Understanding Emotion-Focused Therapy

A Conversation with Les Greenberg

Amalia Rosenblum

April 30, 2020

Following the current series of lists, many readers contacted me, asking for referrals to therapists with an emotion-centered approach. To provide a clearer picture of how the treatment is conducted, I asked Les Greenberg, the founder of the approach, to briefly review this unique therapeutic experience.

What would you say to readers who are considering starting emotion-focused individual therapy?

"You can expect the development of an official relationship with the therapist, which, despite being official, is also an understanding and safe relationship. You should expect to feel emotions, and know that sometimes these will be painful emotions, but the therapist will be there to support you. Expect to go through a deeper emotional experience than you usually do in everyday life.

"You should also know that you will find yourself involved in activities such as talking to an empty chair, using your imagination, and dealing with childhood wounds. It is important for me to emphasize that you should not talk about childhood wounds in the way you might imagine, because in emotion-focused individual therapy, the therapist helps you feel them anew, which is more difficult and hurts more than talking about them.

"Ultimately, if you are in skilled hands, you will finish the process with a new and more positive feeling about yourself, and in general, you will start to feel better. The treatment will result in you enjoying greater emotional flexibility, and when you are in emotional situations that previously would have activated you in a negative way, you will find that they have little effect on you."

How long does this process take?

"Many of the patients can benefit from 16 treatment sessions, but you should know that it can also last longer. In my experience, a minimum dose in individual treatment is between 12 and 16 sessions, which is not much compared to dynamic treatments."

Is it important for patients to understand how the approach works?

"Patients do not need to understand intellectually or academically how emotion-focused therapy works. The significant thing for them is their possibility to have a new emotional experience. However, it is important that the patient and the therapist define a common focus. The patient needs to feel that they are both working together for one goal, and doing it in ways that make sense to the patient and not only to the therapist. That is, even without understanding all the nuances of the approach, it is important that the patients know what the focus of the treatment is and that they feel that this focus makes sense, because the issue that is at the center of the treatment is one of the factors that are at the root of the problems they are dealing with."

Can you give an example?

"Suppose a young girl suffers from exam anxiety. She studies law and takes the certification exam, but in the middle of the exam, she has an anxiety attack. As a result, she comes to emotionally focused therapy. During the first sessions, she talks with the therapist and comes to an informed hypothesis along the lines of: 'My exam anxiety is related to the fact that my father has very high expectations. He is a judge, and he really expects me to excel. He is a cold and distant father, and I feel that he abandons me and criticizes me.'

"In light of this hypothesis, the patient should formulate a statement of this kind to herself: 'My treatment now focuses on my relationship with my father to reduce my performance anxiety because the real basis of this performance anxiety is probably my relationship with my father.' The process is related to the fact that the therapist reflects and summarizes for her what he hears her say.

"If we continue with this example, the therapist can say to the patient: 'It seems to me that it is important to work on the fear of your father's criticism. It sounds to me like this fear stays with you when you enter the exam room, and you feel that you only have two options: excel or fail.' He is responsible for identifying the relevant underlying problem, and he must also be the one who makes the patient feel that working on her relationship with her father is related to her exam anxiety."

Now for the really important question: why should an elderly person talk to an empty chair?

"The empty chair technique developed from the Gestalt approach, which deeply influenced my work. Its effectiveness is based on the fact that there is a significant aspect of emotion that is activated only when we express our feelings directly, and does not come to expression when we talk about them indirectly.

"If the patient talks to the therapist about her father, as in the example I gave, it is not certain that this talk will lead to a strong emotional arousal. Certainly not compared to the emotional arousal that will occur if I instruct her to imagine her father sitting in front of her, and then I ask her to talk to him and tell him about the feelings he arouses in her. The important point is that direct expression is different from awareness. When we speak directly to characters we see in our mind's eye, direct expression activates emotions that were there but may have been buried deeper. These emotions are the raw material of emotion-focused therapy.

"The other significant element is the use of imagination. When you talk about your father, the experience is weaker than when you talk to him, even if you just imagine him sitting in the empty chair. Imagination is an effective tool that activates a great many non-verbal expressions such as hand movements and facial expressions. These empower the emotional message and help therapists see what's going on and help patients become more aware of what they're really feeling."