Sunday, July 15, 2012

Susan Johnson - The Power of Emotion in Therapy

In the May/June issue of Psychotherapy Networker Susan Johnson had an excellent article on the power of emotion in psychotherapy. Johnson covers everything from neuroscience to attachment theory, as well as the use of emotion in the therapeutic relationship. I think it's great that she points out that the so-called cathartic expression of anger can actually be counter-productive for some clients. Great article.

The Power of Emotion in Therapy

How to Harness this Great Motivator

By Susan Johnson

Neuroscientists have recently established that emotion is the prime organizing force shaping how we cope with challenges. Now psychotherapists are learning how to work with emotion, rather than trying to control it.

“God guard me from those thoughts men think in the mind alone. He that sings a lasting song, thinks in a marrow-bone.”—W. B. Yeats.

Mike leans forward, and in a low, intense voice, says, “Look. It wasn’t my idea to see a couples therapist. And I hear that this therapy you do is all about emotions. Well, that about counts me out. First, I don’t have them the way she does.” He points to his wife, Emma, who’s staring angrily at the floor. “Second, I don’t want to have them or talk about them. I work through problems by just staying cool. I hold on tight and use my little gray cells.” He taps his head and sets his jaw. “Just tell me what’s wrong with us—why she’s so upset all the time—and I’ll fix the problem. Just tell me what to say, and I’ll say it. We were just fine until we started to have kids and she started complaining all the time. All this spewing of ‘feelings’ just makes things worse. It’s stupid.” He turns away from me, and the silence is filled with the sound of his wife’s weeping.

The irony of this type of drama never fails to intrigue me. In one of the most emotional scenarios ever—a couple trying to talk about their distressed relationship—here’s a partner insisting that the solution to distress is to ignore the emotion! Worse still, I’m getting emotional! This client is upsetting me. I breathe in and get my balance. After all, I remind myself, what he’s saying is so normal.

Mental health professionals would agree with him. In fact, I agree with him, to some extent. Venting strong, negative emotion—usually called catharsis—is nearly always a dead end. More than that, most of us are wary of strong emotions. Emotions have traditionally been seen, by philosophers like RenĂ© Descartes, for example, as part of our primitive animal nature and, therefore, not to be trusted. Reason, by contrast, has long been thought to reflect our higher spiritual self. In neuroscientific terms, the implication is that we’re at our best when we live out of our prefrontal cortex and leave our limbic brain behind. More specifically, emotion is often associated with disorganization and loss of control. As Latin author Publilius Syrus, known for his maxims, wrote in the first century B.C., “The sage will rule his feelings; the fool will be their slave.”

All this is now changing. We’re in the midst of a revolution, as far as emotion is concerned. Antonio Damasio, one of the great scholars in the emotion field, notes that this revolution began in the 1990s, when the inherent “irrationality” of emotion began to be questioned. We’re now at the point where emotion—the apparently crazy, irresponsible sleazebag of the psyche—has been identified as an inherently organizing force, essential to survival and the foundation of key elements of civilized society, such as moral judgment and empathy. Emotion shapes and organizes our experience and our connection to others. It readies us for specific actions; it’s the great motivator. As the Latin root of emotion, movere (to move) suggests, strong feelings literally move us to approach, to avoid, to act.
Way before this emotion revolution, many therapists accepted that there was more to emotion than simply learning to control it—that directly working with emotion was somehow central to the task of therapy. We recognized that old Publilius was wrong: it’s not always good to control your emotions rigidly, and it’s not always foolish to listen to them! The idea that some kind of “corrective emotional experience” was necessary for any kind of effective psychotherapy was repeated endlessly, at least in the more dynamic psychotherapies. But exactly what the key elements of this experience are and how we get there with our clients remains difficult to define.

Even with this more emotion-friendly attitude, it seems to me that, as a field, we still tend to err on the side of bypassing or containing emotion, rather than actively using it for change. For many years, this seemed to be particularly true in couples and family therapies. It makes sense, in that emotions are especially intense in difficult interactions with loved ones. Therapists have to deal with powerful attachment dramas, which unleash rivers of emotion in their clients, and their own emotional issues can be triggered as they watch these dramas unfold. Such therapists had better know their rivers, and how to swim! Otherwise, it’s safer to sit on the bank, hold on to the traditional distrust of emotion, and try to create change through purely cognitive or behavioral means. But these interventions may not be sufficient, given that emotion and emotional signals are the central organizing forces in intimate relationships and that changes in emotional responses, such as increased love and tenderness, are hard to generate if we don’t work with emotion directly.

For many of us, formal training doesn’t help much here. How many professional training programs—even now, when we know so much more about the significance of emotion—systematically teach how to understand emotion or to engage and use it to create transformation in clients? In clinical psychology programs, young therapists mostly seem to learn how to teach clients techniques for moderating out-of-control emotions. Even if we look at a master therapist who explicitly values emotion, such as the great Carl Rogers, we see less direct focus on emotion than we might expect. So it makes sense that many of us remain a little intimidated or off-balance in the face of the compelling experience of emotion. It’s difficult for us to embrace it as a positive force and use it as a powerful tool for shaping growth in our clients.

“Research tells us that when therapists help clients deepen emotion, clients attain better outcomes in therapy. If we can become comfortable with the power of emotion, it becomes the therapist’s greatest ally, rather than a disruptive force to be contained.”
It’s self-evident that emotion is captivating. If we can tune in to and address clients’ deeper emotions, the therapy process is at once tangibly relevant, and they engage. Research tells us that when therapists help clients deepen emotion, clients attain better outcomes in therapy. When we shape powerful emotional interactions in Emotionally Focused Therapy (EFT), we see seismic shifts in the core interactions that define lifetime relationships. Emotion takes us to the heart of the matter. New emotional mosaics create new perceptions and meanings. Even more important, they move us—psychologically and physiologically—into new response modes. If we can become comfortable with the power of emotion, it becomes the therapist’s greatest ally, rather than a disruptive force to be contained.

Even if we view emotions as essentially problematic, damping them down or circumventing them is no small task. Therapists often try to defuse negative emotion with such techniques as structured skill-building exercises, but the emotion usually seeps through and takes over anyway. We’ve all seen empathy or positive communication exercises miss the mark when they’re done with flat facial expressions or hostile tones. Physiologically, the attempt to suppress emotion is hard work, often resulting in increasing arousal. James Gross, a key researcher in affect regulation, finds that interactional partners pick up on this increased arousal and become more agitated themselves. We can all relate to the argument that goes: “You’re mad,” “No, I’m not” (said with clenched teeth), “Yes, you are; I don’t even want to talk to you.” But perhaps even more important than the effort required to regulate emotion is the fact that new, positive ideas and actions that emerge in session remain peripheral, unless we feel their force and connect with them on an emotional level.

What do therapists need to know to harness the power of emotion in therapy sessions? I remember when I was an idealistic young therapist starting to work with couples and suddenly coming face-to-face with such tsunami-like emotion that, to be able to stay with and focus on the wave, I needed to see the order, the patterned structure of this experience. As I came to understand emotion better, I gained understanding about the way in which key emotions were constructed and processed. I became less intimidated and learned to embrace and ride the wave, using its force to create change. By learning about emotion, I was able to help clients order these experiences and use them positively in their lives.

I could do all of this because I’d been given a great map: I had Attachment Theory—a systematic framework for personality and relationship development—as a guide. This theory of self in relation to others places emotion and its regulation front and center. John Bowlby, its father, saw emotion as the great communicator. It gives us a “felt sense” of our own physiology—our “gut wisdom.” It connects us with our preferences and longings. It links us to others with lightning speed. For Bowlby, the dance of connection and disconnection with loved ones plays a pivotal role in defining who we are; emotion is the music that organizes this dance and gives it rhythm and shape.

In the case of Mike and Emma, I feel more grounded and calm when I can track exactly how Mike regulates his emotions: he dismisses and denies them. This affects how he frames his signals to his partner—a process that elicits particular negative emotional responses from her. These responses then confirm his need to “hold on tight” and deny his emotions. Emotions aren’t just inner sensations and impulses; they’re social scripts. Self and system are molded in an ongoing feedback loop, which neither Mike nor his partner are aware of. The attachment framework sets out the deep logic of seemingly unpredictable emotions and tells me how and why Mike and Emma deal with them the way they do. There are only so many ways to deal with emotional starvation and the universal experiences of rejection and abandonment. When I know the territory, I feel confident enough to explore the terrain.

What Is Emotion, Anyway?
Science suggests that emotion is anything but primitive and unpredictable. It’s a complex, exquisitely efficient information-processing system, designed to organize behavior rapidly in the interests of survival. It’s an internal signaling system, telling us about what matters in the flood of stimuli that bombard us and tuning us in to our own inner needs. Research with brain-damaged subjects shows that without emotion to guide us, we can’t make even the most elementary of decisions; we’re bereft of preferences and have nothing to move us toward one option rather than another.

Emotional signals, especially nonverbal, such as facial expression and tone of voice, communicate our intentions to others. Our brain takes just 100 milliseconds to detect and process the smallest change in a human face and just 300 milliseconds to mirror this change in our own body, so we literally “feel” another’s emotion. The fact that we can rapidly read intentions and coordinate actions has offered our species a huge evolutionary advantage. The ability to read six basic emotional expressions and assign the same meaning to these expressions is universal.

There’s a consensus among experts that these basic emotions are anger, sadness, joy, surprise, shame, and fear. In anger, for example, the stare becomes fixed, eyes widen, and the brows contract; the lips compress and the body tenses. The impulse is to mobilize and move toward the object of the emotional response, so as to take control or eliminate the obstacle. When a client sits in front of me and tells me she has no idea how she feels, it helps me immeasurably to know that, in all probability, she’s feeling her own version of one of these six core emotions.

We have evidence that just naming emotions—literally putting feelings into words—seems to calm down amygdala activity in the brains of subjects viewing negative emotional images or faces. So it may help us “trust” emotion and see it as a positive tool in psychotherapy if we can keep in mind the elements that make up an emotional experience. First, there’s a cue from the environment. This is followed by an initial general perception (such as “bad”) and orientation to this cue and physical arousal. The meaning of cues and sensations is further evaluated in a more reflective cognitive appraisal. All these things prime a “move”—a compelling action tendency. These reactions all happen inside the skin, but they don’t stay there. Emotion isn’t silent or hidden.

The signals that accompany this process create what psychologist and author Daniel Goleman calls a “neural duet” with others. Much of the time, this process is implicit and instantaneous. Mike turns away when Emma asks him about his day; Emma picks up this cue and her brain frames it as “bad” and “dangerous”; Emma’s heart rate speeds up, and her body tenses; she scans for what this means and hits on “I’m losing him, he doesn’t want me”; she moves closer to Mike and, in an intense voice, says, “You never want to talk to me, anyhow”; Mike hears anger, so he closes down and shuts her out.

Once the cue has occurred, all these elements are shaped by Emma. Part of my job as an experiential therapist is to tune in to just how she does this. In this distressed relationship, she constantly monitors Mike’s responses and is exquisitely sensitive to any potential rejection from him. At the first sign of rejection, her mammalian brain lights up in alarm. Neuroscience researcher Jaak Panksepp calls this alarm “primal panic.” The neural circuit used here is the accelerated pathway through the thalamus to the amygdala; information about the responsiveness of an attachment figure has enormous survival significance, so the slower route through the reflective prefrontal cortex is bypassed. The meaning Emma makes here—that she’s unloved and Mike is cold and mean—reflects experiences that remind her how dangerous it can be to reach for others. She moves close to lessen her sense of threat and pushes for a different response from her husband. He sees her as intrusive. When he moves away, he confirms her deeper fears, and so helps to shape her ongoing experience.

What’s missing from this version of Emma’s emotional drama is that she tries to regulate her emotion. Regulation isn’t something we do to emotion; it’s just part of the process. As Dutch psychologist Nico Frijda puts it, we’re continually shifting the balance between letting go and restraint. We have reactions to our initial sense of what’s going on, and we try to cope with them as they’re happening. This translates into different levels of emotional experience.

At the end of this drama, which takes six seconds at most, Emma explodes in reactive anger. If we were to stop the frame at her first visceral response, we’d call her emotion fear. Her overt anger is a response to her sense of threat. An emotionally focused therapist would see her anger as secondary and the fear as her primary emotion. If she could slow down and pay attention to her fear, her action tendency might be different; for example, she might ask for reassurance. She could also, conceivably, have reacted to her own fear by moving into numbing, especially if she’d accessed thoughts of hopelessness and helplessness as part of her search for meaning. But she doesn’t register her fear. When she talks about this drama in my office, she looks angry and blames her husband for his coldness.

Not only do we have different levels of emotion, we have reflexive emotions—emotions about our emotions. Clients often have deep anxiety about the catastrophe that awaits if they stay with their primary softer emotions, like sadness or fear. The general list of negative expectations can be framed as responses to the open-ended sentence, “If I become open and vulnerable, I’ll find that I’m. . . .” The answers—which can be summarized as the 4 D’s—are: defective, disintegrating, drowning, or dismissed. This list seems to cut across gender, class, and culture.

Clients express these fears as follows: “If I feel my softer, deeper emotions, this means that I’m weak or inadequate; others will see me this way and reject me”; “If I feel this, I’ll become more and more distressed; I’ll lose myself”; “If I feel this, the emotion will never go away—it’ll go on forever, and I’ll drown in it”; “If I feel this, no one will respond or be there to save me.”

I used to see clients’ expression of this kind of pain as a metaphor, but it’s more than this. Emotions “are of the flesh, and they sear the flesh,” said Frijda. Until recently, the parallels between emotional pain, such as rejection, and physical pain, like burning your arm, were thought to be purely because of shared psychological distress. Now it’s clear that there’s a neural overlap in the way we process and experience social and physical pain. Tylenol can reduce hurt feelings, and social support can lessen physical pain. As predicted by Attachment Theory, emotional isolation and the helplessness associated with it seem to be key features of this emotional pain. Our need for connection with others has shaped our neural makeup and the structure of our emotional life.

Once we can name implicit core emotions, track them through our clients’ nonverbal communication, and thus create an integrated emotional experience by identifying all the elements and placing them in an attachment context, it isn’t difficult to work with clients who are usually inexpressive or unaware of their feelings. When clients can touch their core emotions, implicit cognitions about the self, others, and the nature of life emerge and become available for review. For example, withdrawn partners often share deeply held negative beliefs about the inadequacy of the self. So we can understand the nature of emotion, its key elements, its different levels, and how it connects to action, cognition, and interaction, but sometimes being around strong emotions feels just plain dangerous.

When Does Emotion Go Wrong?
When we can access, regulate, and integrate our emotions, they provide an essential guide to living. But emotions, like everything, can go wrong. They’re like “best guesses” as to what we should do in a situation, not “surefire winning solutions,” says Stanford psychologist James Gross, who’s done extensive research on emotional regulation. Demystifying the problems that occur with emotion can again increase confidence that emotion shouldn’t be feared by clients or therapists.

For better and for worse, strong emotion tends to restrict our range of attention. A negative emotion, like fear, can elicit irrational beliefs. It can flood us so that we can’t think straight or only think in constricted, black-and-white terms. One metaphor that’s now taking hold among my neuroscience colleagues is that the brain is a ruthless capitalist, which budgets its resources. Being afraid and trying to calm yourself is expensive in terms of resources like blood and glucose; areas specializing in cognitive tasks, like the prefrontal cortex, get starved.

In simple terms, therapists and clients describe problems in terms of too much emotion, too little emotion, or conflicting emotions. Emotions can be overwhelming and create feelings of disorganization or chaos. Some clients can connect with different elements of their emotional experience, but can’t order them into an integrated coherent whole; they use words like fragmented and confused to describe their inner life. Traumatized clients speak of being hijacked by all-encompassing emotional experiences in traumatic flashbacks. Other clients report feeling flat or cut off from any clear sense of their experience; their inability to formulate or name emotions leaves them aimless, without a compass to steer toward what they want or need. Many clients express conflicting emotions. In couples therapy, they speak of longing to be close and fearing to be close. In individual therapy, they may deny the fear laid out in a previous session, shame at vulnerability now blocking the recognition of this emotion. Specific strategies for regulating emotion can be problematic as well, especially if they become habitual and applied across new contexts. Therapists working with trauma survivors need to validate that, at certain times, it’s functional and necessary to compartmentalize or even dismiss emotion. Alan, an Iraq War veteran, tells me, for example, “When you’re landing a helicopter under fire, you just focus on the IAI [Immediate Action Item], coping. Get the chopper down. Never mind your fear. Just step past it and focus on the task.” This saves Alan’s life on deployment. But if suppressing emotion becomes a general strategy, it turns into a trap. Numbing is the most significant predictor of negative outcome in the treatment of PTSD. It also sends Alan’s marriage into a spiral of distress that further isolates and overwhelms him.

A clear model of emotional health helps therapists find their way when these emotional processing problems occur. As a Rogerian and an attachment-oriented therapist, I have five goals for my clients. I want to help them: tune in to their deeper emotions and listen to them; order their emotional experience and make it into a coherent whole; keep their emotional balance so they can trust their experience and follow their inner sense of what they need; send clear, congruent emotional signals to others about these needs; and reciprocally respond to the needs of others. Buddhist teacher Jack Kornfield speaks to these goals in his book The Wise Heart, where he suggests, “We can let ourselves be carried by the river of feeling—because we know how to swim.”

We all encounter negative experiences and emotions; that’s simply how life is. But humans have an invaluable survival adaptation: when we’re emotionally stressed and our prefrontal cortex is “faint” from hunger, we share burdens and turn to others for emotional and cognitive sustenance. When we can learn—often with the help of another who’s a “safe haven” for us and can offer an extra prefrontal cortex—that negative emotions are workable, that we can understand them and find meaningful ways to cope with and embrace them, they lose much of their toxicity. They can become, in fact, a source of aliveness.

Countless studies on infant and adult attachment suggest that our close encounters with loved ones are where most of us attain and learn to hold on to our emotional balance. This echoes ancient Buddhist wisdom encouraging practitioners to meditate on the faces of loved ones or on the experience of being held as a way of finding their balance in an emotional storm. Secure connection with an attachment figure, or a surrogate attachment figure—a therapist, for example—is the natural place to learn to regulate our emotional responses. It’s when we can’t reach for others or access inner models of supportive others in our minds that we resort to more problematic regulation strategies, such as numbing out, blowing up, or rigidly trying to control our inner world and loved ones. The attachment perspective allows a therapist to see past these secondary strategies to discern deeper, more primary emotions—the desperate loneliness and longing for contact behind apparently hostile or dismissing responses, or the sense of rejection and helplessness underlying a withdrawn person’s apparent apathy. The attachment perspective asserts what neuroscientists like James Coan are discovering in their MRIs: regulating emotions with others is a baseline survival strategy for humans. Effective self-regulation, behavioral psychology’s mantra for years, appears to be dependent on and emerge from positive social connection.

Emotion in the Consulting Room
So what are the main messages of this new revolution in emotion for therapists? The first message is that emotion matters. When it’s dismissed or sidelined, we’ll often fail to engage our clients optimally or make the tasks of therapy personally relevant, and thus limit positive outcomes. The second message is that if we know the structure and function of emotion, as well as how it’s shaped in human relationships, we can use its power to create lasting change in a deliberate, effective manner. This is true in individual and couples therapy, and for each, I suggest that the old adage that significant change requires a “corrective emotional experience” applies. But specifically what have experiential therapists learned from the science of emotion about dealing with emotion and creating such corrective experiences?

Nearly all therapy models now agree on the necessity of creating safety in session, if for no other reason than to facilitate our clients’ open exploration of their problems. This safety is particularly essential if a client is to engage with and explore difficult emotions. For an attachment-oriented therapist, it has a specific meaning: in the session, therapists have to be not just kind or empathic, but truly emotionally present and responsive. This creates a holding environment, where clients can risk engaging in what Fritz Perls, the founder of Gestalt Therapy, called the “safe adventure” of therapy. Part of a therapeutic presence relates to transparency, the therapist’s willingness to be seen as a person who can be unsure or confused at times, rather than an all-knowing expert. If I’m emotionally engaged, my mirror neurons will help me check into my own feelings to understand those of a client.

In the treatment of problems such as depression, across different models, “collaborative,” emotionally oriented interventions have been found to predict positive outcome better than more expert-oriented, “coaching” interventions. Collaborative means that therapists join clients wherever they are—in their reactive rage or numb indifference—and find a way to validate these responses before exploring any unopened doors or alternative angles. Rogers told us long ago that the more we accept ourselves and feel accepted, the more we’re open to change. Often, this means that therapists need to resist the pressure to fix problems instantly, and find the inherent logic in how their client is feeling and acting in the moment.

Attachment and neuroscience emphasize the impact of gesture, gaze, facial expression, and tone of voice on the emotional reality of someone who’s anxious and in pain, and who’s sought the counsel of someone presumably “wiser.” The use of a soft, soothing voice on the part of the therapist makes sense here. Emotion is fast, so it makes sense to slow down if we want to help clients process emotion in new ways. Repeating simple, emotional terms that clients have found for themselves seems to foster the exploration of “hot” experiences. This can be summarized, for those who like acronyms, as using the 3 S’s—slow, soft, simple—to create a fourth S—emotional safety. If a client is overwhelmed, for example, in a traumatic flashback, this kind of presence and empathic reflection grounds him and helps him keep a “working distance” from his emotion. Focused empathic reflection soothes clients; they feel seen and heard. In EFT couples research, the initial level of a couples’ distress doesn’t significantly predict outcome, but the level of engagement in the treatment process does. The kind of alliance described above fosters this engagement with the therapist and the tasks he or she presents.

In the case of Mike and Emma, I might say to Mike softly and slowly, “I hear how much you want to fix this problem, Mike. It must be so hard to be turning on those gray cells and not to be able to fix this. It’s hard to keep your balance. So you just try to hold on really tight when Emma gets upset with you, to keep some control here, yes?” After a while, I begin to ask questions about just exactly how he “holds on tight” and what this feels like. This image offers me an emotional handle, a way into Mike’s experience of himself and his relationship.

An Emotional Focus
Experiential therapists learn to use emotion as a touchstone—to stay with, focus on, and return to emotional experience, constantly tracking emotional responses and developing them further. Creating a corrective emotional experience begins with this process. To stay here, rather than to move on to focus on modifying behaviors, creating insight, or offering advice requires a willingness to be relentless in guiding clients past tangential issues. This is infinitely easier if you have a basic knowledge of the science discussed above and a systematic way of working that’s been empirically validated with different kinds of clients. All this offers a secure base for intervention, but it still isn’t easy to keep reflecting and repeating the themes that show up in each client’s emotional responses until the ordered patterns in experiencing and interacting emerge and their consequences become clear. Empathic reflection is the primary tool here, though its versatility is often missed. In one stroke, a tuned-in reflection can calm clients and build safety, focus the therapy process, and slow down the flow of experience and interaction so that grasping key elements is possible. It helps order and distill emotion into something explicit and workable. As this process is repeated and tentative fresh meanings emerge, often in the form of evocative images, a new, coherent picture of inner and interpersonal realities is formed. Fragmented and unformulated elements are integrated into a new whole, which opens up new possibilities for action.

So with Mike and Emma, the therapist might say, “Can you help me, Mike? You’re saying that you want some magic words that would stop Emma from being upset? And you’re worried that if we talk about emotions, it’ll be just like the arguments you have at home?” Mike nods emphatically. “You’re going to hear Emma complaining about you, saying she’s disappointed with the relationship, while you don’t even understand what’s really wrong here? Talking about this is almost like a danger zone you don’t know the way out of. So you get frustrated and just want all this fixed. And when you can’t fix it . . . ?”

“I leave,” Mike says. “I go for a walk. What’s the point of standing there arguing? I just shut the door on her and go for a walk. There’s nothing else to do.” Understanding emotions in the context of attachment, it’s easy to anticipate that Emma experiences Mike’s withdrawal as a sign of abandonment and then protests his distance by further complaining and criticizing. Indeed, she now adds, “Right, and I’m all alone in the house upset. You just walk away like I don’t matter. I hate feeling so hurt all the time. I spew. I can’t let you just walk away.”

The therapist might reflect the whole emotional drama by saying, “And the more you turn away, Mike, to try to stop the upset, the more you feel alone, Emma? You end up spewing words to get him to turn around and not leave you? This loop has kind of taken over. It’s painful for both of you.”

Experiential therapists would be careful to validate and normalize Emma’s hurt so that she’ll continue to explore and own it. Hurt feelings have been identified as a combination of reactive anger, sadness over loss, and fear of abandonment and rejection. Attachment theory predicts that Emma’s critical pursuit is fueled by anxiety and a sense of lost connection with her partner. This knowledge guides the therapist as he or she reads Emma’s emotional cues. As Emma opens up to her emotions, she moves past her rigid, angry stance into deeper emotions of sadness and bewilderment, and begins to tell Mike about her loneliness. The expression of new emotions then evokes new responses. Mike sees her sadness and feels relief and compassion—as it’s happening, in the present.

Therapies that privilege emotion, such as EFT and Accelerated Experiential-Dynamic Psychotherapy, state that the most powerful way to work with emotion is in the present moment, as it’s happening and being encoded in the neurons and synapses. Working with emotion from the bottom up, as it’s being shaped, makes for a vivid encounter with key emotional responses. Clients usually start a session by giving a cognitive account of their feelings or going over past emotional stories. But to access the true power of working with emotion, the therapist must bring pivotal emotional moments and responses into the session. This creates an intense spotlight on process, the specific way emotion is created, shaped, and regulated.

Mostly, we act as if emotions simply happen to us; we don’t see how we shape our own experience and induce negative responses from others. Viewing experience as an active construction is empowering. Clients are then able to face the ironic fact that their habitual ways of dealing with difficult emotion—ways that may have gotten them through many dark nights of the soul—now trap them and create their ongoing pain.

So I ask Mike questions that help him tune in to his own emotional processing. “Mike, right here, right now, Emma is telling you that she’s angry and that the moment that really triggers her is when you turn and walk away. What’s happening for you as you hear this?”

“That’s just what she did yesterday,” he replies, and offers a theory that all women get angry for very little reason.

I try again: “Right now, how do you feel when she says, ‘You just walk away,’ in an angry voice?” Mike just shakes his head. He begins, “I don’t know—don’t know which way is up here—lost my balance.”

I lean in and ask, “Can you feel that sense of being off-balance right now?” He nods again. “What does it feel like?”

He slumps back in his chair and says, “Like I’m lost in space. My world is falling apart and I don’t know what to do.” He gives a long sigh.

Many therapists who are comfortable going to the leading edge of a client’s emotions will go one small step further and make small additions or interpretations, such as, “Falling, losing direction, no balance—that sounds very hard, scary even.” If Mike accepts the inference and allows himself to touch his fear, he might reply, “Yes. I’m scared. We’re falling apart. So I run away. What else is there to do?”

By staying focused on Mike’s experience and continually piecing it together in vivid and specific language, the therapist helps him create a felt sense of his experience and expand it. Continual validation of his experience and reflective summaries allow him to stay engaged with, but not be overwhelmed by, his emotions. He can begin to pay attention to Emma’s messages about how his distancing affects her, and both partners can see how they generate the demand–withdraw dance, which triggers their distress. Once difficult emotions become clear and workable, clients can better hear and empathize with the other partner. They begin to own their problematic emotions, move past surface responses into deeper concerns, and take a metaperspective on inner processing and interpersonal responses. But this is only the first stage in personal and relationship change.

New Emotions, New Signals, New Steps
Emotionally focused therapists have to help clients create positive patterns of effective emotional regulation and response. These patterns build a sense of efficacy and foster positive cycles of emotional responsiveness, which shape secure bonds with others. These, in turn, reinforce the effective regulation of emotion. Moving into deeply felt vulnerabilities and congruently sharing them with a trusted therapist or loved one leads naturally to a new awareness of heartfelt emotional needs. This is the first crucial step to meeting these needs in a positive manner.

In couples therapy, the open, congruent expression of such needs tends to touch and move the other partner, evoking empathy and increased responsiveness. To deepen emotion, therapists can reflect back on and repeat the emotional images and phrases a client has used all through therapy, carefully eliciting the deeply felt elements of an emotion to create a cognitively coherent yet bodily experienced reality. When this core emotion is owned and integrated, it changes a client’s sense of self and engagement with others. After about a dozen sessions of couples therapy, Mike is able to reach for his wife with a new openness and clarity.

He begins, “I know I’ve shut you out. But it’s all I knew how to do. When we get into our fights, I feel so lost [initial perception]. I get all spacey and confused [body response]. I’d tell myself that you’d never loved me—me with my grade-12 education. I just wasn’t good enough for you [catastrophic meaning]. So I’d run [action tendency]. Now, I don’t want to hold on for dear life every time you’re angry, but I want you to stop pushing so hard. Give me a break. I don’t want you to feel alone. I want to learn to be with you. I need you close to me.”

Mike’s longings and needs are now clear, and he reaches for Emma in a way that triggers a reciprocal openness. These fully felt emotional moments and interactions release a torrent of positive feelings and new ways of seeing. A new music of positive emotions—surprise and joy—begins to play. New vistas of safe connection to one’s own experience and to others open up. More coherent emotions lead to more coherent messages to others and more organized, effective action. As the proponents of Positive Psychology suggest, positive emotion has a broadening and building effect on the human psyche.

A Corrective Emotional Experience
Just as we can now unpack the elements of emotional experience, maybe we can unpack this age-old phrase and try to capture the essence of change. “Corrective,” emotion researchers remind us, doesn’t mean that older experience is erased or suppressed. The emotional system doesn’t allow data to be removed or placed to one side easily because nature favors false positives over false negatives where matters of survival are at stake. But old neural networks can be added to or even overwritten. So there’s no need to “get rid of” negative emotions; rather, we should try to expand them. When reactive anger is validated and placed in context, the threat that’s a vital part of that anger comes to the forefront, and this awareness changes how the anger is experienced and expressed. This sense of threat, or any primary emotion, is most easily discovered, distilled, and made into an integrated whole within an emotionally congruent, accepting therapeutic relationship. This sense of safety is necessary for a corrective experience, but it’s not enough.

For a corrective experience to occur, we must engage with and attend to our emotions in new ways and on deeper levels. I remember telling my therapist that, in spite of flying constantly, I was still somewhat afraid. We explored this, going moment by moment through my experience of flying and ordering the elements so that the structure of this experience became clear. Suddenly, we both realized that I was using so many techniques to “deal with” being on the plane that I was never actually present enough to experience anything new! My extensive coping mechanisms had become the problem. Imagine my surprise when I actually sat on a plane, heard my therapist’s voice in my head telling me to just be present, and found that I liked roaring into the air and floating off to new places! Part of correction is also the creation of new meanings. Flying became a way to explore my universe, rather than a near-death experience to be survived.

Corrective experience redefines the experiencer. I became someone who could get used to flying and felt able to fly. With a new sense of mastery comes new emotions; in this case, exhilaration. New action tendencies follow. I joyfully signed up for a trip that included many flights on small planes through foreign lands!

Corrective also implies that the emotional messages I send to others, as well as their impact, will evolve and change as they’re received and reciprocated. As Emma becomes more empathic, her acceptance acts as an antidote to Mike’s acknowledged sense of failure, especially when he directly shares these feelings and takes in her tender acceptance. As Mike feels less lost and overwhelmed in his interactions with his wife, he can tolerate her expressions of disappointment and tune in to her hurt. She accesses her longing and asks for comfort. As he responds, they create powerful bonding interactions. Their new safe-haven connection will continue to reshape not only their old habits of defensive withdrawal and reactive criticism, but also their vigilance for potential threat.

An emotionally corrective experience changes more than how emotions are dealt with (for example, whether they’re suppressed or reframed): it changes how emotional stimuli are perceived. More-secure lovers not only cope more effectively with hurt and anxiety, but perceive cues as less hurtful, in their relationship and in the world. Jim Coan, who uses fMRI scans to study the impact of attachment in the brain, has shown that holding the hand of a loved and dependable partner is a safety cue that changes how the brain perceives and encodes threats, like the threat of electric shock, even lessening the amount of pain such a shock induces.

A corrective emotional experience has been formulated as resulting from new insights, but cognitive insight is only one part of change. Novelist Arnold Bennett’s comment is pertinent here: “There can be no knowledge without emotion. We may be aware of a truth, yet until we have felt its force, it is not ours.” Pivotal, small changes in a living system, such as a person or a relationship, can engender radical qualitative shifts, as when ice suddenly hits 32 degrees Fahrenheit and becomes water. A significant shift in a leading or organizing element in a system—and primary emotion is such an element—can reorganize the whole system relatively abruptly.

We’re in the midst of a revolution in our relationship to emotion. The idea that emotion isn’t the poor cousin to reason but a “higher order of intelligence” has been around for decades, but now the evidence for this assertion is clear. As a result of this change of perspective and the new understanding of the nature of emotion, therapists can more deliberately use these powerful, bone-deep responses to transform their clients’ lives and relationships. It’s time to see emotion for what it is: not a nebulous force to be minimized and mistrusted, but the therapist’s greatest ally in the creation of lasting change.

Susan Johnson, Ed.D., professor of clinical psychology, is one of the developers of Emotionally Focused Therapy, one of the most empirically validated approaches to couples work. She’s the director of the Ottawa Couple and Family Institute and the International Center for Excellence in EFT. Her latest book is Hold Me Tight: Seven Conversations for a Lifetime of Love. Contact: soo@magma.ca.  

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