Emotions that require regulation generally are processing involves in addition, the integration of either secondary emotions, such as despair and cognition and affect (Greenberg, 2002; Greenberg & hopelessness, or primary maladaptive emotions Pascual-Leone, 1995; Greenberg & Safran, 1987; Pos such as the shame of being worthless, the anxiety & Greenberg, 2003). Once contact with emotional of basic insecurity and/or panic. experience is achieved, clients must also cognitively Clients with under-regulated affect have been orient to that experience as information, and shown to benefit both from validation and the explore, reflect on, and make sense of it. learning of emotion regulation and distress toler-

Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 3–16 (2004) 10 L. S. Greenberg ance skills (Linehan, 1993). The provision of a safe, and then act to calm the activation by using coping validating, supportive and empathic environment self-talk and other conscious strategies for self- helps soothe automatically generated under- calming. It appears that simply acknowledging, regulated distress (Bohart & Greenberg, 1997) and allowing and tolerating emotion is an important help strengthen the self. Emotion regulation skills aspect of helping regulate it. This soothing of involve such things as identifying and labelling emotion can be provided by individuals them- emotions, allowing and tolerating emotions, estab- selves, reflexively, by an internal agency, or from lishing a working distance, increasing positive another person. As we have seen self-soothing emotions, reducing vulnerability to negative involves among other things diaphragmatic emotions, self-soothing, breathing, and distraction. breathing, relaxation, development of self- Regulation of under-regulated emotion thus empathy and compassion and self-talk. Soothing involves getting some distance from overwhelm- also comes interpersonally in the form of empathic ing despair and hopelessness and/or developing attunement to one’s affect and through acceptance self-soothing capacities to calm and comfort core and validation by another person. Internal security anxieties and humiliation. Rather than dwelling on develops by feeling that one exists in the mind and these activities, positive experience and support heart of the other and the security of being able to are helpful. Maladaptive emotions of core shame soothe the self develops by internalization of the and feelings of shaky vulnerability also benefit soothing functions of the protective other (Sroufe, from regulation in order to create a working dis- 1996; Stern, 1985). It is important to make a distance from these rather than become overwhelmed tinction in emotion work between intensity of by them. Forms of meditative practice and self- emotion and the depth of processing of the acceptance are often most helpful in achieving a emotion. It is the latter that is the aim, not the working distance from overwhelming core emo- former, and it is the regulation of intensity that tions. The ability to regulate breathing, and to overwhelms that is vital in promoting the required observe one’s emotions and let them come and go depth of processing of emotion. Finally emotion are important processes to help regulate emotional regulation involves not only the restraint of distress. Mindfulness treatments have been shown emotion, but at times its maintenance and to be effective in treating generalized anxiety dis- enhancement. orders and panic (Kabat-Zin et al., 1992), chronic pain (Kabat-Zinn, Lipworth, Burney, & Sellers, 1986), and prevention of relapse in depression EMOTION TRANSFORMATION (Teasdale et al., 2000). Mindful awareness of emotions coupled with awareness of breathing is The third and probably most fundamental princi- helpful in regulating symptoms of depression and ple of emotional processing involves the transfor- anxiety and enhances coping. mation of one emotion into another. Although the Another important aspect of regulation is devel- more traditional ways of transforming emotion oping clients’ abilities to tolerate emotion and to either through their experience, expression and self-soothe. Emotion can be downregulated by completion or through reflection on them to gain developing tolerance and by soothing at a variety new understanding do occur, we have found of different levels of processing. Physiological another process to be more important. This is a soothing involves activation of the parasympa- process of changing emotion with emotion. This novel thetic nervous system to regulate heart rate, principle suggests that a maladaptive emotional breathing and other sympathetic functions that state can be transformed best by undoing it with speed up under stress. At the more deliberate another more adaptive emotion. In time the co- behavioural and cognitive levels, promoting activation of the more adaptive emotion along with clients’ abilities to receive and be compassionate to or in response to the maladaptive emotion helps their emerging painful emotional experience is the transform the maladaptive emotion. Spinoza first step towards tolerating emotion and self- (1967) was the first to note that emotion is needed soothing. Amygdala-based emotional arousal to change emotion. He proposed that ‘An emotion needs to be approached, allowed and accepted cannot be restrained nor removed unless by an rather than avoided or controlled (Greenberg & opposed and stronger emotion’ (Spinoza, 1976, p. Paivio, 1997). In this process people need to use 195). Reason clearly is seldom sufficient to change their higher brain centres to consciously recognize automatic emergency-based emotional responses. the emergency messages sent from the lower level Darwin (1897) on jumping back from the strike of

Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 3–16 (2004) Emotion-focused Therapy 11 a glassed in snake, noted that having approached reviewed research that indicates that specific emo- it with the determination not to start back, that his tions are associated with specific patterns of auto- will and reason were powerless against the imagi- nomic nervous system activity providing evidence nation of a danger which he had never even expe- that different emotions change one’s physiology rienced. Rather than reason with emotion one differentially. Emotion also has been shown to can transform one emotion with another. While be differentially transformed by peoples’ differing thinking usually changes thoughts, only feeling capacity to self-generate imagery to replace can change emotions. unwanted, automatically-generated emotions with Empirical evidence is mounting to support the more desirable imagery scripts (Derryberry & importance of a process of changing emotion with Reed, 1996) suggesting the importance of individ- emotion. Parrot and Sabini (1990) early on found ual differences in this domain. that mood repair occurs by people recalling events Bad feelings appear thus to be able to be replaced that counteract both sad and happy moods by happy feelings, not in a simple manner by and that this is done without awareness. In a trying to look on the bright side, but by the evoca- further interesting line of investigation positive tion of meaningfully embodied alternate experi- emotions have been found to undo lingering neg- ence to undo the negative feeling. For example in ative emotions (Frederickson, 2001; Fredrickson & grief, laughter has been found to be a predictor of Levenson, 1998). The basic observation is that key recovery. Thus being able to remember the happy components of positive emotions are incompatible times, to experience joy, helps as an antidote to with negative emotions. The experience of joy and sadness (Bonanno & Keltner, 1997). Warmth and contentment were found to produce faster cardio- affection similarly often is an antidote to anxiety. vascular recovery from negative emotions than a In depression a protest-filled, submissive, sense of neutral experience. These results suggest that pos- worthlessness can be transformed therapeutically itive emotions fuel psychological resilience. In a by guiding people to the desire that drives their further study Tugade and Frederickson (M. Tugade protest—a desire to be free of their entrapment. & B. Frederickson, paper presented at the meeting Isen (1999) notes that it has been hypothesized that of the International Society for Research in at least some of the positive effect of happy feel- Emotion, Quebec City, August 2000) found that ings depends on the effects of the neurotransmit- resilient individuals cope by recruiting positive ters involved in the emotion of joy on specific parts emotions to regulate negative emotional experi- of the brain that influence purposive thinking. ences. They found that these individuals mani- Mild positive affect has been found to facilitate fested a physiological bounce back that helped problem solving. There is growing evidence that them to return to cardiovascular baseline more positive affect enhances flexibility, problem solving quickly. In a study of dealing with self-criticism and sociability (Isen, 1999). In addition research on Whelton and Greenberg (2000) found that people mood congruent judgement has shown that moods who were more vulnerable to depression showed effect thinking and types of reasoning (Mayer & more contempt but also less resilience in response Hanson, 1995; Palfia & Salovey, 1993). Shifts in to self-criticism than peoples less vulnerable to mood lead to shifts in thinking. Good moods lead depression. The less vulnerable people were able to optimism, bad moods to pessimism. to recruit positive emotional resources like pride In a different line of research on the effect of and anger to combat the depressogenic contempt motor expression on experience Berkowitz (1999) and negative cognitions. These studies together reports a study on the effect of muscular action on indicate that emotion can be used to change mood. Subjects who had talked about an angering emotion. incident while making a tightly clenched fist Davidson, also suggests that the right hemi- reported having stronger angry feelings, whereas spheric, withdrawal-related, negative affect system fist clenching led to a reduction in sadness when can be transformed by activation of the approach talking about a saddening incident. This indicates system in the left prefrontal cortex. He defines both the effects of motor expression on intensify- resilience as the maintenance of high levels of pos- ing congruent emotions but on dampening other itive affect and well-being in the face of adversity emotions. Thus it appears that the expression of and highlights that it is not that resilient people do even the muscular expressions of one emotion can not feel negative affect but that what characterizes change another emotion. In addition, in line with resilience is that the negative affect does not per- the James Lange theory, Flack, Laird and Cavallaro sist (Davidson, 2000). Levenson (1992) has also (1999) have demonstrated that adopting the facial,

Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 3–16 (2004) 12 L. S. Greenberg postural and vocal expressions of an emotion it. Although exposure to emotion at times may be increases the experience of the emotion whether or helpful to overcome affect phobia in many situa- not the subject is aware of what emotion they are tions in therapy, change occurs because one expressing. The experience of an emotion to some emotion transforms into or is replaced by another degree can thus be induced or intensified by emotion rather than simply attenuating. In these putting one’s body into its expression. It is inter- instances emotional change occurs by the activa- esting to note that there are individual differences tion of an incompatible, more adaptive experience in this capacity, with those who are more body sen- that undoes or transforms the old response. sitive showing this tendency to a greater degree. A Clinical observation and our descriptive more general line of research in social psychology research suggest that emotional transformation on the effects of role playing on attitude change, often occurs by a process of dialectical synthesis of also supports the idea that performing actions in a opposing schemes. When opposing schemes are role brings people’s experience and attitudes in co-activated they synthesize compatible elements line with the role (Zimbardo, Ebbesen, & Malasch, from the co-activated schemes to form new higher 1997). Thus role-playing can transform what is at level schemes, just as in development when first not real into something real, as saying some- schemes for standing and falling in a toddler, are thing can lead to believing it (Myers, 1996). Thus a dynamically synthesized into a higher level possible way to evoke another emotion is to have scheme for walking (Greenberg & Pascual-Leone, people role-play its expression. As they express an 1995; Pascual-Leone, 1991). Schemes of different emotion it will change their experience towards the emotional states similarly are synthesized to form expression. new integrations. Thus in therapy maladaptive In psychotherapy research music has been found fear, once aroused, can be transformed into secu- to be helpful in evoking alternate emotions and rity by the more boundary-establishing emotions even more helpful than imagery for changing of adaptive anger or disgust, or by evoking the emotion (Russell, 1992). Right frontal EEG activa- softer feelings of compassion or forgiveness. Simi- tion normally associated with sad affect was larly maladaptive anger can be undone by adap- shifted toward symmetry by both massage and tive sadness resulting in acceptance. Maladaptive music (Fields, 1998). Shifts to more positive mood shame can be transformed into acceptance by or at least to symmetry between sad and happy accessing both anger at violation, self-comforting affect were accompanied by shifts from right to left compassion and by accessing pride and self worth. frontal EEG activation, in both mothers and chil- Thus the tendency to shrink into the ground in dren (Fields, 1998). shame is transformed by the thrusting forward Finally results of our single case investigations of tendency in newly accessed anger at violation therapies of depression combined with the larger to produce confidence. Withdrawal emotions from groups studies, relating emotional arousal to one side of the brain are transformed by approach outcome (Greenberg, 2002; N. Warwar & L. emotions from another part of the brain or vice Greenberg, paper presented at the International versa (Davidson, 2000). Society for Psychotherapy Research, Annual How then are new emotions accessed? How does Meeting, Braga, Portugal, June, 1999), supported the a therapist help people in the midst of their mal- principle that emotional arousal, and the attendant adaptive experience to access emotions that will replacement of emotion with emotion, occurred help them transform their maladaptive feelings significantly more in good than in poor outcome and beliefs? A number of ways are listed below cases. In a number of intensive analyses of good out- (see Greenberg (2002) for a fuller description of comes we found reductions in shame and fear and methods of accessing new emotions). increases in anger, sadness, contentment and joy. The patterns of emotional transformation however were idiosyncratic. Which emotions replaced which Shift Attention were idiosyncratic to each case. It is important to note that the process of chang- Shifting people’s focus of attention to pay attention ing emotion with emotion goes beyond ideas of to a background or subdominant feeling is a key catharsis or completion, exposure or habituation, method of helping them change their states. The in that the maladaptive feeling is not purged, nor subdominant emotion is often present in the does it simply attenuate by the person feeling it. room non-verbally in tone of voice or manner of Rather another feeling is used to transform or undo expression.

Access Needs/Goals CASE EXAMPLE Ask clients, when they are in their maladaptive This therapy focused on a client with multiple pre- state, what they need to resolve their pain. Raising senting concerns, including major depression, a need or a goal to a conscious self-organizing anxiety disorder and interpersonal problems over- system opens a problem space to search for a solu- coming her core maladaptive fear by accessing her tion. At the affective level it conjures up a feeling sadness at loss and anger at violation, and mobi- of what it is like to reach the goal and opens up lizing her current abilities to protect herself. Three neural pathways both the feeling and the goal. major means of acessing new emotions are exem- plified, shifting attention, accessing needs and expres- Positive Imagery sive enactment. Having spent the first three sessions establishing an empathic bond the therapy first Imagination is a means of bringing about an emo- focused on her primary fear of her abusive parents tional response. With practice people can learn and her fear of her dependence/weakness and how to generate opposing emotions through vulnerability. Her frequent expressions of shame imagery and use these as an antidote to negative and embarrassment in therapy were often mixed emotions. with her fear. Her parents had disciplined her with harsh criticism and ridicule, as well as physical abuse, and she stated that her greatest pain was Expressive Enactment of the Emotion that ‘they never believed in me’. She was called Ask people to adopt certain emotional stances stupid, crazy, a whore and a slut and grew up and help them deliberately assume the expressive utterly paralysed in interpersonal relationships. posture of that feeling and then intensify it. Thus Interventions were aimed at becoming aware of you might use psychodramatic enactments and and accessing her fear and shame in the session by instruct your client to ‘try telling him I’m angry. talking about her childhood. This led to experienc- Say it again, yes louder. Can you put your feet on ing and reprocessing these emotions and to a the floor and sit up straight?’ Coach the person in strengthening of her sense of self. expressing until the emotion is experienced. One of her earliest memories was of her father forcing her and her siblings to watch him drown a litter of kittens. This was to ‘teach her a lesson Remember Another Emotion about life’ and the client believed that he enjoyed it. The client accessed a core self-organization, Remembering a situation in which an emotion which included her ‘suppressed scream of horror’ occurred can bring the memory alive in the from this experience. While imaginally reliving present. this scene in therapy the therapist guided her attention to the expression of disgust in her mouth while she was feeling afraid. This mobilized this sub- Cognitively Create a New Meaning dominant adaptive emotion as a resource to begin Changing how one views a situation or talking building a stronger sense of self. Rather than about the meaning of an emotional episode often feeling afraid she accessed her alternate emotions helps people experience new feelings. of disgust and anger, which she actively expressed toward her father in an empty chair. She mobilized her adaptive needs to not be violated by her father The Therapist Expresses the Emotion and to be protected by her mother and expressed for the Client these to her parent in the empty chair dialogues. Expression and exploration of her vulnerability The therapist might express the outrage, pain or (fear and sadness) took place, not to the imagined sadness the client is unable to express. father, but in the affirming and safe dialogue with the therapist. There often were times of shame mixed with fear Utilizing the Therapy Relationship to in therapy. For example, in evoking the shame in Generate New Emotion the session she felt small and insignificant in front A new emotion is evoked in response to new inter- of her imagined parents, at first she was completely actions with the therapist. unable to imagine facing them or to look them in

Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 3–16 (2004) 14 L. S. Greenberg the eye, and shrunk away from being the object of been accessed to guide action and transform mal- their scorn. The shame associated with her father adaptive emotions, experience is reflected on and was mixed with fear and disgust at recalling his incorporated into new views of self that are used sexual innuendoes. These imaginary confronta- to transform personal narratives. tions with the father evoked her fear and her painful memories of childhood beatings, of being REFERENCES told she was bad, and of being aware of nothing but her desperate need to escape. The therapist Arnold, M.B. (1960). Emotion and personality. New York: responded supportively to her overwhelming fear Columbia University Press. Bechera, A., Damasio, H., Tranel, D., & Damasio, A. and powerlessness at the time and asked how she (1997). 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