Deliberate Practice in Emotion-Focused Therapy [1 ed.] 1433832852, 9781433832857

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DELIBERATE PRACTICE IN

EMOTION-FOCUSED THERAPY

Essentials of Deliberate Practice Series Deliberate Practice in Cognitive Behavioral Therapy James F. Boswell and Michael J. Constantino Deliberate Practice in Emotion-Focused Therapy Rhonda N. Goldman, Alexandre Vaz, and Tony Rousmaniere

DELIBERATE PRACTICE IN

EMOTION-FOCUSED THERAPY RHONDA N. GOLDMAN ALEXANDRE VAZ TONY ROUSMANIERE

Copyright © 2021 by the American Psychological Association. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, including, but not limited to, the process of scanning and digitization, or stored in a database or retrieval system, without the prior written permission of the publisher. The opinions and statements published are the responsibility of the authors, and such opinions and statements do not necessarily represent the policies of the American Psychological Association. Published by American Psychological Association 750 First Street, NE Washington, DC 20002 https://www.apa.org Order Department https://www.apa.org/pubs/books [email protected] In the U.K., Europe, Africa, and the Middle East, copies may be ordered from Eurospan https://www.eurospanbookstore.com/apa [email protected] Typeset in Cera Pro by Circle Graphics, Inc., Reisterstown, MD Printer: King Printing Company, Inc., Lowell, MA Cover Designer: Naylor Design, Washington, DC Library of Congress Cataloging-in-Publication Data Names: Goldman, Rhonda N., author. | Vaz, Alexandre, author. | Rousmaniere, Tony, author. Title: Deliberate practice in emotion-focused therapy / by Rhonda N. Goldman, Alexandre Vaz, and Tony Rousmaniere. Description: Washington, DC : American Psychological Association, [2021] | Series: Essentials of deliberate practice | Includes bibliographical references and index. Identifiers: LCCN 2020041398 (print) | LCCN 2020041399 (ebook) | ISBN 9781433832857 (paperback) | ISBN 9781433832864 (ebook) Subjects: LCSH: Emotion-focused therapy. Classification: LCC RC489.F62 G65 2021 (print) | LCC RC489.F62 (ebook) | DDC 616.89/14—dc23 LC record available at https://lccn.loc.gov/2020041398 LC ebook record available at https://lccn.loc.gov/2020041399 https://doi.org/10.1037/0000227-000 Printed in the United States of America 10 9 8 7 6 5 4 3 2 1

Contents

Series Preface   vii Tony Rousmaniere and Alexandre Vaz

Acknowledgments  xi



Part I Overview and Instructions   1

CHAPTER 1. Introduction to and Overview of Deliberate Practice and Emotion-Focused Therapy    3 CHAPTER 2. Instructions for the Emotion-Focused Therapy Deliberate Practice Exercises  19



Part II Deliberate Practice Exercises for Emotion-Focused Therapy Skills    23 Exercises for Beginner Emotion-Focused Therapy Skills EXERCISE 1.  Therapist Self-Awareness  25 EXERCISE 2.  Empathic Understanding  33 EXERCISE 3.  Empathic Affirmation and Validation   43 EXERCISE 4. Exploratory Questions  53

Exercises for Intermediate Emotion-Focused Therapy Skills EXERCISE 5. Providing Treatment Rationale for Emotion-Focused

Therapy   63 EXERCISE 6.  Empathic Explorations  73 EXERCISE 7.  Empathic Evocations  83 EXERCISE 8.  Empathic Conjectures  93

Exercises for Advanced Emotion-Focused Therapy Skills EXERCISE 9.  Staying in Contact in the Face of Intense Affect   103 EXERCISE 10.  Self-Disclosure  113 EXERCISE 11.  Marker Recognition and Chair Work Task Setup   123 EXERCISE 12.  Addressing Ruptures and Facilitating Repair   137

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Contents

Comprehensive Exercises EXERCISE 13. Annotated Emotion-Focused Therapy Practice Session

Transcript  149 EXERCISE 14.  Mock Emotion-Focused Therapy Sessions   155



Part III Strategies for Enhancing the Deliberate Practice Exercises   163



CHAPTER 3. How to Get the Most Out of Deliberate Practice:

Additional Guidance for Trainers and Trainees    165 APPENDIX A.  Difficulty Assessments and Adjustments   179 APPENDIX B.  Distinguishing Between Empathic Responses   183 APPENDIX C. Sample Emotion-Focused Therapy Syllabus With Embedded Deliberate

Practice Exercises  187

References  197 Index  205 About the Authors  211

Series Preface Tony Rousmaniere and Alexandre Vaz

We are pleased to introduce the Essentials of Deliberate Practice series of training books. We are developing this book series to address a specific need that we see in many psychology training programs. The issue can be illustrated by the training experiences of Mary, a hypothetical second-year graduate school trainee. Mary has learned a lot about mental health theory, research, and psychotherapy techniques. Mary is a dedicated student; she has read dozens of textbooks, written excellent papers about psychotherapy, and receives near-perfect scores on her course exams. However, when Mary sits with her clients at her practicum site, she often has trouble performing the therapy skills that she can write and talk about so clearly. Furthermore, Mary has noticed herself getting anxious when her clients express strong reactions, such as getting very emotional, hopeless, or skeptical about therapy. Sometimes this anxiety is strong enough to make Mary freeze at key moments, limiting her ability to help those clients. During her weekly individual and group supervision, Mary’s supervisor gives her advice informed by empirically supported therapies and common factor methods. The supervisor often supplements that advice by leading Mary through role-plays, recommending additional reading, or providing examples from her own work with clients. Mary, a dedicated supervisee who shares tapes of her sessions with her supervisor, is open about her challenges, carefully writes down her supervisor’s advice, and reads the suggested readings. However, when Mary sits back down with her clients, she often finds that her new knowledge seems to have flown out of her head, and she is unable to enact her supervisor’s advice. Mary finds this problem to be particularly acute with the clients who are emotionally evocative. Mary’s supervisor, who has received formal training in supervision, uses supervisory best practices, including the use of video to review supervisees’ work. She would rate Mary’s overall competence level as consistent with expectations for a trainee at Mary’s developmental level. But even though Mary’s overall progress is positive, she experiences some recurring problems in her work. This is true even though the supervisor is confident that she and Mary have identified the changes that Mary should make in her work. The problem with which Mary and her supervisor are wrestling—the disconnect between her knowledge about psychotherapy and her ability to reliably perform psychotherapy—is the focus of this book series. We started this series because most therapists experience this disconnect, to one degree or another, whether they are beginning trainees or highly experienced clinicians. In truth, we are all Mary.

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To address this problem, we are focusing this series on the use of deliberate practice, a method of training specifically designed for improving reliable performance of complex skills in challenging work environments (Rousmaniere, 2016, 2019; Rousmaniere et  al., 2017). Deliberate practice entails experiential, repeated training with a particular skill until it becomes automatic. In the context of psychotherapy, this involves two trainees role-playing as a client and a therapist, switching roles every so often, under the guidance of a supervisor. The trainee playing the therapist reacts to client statements, ranging in difficulty from beginner to intermediate to advanced, with improvised responses that reflect fundamental therapeutic skills. To create these books, we approached leading trainers and researchers of major therapy models with these simple instructions: Identify 10 to 12 essential skills for your therapy model where trainees often experience a disconnect between cognitive knowledge and performance ability—in other words, skills that trainees could write a good paper about but often have challenges performing, especially with challenging clients. We then collaborated with the authors to create deliberate practice exercises specifically designed to improve reliable performance of these skills and overall responsive treatment (Hatcher, 2015; Stiles et al., 1998; Stiles & Horvath, 2017). Finally, we rigorously tested these exercises with trainees and trainers at multiple sites around the world and refined them based on extensive feedback. Each book in this series focuses on a specific therapy model, but readers will notice that most exercises in these books touch on common factor variables and facilitative interpersonal skills that researchers have identified as having the most impact on client outcome, such as empathy, verbal fluency, emotional expression, persuasiveness, and problem focus (e.g., Anderson et al., 2009; Norcross et al., 2019). Thus, the exercises in every book should help with a broad range of clients. Despite the specific theoretical model(s) from which therapists work, most therapists place a strong emphasis on pantheoretical elements of the therapeutic relationship, many of which have robust empirical support as correlates or mechanisms of client improvement (e.g., Norcross et al., 2019). We also recognize that therapy models have already-established training programs with rich histories, so we present deliberate practice not as a replacement but as an adaptable, transtheoretical training method that can be integrated into these existing programs to improve skill retention and help ensure basic competency.

About This Book The first book in the series is on emotion-focused therapy (EFT), which is situated in the humanistic–experiential approach that emerges from a rich tradition of psychotherapy training and supervision (Greenberg & Goldman, 1988, 2019; Greenberg & Tomescu, 2017). EFT training combines the study of theory, the observation of expert practice, hands-on experiential learning, and process supervision. Experiential learning involves trainees taking the role of both client and therapist, while the “client” works on personal material. Trainees often find the experiential component to be particularly potent, as the therapeutic approach is experienced in a bottom-up, hands-on manner from the inside out. Process supervision involves trainees bringing their own recorded sessions into supervision, after having identified concepts or skills with which they want help. Supervisor and supervisee collaboratively choose key moments to stop the recording and inquire as to the supervisee’s perception of the client’s affect and meaning and to allow the supervisee to reflect on ideal, retrospective responses.

Series Preface

Deliberate practice is intended as an additional piece designed to enhance this rich training tradition. Practice of the skills set forth in this book can allow trainees to have the skills at their fingertips. Ideally, deliberate practice can help therapists integrate the core skills into their repertoire, allowing them access to needed skills in an automatic fashion in response to the client context. The skills set forth in this book are basic; they are not intended to be wholistic or comprehensive. Deliberate practice is not intended to be the only delivery format through which EFT skills are acquired. The response types presented in this book will supplement the important perceptual skills (Greenberg & Goldman, 1988) that strong EFT therapists must also learn to offer moment-by-moment, accurate, and empathic reflections or empathic conjectures that emotionally deepen client experience on the path toward emotional transformation. Enjoy your learning, enjoy the process! Thank you for including us in your journey toward psychotherapy expertise. Now let’s get to practice!

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Acknowledgments

We’d like to acknowledge Rodney Goodyear for his significant contribution to starting and organizing this book series. We are grateful to Susan Reynolds, David Becker, and Emily Ekle at American Psychological Association (APA) Books for providing expert guidance and insightful editing that has significantly improved the quality and accessibility of this book. We are deeply grateful to Leslie Greenberg, developer of emotion-focused therapy (EFT), for his careful feedback, particularly in regard to the many therapist responses provided throughout the book. We are also grateful to co-EFT developers Jeanne Watson, Robert Elliott, and many others in the ISEFT (International Society for EmotionFocused Therapy) community who “tried out” the responses and gave us extremely helpful feedback. We are deeply grateful to K. Anders Ericsson, the inventor of the concept of deliberate practice, who, sadly, passed away during the development of this book. Without his pioneering work on the development of expertise, this book series would not have been possible. We are also grateful to Scott D. Miller, the psychologist who first introduced us to the idea of using deliberate practice for psychotherapy training. Simon Goldberg, Jason Whipple, and Jan Carlsson provided valuable feedback on early drafts of this book. The exercises in this book underwent extensive testing at training programs around the world. We are deeply grateful to the following supervisors and trainees who tested exercises and provided invaluable feedback: • Jordan Bate at Ferkauf Graduate School of Psychology, Yeshiva University, New York, New York • Risa Broudy at The George Washington University, Washington, DC • Joyce Yuying Chen, Jennifer Liu, and Celia Wu at Care Corner Counseling Center, Shanghai, China • Stephanie Ellis, in private practice in Texas • Shari Geller at the Centre for Mind Body Health, Toronto, Ontario, Canada • Chris Heffner at Antioch University Seattle, Seattle, Washington

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• Rafael Jódar Anchía, Alvaro Sanz Esteban, Ana Torrenova Pineda, Laura García Martín, Laura Valentina Moreno Muelas, and Marcos Morales Rodríguez at Pontifical Comillas University, Madrid, Spain • Kim Lampson, Tyler Jansen, Dodi Forgione, Eric Dooley, Mollie Luallen, Connie Zollner, Bralin Barnes, Deanna Zarei, Diane Shin, Karen Trujillo, Raisa Felts, Alissa Sarbiewski, Wesley Westbrook, Jacob Fantin, Jean Varghese, Moriah Boggs, and Nicole Lemos at Northwest University, Kirkland, Washington • Eng-Chuan Neo, Zhangjin Huang, and Grace Goh at the Caper Institute, Singapore • Jackie Persons at Oakland Cognitive Behavior Therapy Center, Oakland, California • Steen Rassing, couples therapist and supervisor, trainer at the EFT Institute in Copenhagen, Denmark • Salina M. Renninger, Lizzy Egbert, Elizabeth Harris, and Habib Mogib Salama at the University of St. Thomas, St. Paul, Minnesota • Thomas Rodebaugh, Meghan McDarby, Madelyn Frumkin, and Grace Monterubio at Washington University in St. Louis, St. Louis, Missouri • Ryan B. Seedall, Ashley Bell, and Andreia Scotto at Utah State University, Logan • Stacey Steele at Southeastern Alberta Sexual Assault Response Committee, Medicine Hat, Alberta, Canada • Marielle Sutter, Hannah Dietrich, and Bayane Boulhazayez at the Swiss Institute for Emotion-Focused Therapy, Bern, Switzerland • Catalina Woldarsky Meneses, Psychology and Counseling Department, Webster University, Geneva Campus, Switzerland • Garret G. Zieve at University of California, Berkeley

PA R T

Overview and Instructions In Part I, we provide an overview of deliberate practice, including how it can be integrated into clinical training programs for emotion-focused therapy (EFT), and instructions for performing the deliberate practice exercises in Part II. We encourage both trainers and trainees to read both Chapters 1 and 2 before performing the deliberate practice exercises for the first time. Chapter 1 provides a foundation for the rest of the book by introducing important concepts related to deliberate practice and its role in psychotherapy training more broadly and EFT training more specifically. We also review the different types of EFT skills—relational and alliance-building skills and technical, process-diagnostic skills—that are covered by the deliberate practice exercises in Part II. Chapter 2 lays out the basic, most essential instructions for performing the EFT deliberate practice exercises in Part II. They are designed to be quick and simple and provide you with just enough information to get started without being overwhelmed by too much information. Chapter 3 in Part III provides more in-depth guidance, which we encourage you to read once you are comfortable with the basic instructions in Chapter 2.

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I

Introduction to and Overview of Deliberate Practice and Emotion-Focused Therapy

As a young graduate student, I (RG) had the incredible privilege of being mentored by Leslie Greenberg and Laura North Rice. Les was a student of Laura, and Laura was a student of Carl Rogers. I was lucky to be trained and supervised by both of them at York University. While I learned so much about how to be a therapist from Les, I learned a great deal about empathic responding from Laura. It was through this lineage that I participated in the tradition of process supervision, a process that turned out to be seminal to my learning emotion-focused therapy (EFT). Process supervision involves listening closely to recordings of therapy sessions as the process unfolds, choosing key moments to stop and reflect on ideal responses. I have very distinct memories of playing my taped psychotherapy sessions for Laura Rice in particular. As we sat listening, Laura would turn off the tape recorder (at what, to me, seemed like a random point) and rather pointedly ask me what I thought the client was feeling or meaning in that particular moment. I completely froze, shutting down with anxiety. I knew there was an answer she was looking for, and I knew I didn’t have it. After a number of excruciatingly long seconds that felt like hours, she would tell me. Then she would ask me what might have been a better empathic response than whatever I had offered the client. I knew she was hoping I would supply an accurate empathic reflection, but, still frozen, I was at a complete loss. Somehow I survived the whole ordeal, and so did my clients. I eventually learned to be a strong EFT therapist. Over time, I was able to calm down and “hear” client core feelings and meanings. I also became quite skilled at crafting accurate empathic responses, and eventually at EFT. As incredibly valuable as I found those supervision sessions, my training could have benefitted from the addition of deliberate practice. Had I practiced the variety of empathic responses covered in this book, I believe that, going into therapy and supervision sessions, I would have been able to calm down and pull them out of my repertoire as needed. This book is designed to facilitate the acquisition of the basic skills of EFT. Deliberate practice is a methodology used by professionals from across many fields that is being applied in psychotherapy training. EFT, grounded in the humanistic–experiential field,

https://doi.org/10.1037/0000227-001 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Overview and Instructions

is situated within a rich tradition of psychotherapy training, with a strong emphasis on experiential learning. Deliberate practice is an innovative way to enhance the experiential training process. Through continual practice, these fundamental EFT skills eventually become natural. Theoretically, this will provide the trainee the opportunity to draw upon the skill automatically when presented with an appropriate moment in a real therapy session.

Overview of the Deliberate Practice Exercises The main focus of the book is a series of 14 exercises that have been thoroughly tested and modified on the basis of feedback from EFT trainers and trainees. Each of the first 12 exercises represents an essential EFT skill. The last two exercises are more comprehensive, consisting of an annotated EFT transcript and improvised mock therapy sessions that teach practitioners how to integrate all these skills into more expansive clinical scenarios. Table 1.1 presents the 12 skills that are covered in these exercises. Throughout the exercises, trainees work in pairs under the guidance of a supervisor and role-play as a client and a therapist, switching back and forth between the two roles. The 12 skill-focused exercises consist of multiple client statements grouped by difficulty (beginner, intermediate, and advanced) that each call for a specific EFT skill. Trainees are asked to read through and absorb the description of each skill, its criteria, and some examples of it. The trainee playing the client then reads the statements, which present possible problems and emotional states, or client markers. The trainee playing the therapist then responds in a way that demonstrates the appropriate skill. Trainee therapists will have the option of practicing a response using the one supplied in the exercise or immediately improvising and supplying their own. After each client statement and therapist response couplet is practiced several times, the trainees will stop to receive feedback from the supervisor. Guided by the supervisor, the trainees will be instructed to try statement–response couplets several times, working their way down the list. In consultation with the supervisor, trainees will go through the exercises, starting with the least challenging and moving through to more advanced levels. The triad (supervisor–client–therapist) will have the opportunity to discuss whether exercises present too much or too little challenge and adjust up or down depending on the assessment. Some exercises provide optional modifications so that trainees role-playing as clients can improvise based on personal experience rather than using scripted statement.

TABLE 1.1.  The 12 Emotion-Focused Therapy Skills Presented in the Deliberate

Practice Exercises Beginner Skills

Intermediate Skills

Advanced Skills

5. Providing treatment rationale for emotion-focused therapy

9. Staying in contact in the face of intense affect

3. Empathic affirmation and validation

6. Empathic explorations

11. Marker recognition and chair work task setup

4. Exploratory questions

8. Empathic conjectures

1. Therapist selfawareness 2. Empathic understanding

7. Empathic evocations

10. Self-disclosure

12. Addressing ruptures and facilitating repair

Introduction to and Overview of Deliberate Practice and Emotion-Focused Therapy

Trainees, in consultation with supervisors, can decide which skills they wish to work on and for how long. Based on our testing experience, we have found practice sessions should last about 1 to 1.25 hours to receive maximum benefit. After this, trainees become saturated and need a break. Ideally, EFT learners will both gain confidence and achieve competence through practicing these exercises. Competence is defined here as the ability to perform an EFT skill in a manner that is flexible and responsive to the client. We have chosen skills that are considered essential to EFT and that practitioners often find challenging to implement. The skills identified in this book are not comprehensive in the sense of representing all one needs to learn to become a competent EFT clinician. Some present particular challenges for trainees. A short history of EFT and a brief description of the deliberate practice methodology are provided to explain how we have arrived at the union between them.

Goals of This Book The primary goal of this book is to help trainees achieve competence in core EFT skills. Therefore, the expression of that skill or competency may look somewhat different across clients or even within session with the same client. The EFT deliberate practice exercises are designed to achieve the following: 1. Help EFT therapists develop the ability to apply the skills in a range of clinical situations. 2. Move the skills into procedural memory (Squire, 2004), so that EFT therapists can access them even when they are tired, stressed, overwhelmed, or discouraged. 3. Provide EFT therapists-in-training with an opportunity to exercise the particular skill using a style and language that is congruent with who they are. 4. Provide the opportunity to use the EFT skills in response to varying client statements and affect. This is designed to build confidence to adopt skills in a broad range of circumstances within different client contexts. 5. Provide EFT therapists-in-training with many opportunities to fail and then correct their failed response on the basis of feedback. This helps build confidence and persistence. Finally, this book aims to help trainees discover their own personal learning style so that they can continue their professional development long after their formal training is concluded.

Who Can Benefit From This Book? This book is designed to be used in multiple contexts, including graduate-level courses, supervision, postgraduate training, and continuing education programs. It assumes that 1. The trainer is knowledgeable about and competent in EFT. 2. The trainer is able to provide good demonstrations of how to use EFT skills across a range of therapeutic situations, via role-play or video, or that the trainer has access to

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examples of EFT being demonstrated through the many psychotherapy video examples available (see Elliott, 2018; Geller, 2015; Goldman, 2013, 2018; Greenberg, 2007a, 2007b; Paivio, 2014; Timulak, 2020; Watson, 2013). 3. The trainer is able to provide feedback to students regarding how to craft and improve their application of EFT skills. 4. Trainees will have accompanying reading, such as books and articles, that explains the theory, research, and rationale of EFT and each particular skill. Recommended reading for each skill is provided in the sample syllabus (Appendix C). The exercises covered in this book were piloted at 16 training sites across three continents (North America, Europe, and Asia). Some training sites chose to translate the exercises into their native language to adapt them for use with their trainees. This book is designed for trainers and trainees from different cultural backgrounds worldwide. This book is also designed for those who are training at all career stages, from beginning trainees, including those who have never worked with real clients, to seasoned therapists. All exercises provide guidance for assessing and adjusting the difficulty to precisely target the needs of each individual learner. The term trainee in this book is used broadly, referring to anyone in the field of professional mental health who is endeavoring to acquire EFT psychotherapy skills.

Deliberate Practice in Psychotherapy Training How does one become an expert in their professional field? What is trainable, and what is simply beyond our reach due to innate or uncontrollable factors? Questions such as these touch on our fascination with expert performers and their development. A mixture of awe, admiration, and even confusion surround people such as Mozart, Leonardo da Vinci, or more contemporary top performers such as basketball legend Michael Jordan and chess virtuoso Garry Kasparov. What accounts for their consistently superior professional results? Evidence suggests that the amount of or time spent on a particular type of training is a key factor in developing expertise in virtually all domains. Deliberate practice is an evidence-based method that can improve performance in an effective and reliable manner. The concept of deliberate practice has its origins in a classic study by K. Anders Ericsson and colleagues (Ericsson et  al., 1993). They found that the amount of time practicing a skill and the quality of the time spent doing so were key factors predicting mastery and acquisition. They identified five key activities in learning and mastering skills: (a) observing one’s own work, (b) getting expert feedback, (c) setting small incremental learning goals just beyond the performer’s ability, (d) engaging in repetitive behavioral rehearsal of specific skills, and (e) continuously assessing performance. Ericsson and his colleagues termed this process deliberate practice, a cyclical process that is illustrated in Figure 1.1. Research has shown that lengthy engagement in deliberate practice is associated with expert performance across a variety of professional fields, such as medicine, sports, music, chess, computer programming, and mathematics (Ericsson et al., 2018). People may associate deliberate practice with the widely known “10,000-hour rule” popularized by Malcolm Gladwell in his 2008 book, Outliers, although the actual number of hours required for expertise varies by field and by individual (Ericsson & Pool,

Introduction to and Overview of Deliberate Practice and Emotion-Focused Therapy

FIGURE 1.1.  Cycle of Deliberate Practice

Observe Work

Assess Performance

Expert Feedback Career-Long Repetition

Behavioral Rehearsal

Small Learning Goals

2016). This, however, perpetuated two misunderstandings. The first is that this is the number of deliberate practice hours that everyone needs to attain expertise, no matter the domain. In fact, there can be considerable variability in how many hours are required. The second misunderstanding is that engagement in 10,000 hours of work performance will lead one to become an expert in that domain. This misunderstanding holds considerable significance for the field of psychotherapy, where hours of work experience with clients has traditionally been used as a measure of proficiency (Rousmaniere, 2016). But, in fact, we know (Goldberg, Rousmaniere, et al., 2016) that amount of experience alone does not predict therapist effectiveness. It may be that the quality of deliberate practice is a key factor. Psychotherapy scholars, recognizing the value of deliberate practice in other fields, have recently called for deliberate practice to be incorporated into training for mental health professionals (e.g., Bailey & Ogles, 2019; Hill et al., 2020; Rousmaniere et al., 2017; Taylor & Neimeyer, 2017; Tracey et al., 2015). There are, however, good reasons to question analogies made between psychotherapy and other professional fields, such as sports or music, because by comparison, psychotherapy is so complex and free form. Sports have clearly defined goals, and classical music follows a written score. In contrast, the goals of psychotherapy shift with the unique presentation of each client at each session. Therapists do not have the luxury of following a score. Instead, good psychotherapy is more like improvisational jazz (Noa Kageyama, cited in Rousmaniere, 2016). In jazz improvisations, a complex mixture of group collaboration, creativity, and interaction are coconstructed among band members. Like psychotherapy, no two jazz improvisations are identical. However, improvisations are not a random collection of notes. They are grounded in a comprehensive theoretical understanding and technical proficiency that is only developed through continuous deliberate practice. For example, prominent jazz instructor Jerry Coker (1990) listed 18 skill areas that students must master, each of which has multiple discrete skills, including

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tone quality, intervals, chord arpeggios, scales, patterns, and licks. In this sense, more creative and artful improvisations are actually a reflection of a previous commitment to repetitive skill practice and acquisition. As legendary jazz musician Miles Davis put it, “You have to play a long time to be able to play like yourself” (Cook, 2005). The main idea that we would like to stress here is that we want deliberate practice to help EFT therapists become themselves. The key is to learn the skills so that you have them on hand when you want them. Practice the skills to make them your own. Incorporate those aspects that feel right for you. Ongoing and effortful deliberate practice should not be an impediment to flexibility and creativity. Ideally, it should enhance it. We recognize and celebrate that psychotherapy is an ever-shifting encounter and by no means want it to become or feel formulaic. Strong EFT therapists mix an eloquent integration of previously acquired skills with properly attuned flexibility. The core EFT responses provided are meant as templates or possibilities, rather than “answers.” Please interpret and apply them as you see fit in a way that makes sense to you. We encourage flexible and improvisational play!

Simulation-Based Mastery Learning Deliberate practice uses simulation-based mastery learning (Ericsson, 2004; McGaghie et al., 2014). That is, the stimulus material for training consists of “contrived social situations that mimic problems, events, or conditions that arise in professional encounters” (McGaghie et al., 2014, p. 375). A key component of this approach is that the stimuli being used in training are sufficiently similar to the real-world experiences, so that they mimic that they provoke similar reactions. This facilitates state-dependent learning, where professionals acquire skills in the same psychological environment where they will have to perform the skills (Smith, 1979). For example, pilots train with flight simulators that present mechanical failures and dangerous weather conditions, and surgeons practice with surgical simulators that present medical complications. Training in simulations with challenging stimuli increases professionals’ capacity to perform effectively under stress. For the psychotherapy training exercises in this book, the “simulators” are typical client statements that might actually be presented in the course of therapy sessions and call upon the use of the particular skill.

Declarative Versus Procedural Knowledge Declarative knowledge is what a person can understand, write, or speak about. It often refers to factual information that can be consciously recalled through memory and often acquired relatively quickly. In contrast, procedural learning is implicit in memory and “usually requires repetition of an activity, and associated learning is demonstrated through improved task performance” (Koziol & Budding, 2012, p. 2694, emphasis added). Procedural knowledge is what a person can perform, especially under stress (Squire, 2004). There can be a wide difference between their declarative and procedural knowledge. For example, an “armchair quarterback” is a person who understands and talks about athletics well but would have trouble performing it at a professional ability. Likewise, most dance, music, or theater critics have a very high ability to write about their subjects but would be flummoxed if asked to perform them. In EFT training, the gap between declarative and procedural knowledge appears when a trainee or therapist can recognize and perhaps even deeply appreciate, for example, a highly attuned empathic exploratory response that lands adeptly on the edge of the client’s experience, pushing the client forward every so subtly, but has

Introduction to and Overview of Deliberate Practice and Emotion-Focused Therapy

trouble providing empathic explorations with real clients in a given moment. The sweet spot for deliberate practice is the gap between declarative and procedural knowledge. In other words, effortful practice should target those skills that the trainee could write a good paper about but would have trouble actually performing with a real client. We start with declarative knowledge, learning skills theoretically and observing others perform them. Once learned, with the help of deliberate practice, we work toward the development of procedural learning, with the aim of therapists having “automatic” access to each of the skills that they can pull on when necessary. Let us turn to a little theoretical background on EFT to help contextualize the skills of the book and how they fit into the greater training model.

Emotion-Focused Therapy EFT is a neo-humanistic, experiential treatment approach that is empirically supported and research-informed (Elliott et  al., 2004; Goldman & Greenberg, 2015; Goldman et al., 2006; Greenberg, 2015; Greenberg & Goldman, 2019; Watson et al., 2007). EFT is founded on an integration of client-centered relational principles, gestalt therapy methods, contemporary emotion theory, and affective neuroscience. The approach started in the 1980s as an in-depth exploration of psychotherapy change processes (Rice & Greenberg, 1984) and continued to evolve into its current form as a comprehensive theory of psychological functioning and clinical practice (Greenberg & Goldman, 2019; Greenberg et al., 1993). EFT has developed from research. EFT treatments have been shown to be effective in multiple randomized clinical trials (for a review, see Timulak et al., 2019). In addition, extensive process–outcome, qualitative, case study, and outcome research has been conducted (Angus et al., 2015; Elliott et al., 2013; Ellison et al., 2009; Goldman et al., 2006; Timulak et al., 2019). EFT has been shown effective in treating a variety of clinical conditions, including depression (Goldman et al., 2006), generalized anxiety (Timulak & McElvaney, 2018; Watson & Greenberg, 2017), social anxiety (Elliott, 2013), complex trauma (Paivio & Pascual-Leone, 2010), and couples therapy (Woldarsky Meneses & McKinnon, 2019). It has more recently been applied with and shown positive effects in the treatment of eating disorders (Dolhanty & LaFrance, 2019). EFT places considerable importance on facilitating clients to identify, experience, and accept emotions. A major focus of therapy sessions is accessing, processing, and transforming negative problematic emotions that are seen as contributing to symptoms and problems presented in therapy. EFT skills are thus designed to aid in the exploration, deepening, regulation, and transformation of emotion. The focus of this book is EFT skills; however, it is important that therapists keep in mind the overarching aim of treatment. A major goal of change in EFT is to understand, explore, and ultimately shift underlying core emotion schemes. Emotion schemes are implicit structures at the core of self-organization that are seen as organizing identity, consciousness, and action. They develop throughout the lifetime and represent a complex and highly personal synthesis of emotion memory structures that govern affective, motivational, cognitive, and behavioral elements (Angus & Greenberg, 2011; Greenberg & Paivio, 1997; Greenberg et al., 1993). These schematic organizations usually exist outside of awareness and can be rapidly activated by relevant cues. Although emotion schemes usually organize the emotional system in an adaptive and flexible

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Overview and Instructions

manner, they may also be maladaptive and form the basis of psychological disturbance. Emotion schemes that underlie and drive presenting difficulties and symptoms thus become the focus of therapy. EFT skills, including those presented in this book’s deliberate practice exercises, are thus used to unearth the multifaceted elements of emotion schemes—including implicit sensations, feelings, perceptions, and beliefs—so that they can be explored and reintegrated in a manner that feels more comfortable and in keeping with client goals. EFT has developed three broad-based categories that describe different aspects of working with emotion in therapy to produce change. They include emotion utilization, which relates to increasing awareness, expression, and reflection upon emotion to use it productively; emotion transformation, which includes the two major processes of changing emotion with emotion or changing emotion through corrective emotional experience; and emotion regulation, which involves different processes of either soothing or more deliberately regulating emotion so that it can be used more effectively (Greenberg & Goldman, 2019). EFT skills are used in service of one of these three emotional change principles, and these principles inform the deliberate practice exercises in this book. Important distinctions are made between primary, secondary, instrumental, and adaptive or maladaptive emotions (Goldman & Greenberg, 2015; Greenberg & Goldman, 2019; Greenberg & Paivio, 1997). It is important for therapists to be aware of these theoretical differentiations as they guide the use of the EFT skills. Primary adaptive emotions are those that help organize complex situational information and prepare the person for effective action. Primary maladaptive emotions, in contrast, are direct reactions to situations that interfere with effective functioning. In essence, these emotions involve learned responses, often stemming from previous traumatic experiences, that propel the person into ineffective or even harmful coping responses (e.g., the abused client who reacts with maladaptive fear in response to closeness and intimacy). Secondary reactive emotions are responses to other, more primary emotions, or emotional reactions to thought processes. Secondary emotions usually obscure or defend the person from experiencing their more painful core emotions. For example, a client who feels ashamed of their primary adaptive sadness could be experiencing secondary shame; another client who feels primary fear might experience secondary anger instead. Finally, instrumental emotions are those expressed to influence or control others. These may be expressed deliberately or out of awareness. Regardless, their main aim is to invoke an external response. This is exemplified by the expression of “crocodile tears” to elicit the other’s pity or support. Therapists can use the EFT skills in this book to help clients access and allow primary emotions, transform maladaptive emotions, validate and bypass secondary emotions, or explore instrumental emotions to gain awareness of their aim. However, EFT therapists must develop further case formulation, process-diagnostic skills (Goldman & Greenberg, 2015) to discern when to guide clients toward adaptive primary emotions, when to work toward shifting maladaptive emotions, and when to help regulate overwhelming emotional experiences. This can be also be achieved with additional supervision (Greenberg & Tomescu, 2017). It has been observed that clients often present secondary emotions before primary emotions in therapy sessions (Pascual-Leone & Greenberg, 2007, 2009; Pascual-Leone & Kramer, 2019)—for example, “I am so angry at her for rejecting me.” Therapists can adopt the skills offered in this book to help clients move attention to primary emotions underneath such as hurt, pain, or shame. Productive therapy sessions (Greenberg et al.,

Introduction to and Overview of Deliberate Practice and Emotion-Focused Therapy

2007; Hermann & Auszra, 2019) will focus on primary emotions, helping clients allow and feel them if they are adaptive, or transform them if they are maladaptive by accessing and expressing new, sometimes previously disallowed adaptive emotions. It is thus important for therapists to develop perceptual capacities to be able to differentiate between different types of emotions and the operational skills to be able to help client’s access, express, or transform emotions as necessary. EFT has systematically developed an extensive array of clinical tasks (Elliott et al., 2004; Greenberg & Goldman, 2019). Tasks line up with the emotional change principles in that they facilitate awareness, expression, reflection upon, regulation, or transformation of emotion. Tasks are indicated by in-session markers that therapists learn to identify. While one of the EFT skills in this book (Exercise 11: Marker Recognition and Chair Work Task Setup) is designed to aid in marker recognition and the very initial stages of task facilitation, many of the conceptual skills necessary to complete tasks are beyond the scope of this book. For a fuller review of the many EFT tasks and the steps of change, please refer to Elliott et al. (2004). The EFT skills in this book can be seen as the basic building blocks to be integrated into the therapist’s repertoire and thus adopted for moment by moment use when needed. Trainees are further referred to Goldman and Greenberg’s (2015) book on EFT case formulation to aid in the construction of higher order conceptual maps that guide when in session to respond with the particular microresponses covered in this book, as well as markers and initiate tasks.

­EFT Skills in Deliberate Practice To form a solid, safe therapeutic relationship and facilitate meaningful emotional change, the EFT therapist must develop two broad categories of skill. First, relational and alliance-building skills are essential, core building blocks. Second, key technical, process-diagnostic skills aid in the recognition of markers and the facilitation of tasks. Altogether, EFT happens on a moment-by-moment basis, in the context of a high degree of empathic attunement to affect. The attuned therapist employs different therapeutic stances and interventions in response to the client’s presenting emotions and in-session markers. Relational and technical/process-diagnostic skills are inter­ connected and play a part in delivering effective EFT treatment. They represent a fundamental complementarity between ways of being and ways of doing that make this approach a rich, although challenging, model to practice and master.

Relational and Alliance Building Skills Of the 12 skills identified in this book, 11 fall into the relational category. They are grounded in therapeutic presence and facilitated by empathic attunement. They are used throughout therapy, outside and within tasks. They describe how to start therapy, foster presence, tolerate intense affect, engage and validate clients, self-disclose, explore and deepen affect, deal with challenges, address ruptures, and facilitate repair. They are the essential bases of EFT. The skills occur within the coconstruction of a safe, secure, collaborative therapeutic relationship, seen as key to facilitating emotional change and the creation of meaningful narratives (Angus & Greenberg, 2011; Greenberg & Goldman, 2019). The therapeutic relationship is characterized by empathy, genuineness, and unconditional positive regard (Rogers, 1951, 1957, 1981). The therapist is continuously empathically

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Overview and Instructions

attuned and emotionally present (Geller, 2019; Rogers, 1951; Watson, 2019), remaining grounded in their own experience and bodily felt sense (Gendlin, 1981). EFT therapists strive to convey a general stance of warmth, empathy, and acceptance for their clients. The attitudes are conveyed not just in words but also in nonverbal and paralinguistic cues, such as vocal quality and tone. Such attitudes themselves must be fostered and nurtured over time. Two key aspects of the relationship are emphasized in EFT. First, moment-bymoment empathic attunement to affect is considered a necessity in setting up a trusting relationship, symbolizing and deepening emotion; the relationship itself can lead to the transformation of maladaptive to adaptive emotional processes (Greenberg & Goldman, 2019; Watson, 2019). Second, competent empathic attunement hinges on a strong therapeutic presence (Geller, 2017, 2019; Geller & Greenberg, 2012), an intrapersonal quality of the therapist, a way of being that influences the doing of therapy. The therapist’s presence has been linked to neurophysiological mechanisms that support feelings of safety, connectedness, and growth promotion (Geller & Porges, 2014). Overall, both empathic attunement to affect and therapeutic presence require the EFT therapist’s more explicit use of self. The therapist must develop the capacity to be aware of, tolerate, and make sense of one’s own issues, reactions, and other internal processes. These key therapeutic attitudes comprise more than a set of skills; that is, the skills are not intended to be stand-ins or to substitute for the development of the therapeutic attitudes. In addition to training in the therapeutic attitudes, therapists must develop the key perceptual skills necessary to apply the core skills with clients at the appropriate moment. Learning and practicing these skills will increase the likelihood that therapists will have them at their fingertips and be able to engage them when it is most optimal in the therapy hour. Therapists should seek further supervision, however, to guide them in when and how to engage these skills in a therapeutic context, with actual clients. The relational skills can also be categorized as either intrapersonal or interpersonal. Interpersonal skills focus on understanding, attuning, and validating clients, whereas intrapersonal focus on the therapists’ ability to be aware of, symbolize, and express (if desirable) their own inner experience. Examples include self-reflection, symbolization of emotional experience, mindfulness, and therapeutic presence. Interpersonal skills require intrapersonal skills. A variety of experiences that clients present may strongly affect the internal experience of the therapist and thus require them to draw upon intrapersonal skills. For example, a therapist may experience discomfort when clients are angry or suicidal or they describe trauma. This can cause the therapist to detach, change the subject, or even argue with clients. Therapists’ tendency to move away from their own difficult internal experience has been identified as a major barrier to success across a wide range of therapy models, including EFT (e.g., Bennett-Levy, 2019; Eubanks-Carter et al., 2015; Geller & Greenberg, 2012; Hayes et al., 2004; Hembree et al., 2003). There are two intrapersonal skill exercises in the book. The first is Exercise 1: Therapist Self-Awareness; the other is Exercise 9: Staying in Contact in the Face of Intense Affect. Both are designed to develop self-awareness and work with the tendency to move away from or react to difficult experience, which in turn interferes with the therapist’s presence and attunement to the client, one of their most important capacities. Common responses and styles of distraction are listed at the bottom of the Reaction Form presented in Appendix A. When reactions are too strong, they can impede the

Introduction to and Overview of Deliberate Practice and Emotion-Focused Therapy

therapist’s ability to be present and available, and they can therefore limit the therapist’s ability to help clients. Exercises are meant to increase therapist’s presence (Geller & Greenberg, 2012) and what Rousmaniere (2019) termed their psychological capacity threshold—that is, their capacity to become aware of moments when they may be moving away from, or unhelpfully reacting to, their own internal experience— so they can stay attuned and helpful with a broader range of clients.

Technical and Process-Diagnostic Skills The facilitation of tasks is a core aspect of therapy. Chair tasks, in particular, are a fundamental component of EFT. They help to access core emotion and deepen it fairly quickly. Engagement in tasks will often facilitate major emotional shifts. Approximately 35% of EFT sessions involve facilitation of and participation in tasks (Greenberg & Goldman, 2019). Beyond marker recognition and chair task setup, many of the technical skills necessary for the facilitation and completion of EFT tasks are not covered in these pages. They are complex skills that are beyond the scope of this book. The one skill that falls into the technical category is described by Exercise 11: Marker Recognition and Task Setup. Marker recognition leading to task set up is a key skill for the EFT therapist to master. Exercise 11 is designed to train therapists to be able to hear and recognize markers and act toward setting up two-chair dialogues in response to markers of self-criticism and self-interruption and an empty-chair dialogue in response to a marker of unfinished business. It should be noted that all therapy tasks occur only after a secure, safe therapeutic relationship is established. Generally speaking, they are not proposed or undertaken in the first session. Once tasks begin, therapists will need to learn other specific skills to see the tasks through to completion, and these are not covered in these pages. It should also be noted that there are other ancillary EFT tasks that are done without chairs (Elliott et al., 2004; Greenberg, 2015; Greenberg & Goldman, 2019) and are also not covered in the book.

The EFT Skills Presented in Exercises 1 Through 12 The exercises in this text use a developmentally informed pedagogy in which more advanced skills build on less advanced skills, as indicated in Table  1.1. The beginnerlevel exercises consist of the most basic skills that an EFT therapist regularly relies on. Therapist Self-Awareness (Exercise 1) is considered fundamental when conducting EFT because clients often present fragile emotional states that require therapists to be selfaware so that they can provide a steady calm in the face of a range of strong emotional presentation. In forming and sustaining an initial therapeutic relational bond, the EFT therapist delivers empathic understanding (Exercise 2), attempting to imagine themselves into the client’s internal world and convey a nonjudgmental understanding, thereby calming and soothing distressing and vulnerable emotional states. Empathic affirmations and validations (Exercise 3) are elusively simple responses that provide a high degree of emotional safety and thus invite and allow further exploration of difficult emotional states, a necessary reality of engagement in EFT. Exploratory questions (Exercise 4) are a particular form of question that EFT therapists use throughout therapy to help with the key task of exploring and deepening emotion. The first of the intermediate exercises is about providing the treatment rationale for EFT (Exercise 5). Readers may query why explaining treatment rationale is placed at the intermediate stage rather than at the beginning. Although a rationale for treatment is sometimes provided at the beginning of therapy, particularly when requested

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Overview and Instructions

by the client, EFT therapists generally prefer to begin by forming a solid, safe therapeutic relationship. The security of a more solid relational bond allows therapists to demonstrate and explain how they work. This follows the basic humanistic principle of “contact before contract” (Gendlin & Beebe, 1968). The client is often more able to absorb what the therapist is offering when emotional safety has been provided. This skill is considered to be a form of emotion coaching (Greenberg, 2015; Warwar & Ellison, 2019) that serves the dual function of solidifying the alliance by providing a deeper purpose and direction for therapeutic work and educating clients at a more conceptual level as to how therapy works. Education in EFT is done through experiential teaching (Goldman, 1991; Warwar & Ellison, 2019). Conceptual learning is seen as best provided in a bottom-up fashion, on top of experiential learning (Pascual-Leone & Greenberg, 2007). The other intermediate exercises present three types of empathic responses, empathic explorations, evocations, and conjectures (Exercises 6–8). Each of these response types is used to help clients explore and deepen experiencing. However, they are used differentially at different times, depending on therapist momentary intention and how they best see fit to accomplish their goal at the particular time. Readers and learners may find it helpful to read Appendix B to be able to further distinguish between these types of responses and when to best use them. The advanced exercises are placed at the end because they require more complex interpersonal skill or a deeper understanding of EFT theory. All the skills in the advanced section are dependent upon Exercise 9: Staying in Contact in the Face of Intense Affect, because it requires the therapist to remain present to apply the advanced skills in a facilitative manner that is not disruptive to the therapeutic process. Like many therapeutic approaches, EFT therapists self-disclose, although there are specific guidelines about how and when to do so. Self-disclosure (Exercise 10) in EFT is most often a provision of the therapist’s immediate experience. This skill draws on therapist presence and requires the disclosure of their own experience in a congruent, nonthreatening, direct, manner that promotes client deepening of emotional experiencing. EFT therapists adopt the judicious use of self-disclosure to either empathize with clients or address ruptures in the relationship (Watson, 2019). Therapists must learn when, how, and why to disclose therapist experiencing to clients (Elliott et al., 2004; Greenberg & Tomescu, 2017). Marker recognition and task setup (Exercise 11) is a complex skill that involves multiple operations and requires therapists to have a certain amount of prior conceptual EFT knowledge and understanding. Addressing ruptures and facilitating repair (Exercise 12) also draws on complex interpersonal skills and the ability to stay with intense affect while navigating through ruptures in a manner that is beneficial to clients while facilitative of the therapeutic process.

A Note About Vocal Tone, Facial Expression, and Body Posture Humanistic–experiential therapies in general, and EFT in particular, strongly attend to the nonverbal and paralinguistic cues expressed by both client and therapist (Gendlin, 1996; Rogers, 1975; Watson, 2019; Watson et  al., 1997; Weiser Cornell, 2013). The empathic process of EFT involves a careful moment-by-moment reading by the therapist of the client’s message as communicated through both verbal expression and nonverbal styles. The therapist in turn is coached and trained to be aware of their tone of voice, facial expression, and body posture to convey the attitudes of warmth, empathy, genuine curiosity, and openness through their moment-by-moment responding. Each one of the EFT skill and response types covered in the book is delivered with a

Introduction to and Overview of Deliberate Practice and Emotion-Focused Therapy

particular therapeutic tone that cannot be completely conveyed through the written medium. Specifications are provided throughout the exercises to guide therapists to be aware of client and therapist’s nonverbal qualities, such as tone of voice and to match client’s verbal and nonverbal communications. However, it is additionally useful for EFT learners to watch recorded examples of EFT experts performing therapy so that they can observe this key principle in action.

The Role of Deliberate Practice in EFT Training Emotion-focused therapy emerges from a strong tradition of supervision and training in the client-centered and experiential therapy traditions (Greenberg & Goldman, 1988; Rice & Greenberg, 1984). Training can be traced back to Rogers’s (1957) graded experiences, where students listened to tape-recorded interviews, experienced live demonstrations by a supervisor, partook in group and personal therapy, conducted individual psychotherapy, and recorded their own interviews for discussion with a facilitative supervisor. Thus, Rogers implemented the method of recording interviews for the purpose of facilitative supervision. The method was carried forward by Laura Rice and Leslie Greenberg and is now termed process supervision (Greenberg & Tomescu, 2017). Greenberg and Goldman (1988) outlined four core aspects of training in this approach in a 1988 paper titled “Training in Experiential Therapy.” They recommended a balanced combination of didactic, skills training, experiential, and personal growth. Indeed, the many EFT trainings (Greenberg & Goldman, 2019) that are conducted across the world follow this combination of methods. Theoretical knowledge is fundamental, exposure to and observation of EFT practice is key, therapist self-experiencing is important, and skill practice is essential. Deliberate practice can thus be situated within the larger training framework. Deliberate practice is a form of skills training. It is recommended that EFT therapists-in-training additionally acquire knowledge through the multitude of EFT resources that are available (see Greenberg & Goldman, 2019). To learn EFT more completely, deliberate practice trainings should be combined with (a) didactic training through courses and workshops; (b) observation of multiple experts practicing EFT; (c) engagement in therapist personal and experiential growth work; and (d) process supervision, particularly at later stages of training when higher skill acquisition has been achieved. The skills set forth in this book are not intended to be wholistic or comprehensive; they are the basic skills. Deliberate practice is not intended to be the only delivery format through which EFT proficiency is acquired. Simply engaging in one aspect of training would not be sufficient. Deliberate practice for EFT is intended as one core element of the incredibly complex and highly rewarding process of learning EFT. To expose themselves to the theory or research behind the skills, EFT learners may want to turn to such books as the Clinical Handbook of Emotion-Focused Therapy (Greenberg & Goldman, 2019), Case Formulation in Emotion-Focused Therapy (Goldman & Greenberg, 2015), Emotion-Focused Therapy (Greenberg, 2015), or Learning EmotionFocused Therapy: The Process-Experiential Approach to Change (Elliott et  al., 2004). For specific application to various clinical populations, learners may wish to review Emotion-Focused Therapy for Depression (Greenberg & Watson, 2006), Case Studies in Emotion-Focused Treatment of Depression (Watson et al., 2007), EmotionFocused Therapy for Complex Trauma (Paivio & Pascual-Leone, 2010), Emotion-Focused

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Overview and Instructions

Therapy for Generalized Anxiety (Watson & Greenberg, 2017), and Transforming Generalized Anxiety: An Emotion-Focused Approach (Timulak & McElvaney, 2018). In addition, the syllabus in Appendix C has further recommended readings.

Training in Empathic Responding Of the 12 skills covered in the book, five are types of empathic responses, including empathic understanding (Exercise 2), empathic affirmation or validation (Exercise 3), empathic exploration (Exercise 6), empathic evocation (Exercise 7), and empathic conjecture (Exercise 8). The empathic responses covered here originated when Goldman (1991) created a manual that described both the general therapeutic empathic attitude and three types of empathic response types: reflections, explorations, and conjectures. The response types were further developed by Watson et  al. (1997) and Elliott et  al. (2004). The high proportion of basic skills that are empathic responses reflects how fundamental empathic responding is to EFT. The responses are key in exploring, deepening, and facilitating the transformation of emotion. Despite seeming simple at first glance, empathic responses can be complex and difficult to master. Yet when used adeptly, they can be incredibly powerful. Competent empathic responding, however, takes time and practice to learn. There has been much debate about what it means to be an empathic therapist, whether it is more of an attitude or a skill (Ivey, 1971; Truax & Carkhuff, 1967), and how best to train therapists in empathic responding (Greenberg & Goldman, 1988, 2019; Rogers, 1957, 1975). We take the approach that therapeutic empathy is a multidimensional, complex process and is both an attitude and a skill (Bohart & Greenberg, 1997; Elliott et al., 2004). Being empathic involves stepping into the shoes of the other, affectively resonating with their experience (Barrett-Lennard, 1981), being responsively and differentially attuned, and selecting that which is most alive in the client’s experience (Greenberg & Goldman, 2019; Watson, 2019). Each of the empathic responses reviewed in this book may have multiple intentions guiding it (Elliott et al., 2004). Furthermore, the meanings and effects of different empathic responses will depend on their particular contexts. An empathic affirmation response to a client’s statement of underlying vulnerability will have a different purpose and effect than the same type of empathic response to a client’s voiced reactive frustration. Alternatively, an empathic exploration response in a context of consistent empathic responding is different from an empathic response following a confrontation (Greenberg & Goldman, 1988; Rice & Greenberg, 1984). Deliberate practice in EFT is designed to help therapists learn the different types of empathic responses. It is important, however, for trainees to supplement their empathy training with additional training elements. It is recommended that trainees learn to develop an empathic relational attitude (Elliott et  al., 2004; Greenberg & Goldman, 2019; Rogers, 1975). It is also important to train the perceptual skills behind the response modes themselves. There are many criteria that guide therapists in choosing the best type of the empathic response in a given moment. Deliberate practice can help trainees learn the different responses available and the forms they may take. Once learned, therapists will need to “put all the pieces together” and “play the symphony.” As they sit down with real clients, they can begin by adopting an empathic attitude; stepping into the shoes of their clients; resonating with their experience; selecting that aspect of the client’s experience that feels most important; and, guided by theoretical knowledge, personal experience, and moment-by-moment intention, offer the best possible response at that moment.

Introduction to and Overview of Deliberate Practice and Emotion-Focused Therapy

Overview of the Book’s Structure This book is organized into three parts. Part I contains this chapter and Chapter  2, which provide basic instructions on how to perform these exercises. We found through testing that providing too many instructions upfront overwhelmed trainers and trainees, and they ended up skipping past them as a result. Therefore, we kept these instructions as brief and simple as possible to focus on only the most essential information that trainers and trainees will need to get started with the exercises. Further guidelines for getting the most out of deliberate practice are provided in Chapter 3, and additional instructions for monitoring and adjusting the difficulty of the exercises are provided in Appendix A. Do not skip the instructions in Chapter 2, and be sure to read the additional guidelines and instructions in Chapter 3 and Appendix A once you are comfortable with the basic instructions. Part  II contains the 12 skill-focused exercises, which are ordered based on their difficulty: beginner, intermediate, and advanced (see Table  1.1). They each contain a brief overview of the exercise, example client–therapist interactions to help guide trainees, step-by-step instructions for conducting that exercise, and a list of criteria for mastering the relevant skill. The client statements and sample therapist responses are then presented, also organized by difficulty (beginner, intermediate, and advanced). The statements and responses are presented separately so that the trainee playing the therapist has more freedom to improvise responses without being influenced by the sample responses, which should only be turned to if the trainee has difficulty improvising their own responses. The last two exercises in Part II provide opportunities to practice the 12 skills within simulated psychotherapy sessions. Exercise 13 provides a sample psychotherapy session transcript in which the EFT skills are used and clearly labeled, thereby demonstrating how they might flow together in an actual therapy session. EFT trainees are invited to run through the sample transcript with one playing the therapist and the other playing the client to get a feel for how a session might unfold. Exercise 14 provides suggestions for undertaking actual mock sessions, as well as client profiles ordered by difficulty (beginner, intermediate, and advanced) that trainees can use for improvised role-plays. Part  III contains Chapter  3, which provides additional guidance for trainers and trainees. While Chapter 2 is more procedural, Chapter 3 covers big-picture issues. It highlights six key points for getting the most out of deliberate practice and describes the importance of appropriate responsiveness, attending to trainee well-being and respecting their privacy, and trainer self-evaluation, among other topics. Three appendixes conclude this book. Appendix A provides instructions for monitoring and adjusting the difficulty of each exercise as needed. It provides a Deliberate Practice Reaction Form for the trainee playing the therapist to complete to indicate whether the exercise is too easy or too difficult. Appendix B helps trainees and supervisors distinguish between different types of empathic responses, which is common challenge among EFT practitioners. Appendix C presents a sample syllabus demonstrating how the 14 deliberate practice exercises and other support material can be integrated into a wider EFT training course. Instructors may choose to modify the syllabus or pick elements of it to integrate into their own courses. This series has a companion website (http://pubs.apa.org/books/supp/deliberatepractice) where the three appendixes are available for download.

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Instructions for the Emotion-Focused Therapy Deliberate Practice Exercises

This chapter provides basic instructions that are common to all the exercises in this book. More specific instructions are provided in each exercise. Chapter  3 also provides important guidance for trainees and trainers that will help them get the most out of deliberate practice. Appendix A offers additional instructions for monitoring and adjusting the difficulty of the exercises as needed after getting through all the client statements at a single difficulty level, including a Deliberate Practice Reaction Form that the trainee playing the therapist can complete to indicate whether they found the statements too easy or too difficult. Difficulty assessment is an important part of the deliberate practice process and should not be skipped.

Overview The deliberate practice emotion-focused therapy (EFT) exercises in this book involve role-plays of hypothetical situations in therapy. The role-play involves three people: one trainee role-plays the therapist, another trainee role-plays the client, and a trainer (professor or supervisor) observes and provides feedback. Alternatively, a peer can observe and provide feedback. This book provides a script for each role-play, each with a client statement and also with an example therapist response. The client statements are graded in difficulty from beginning to advanced, although these difficulty grades are only estimates. The actual perceived difficulty of client statements is subjective and varies widely by trainee. For example, some trainees may experience a stimulus of a client being angry as be easy to respond to, whereas another trainee may experience it as very difficult. Thus, it is important for trainees to provide difficulty assessments and adjustments to ensure that they are practicing at the right difficulty level—neither too easy nor too hard.

https://doi.org/10.1037/0000227-002 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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CHAPTER

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Overview and Instructions

Time Frame We recommend a 90-minute time block for every exercise, structured roughly as follows: • First 20 minutes: Orientation. The trainer explains the EFT skill and demonstrates the exercise procedure with a volunteer trainee. • Middle 50 minutes: Trainees perform the exercise in pairs. The trainer or a peer provides feedback throughout this process and monitors or adjusts the exercise’s difficulty as needed after each set of statements (see Appendix A for more information about difficulty assessment). • Final 20 minutes: Evaluation/feedback and discussion

Preparation 1. Every trainee will need their own copy of this book. 2. Each exercise requires the Deliberate Practice Reaction Form that is available to download or print at http://pubs.apa.org/books/supp/deliberate-practice. 3. Trainees are grouped into pairs. One volunteers to role-play the therapist and one to role-play the client (they will switch roles after 15 minutes of practice). As noted previously, an observer who might be either the trainer or a fellow trainee will work with each pair.

Role of the Trainer The primary responsibilities of the trainer are as follows: 1. Provide corrective feedback, which includes both information about how well the trainees’ response met expected criteria and any necessary guidance about how to improve the response. 2. Remind trainees to do difficulty assessments and adjustments after each level of client statements is completed (beginning, intermediate, and advanced).

How to Practice Each exercise provides more specific instructions. Trainees should follow these instructions carefully because every step is important. Two of the exercises—Exercise 11: Marker Recognition and Chair Work Task Setup, and Exercise 12: Addressing Ruptures and Facilitating Repair—consist of two phases.

Skill Criteria Each of the first 12 exercises focuses on one essential EFT skill with three to five Skill Criteria that describe the important components or principles for that skill. The goal of the role-play is for trainees to practice improvising responses to the client statement in a manner that (a) is attuned to the client, (b) meets skill criteria as much as possible, and (c) feels authentic for the trainee. Trainees are provided

Instructions for the Emotion-Focused Therapy Deliberate Practice Exercises

scripts with example therapist responses to give them a sense of how to incorporate the skill criteria into a response. It is important, however, that trainees do not read the example responses verbatim in the role-plays! Therapy is highly personal and improvisational; the goal of deliberate practice is to develop trainees’ ability to improvise within a consistent framework. Memorizing scripted responses would be counterproductive for helping trainees learn to perform therapy that is responsive, authentic, and attuned to each individual client. Rhonda Goldman, codeveloper and expert in EFT, wrote the scripted example responses. However, trainees’ personal style of therapy may differ slightly or greatly from that in the example scripts. It is essential that, over time, trainees develop their own style and voice, while simultaneously being able to intervene according to the model’s principles and strategies. To facilitate this, the exercises in this book were designed to maximize opportunities for improvisational responses informed by the skill criteria and ongoing feedback. Trainees will note that some of the scripted responses do not meet all the Skill Criteria: These responses are provided as examples of flexible application of EFT skills in a manner that prioritizes attunement with the client. The goal for the role-plays is for trainees to practice improvising responses to the client statements in a manner that • is attuned to the client, • meets as many of the skill criteria as possible, and • feels authentic for the trainee.

Feedback The review and feedback sequence after each role-play has these two elements: • First, the trainee who played the client briefly shares how it felt to be on the receiving end of the therapist response. This can help assess how well trainees are attuning with the client. • Second, the trainer provides brief feedback (less than 1 minute) based on the skill criteria for each exercise. Keep feedback specific, behavioral, and brief to preserve time for skill rehearsal. If one trainer is teaching multiple pairs of trainees, the trainer walks around the room, observing the pairs and offering brief feedback. When the trainer is not available, the trainee playing the client gives peer feedback to the therapist, based on the skill criteria and how it felt to be on the receiving end of the intervention. Alternatively, a third trainee can observe and provide feedback. Trainers (or peers) should remember to keep all feedback specific and brief and not to veer into discussions of theory. There are many other settings for extended discussion of EFT theory and research. In deliberate practice, it is of utmost importance to maximize time for continuous behavioral rehearsal via role-plays.

Final Evaluation and Discussion After both trainees have role-played the client and the therapist, the trainer provides an evaluation. Finally, participants should engage in a short group discussion based on this evaluation. This discussion can provide ideas for where to focus homework and future deliberate practice sessions.

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PA R T

Deliberate Practice Exercises for Emotion-Focused Therapy Skills This section of the book provides 12 deliberate practice exercises for essential emotionfocused therapy (EFT) skills. These exercises are organized in a developmental sequence, from those that are more appropriate to someone just beginning EFT training to those who have progressed to a more advanced level. Although we anticipate that most trainers would use these exercises in the order we have suggested, some trainers may find it more appropriate to their training circumstances to use a different order. We also provide two comprehensive exercises that bring together the EFT skills using an annotated EFT session transcript and mock EFT sessions. Trainers and trainees should carefully review Chapter 2 before using any of the exercises. Exercises for Beginner Emotion-Focused Therapy Skills EXERCISE 1: Therapist Self-Awareness  25 EXERCISE 2: Empathic Understanding   33 EXERCISE 3: Empathic Affirmation and Validation   43 EXERCISE 4: Exploratory Questions   55 Exercises for Intermediate Emotion-Focused Therapy Skills EXERCISE 5: Providing Treatment Rationale for Emotion-Focused Therapy   63 EXERCISE 6: Empathic Explorations   73 EXERCISE 7: Empathic Evocations   83 EXERCISE 8: Empathic Conjectures   93 Exercises for Advanced Emotion-Focused Therapy Skills EXERCISE 9: Staying in Contact in the Face of Intense Affect   103 EXERCISE 10: Self-Disclosure  113 EXERCISE 11: Marker Recognition and Chair Work Task Setup   123 EXERCISE 12: Addressing Ruptures and Facilitating Repair   137 Comprehensive Exercises EXERCISE 13: Annotated Emotion-Focused Therapy Practice Session Transcript   149 EXERCISE 14: Mock Emotion-Focused Therapy Sessions   155

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EXERCISE

Therapist Self-Awareness Preparation 1. Read the instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Beginner Therapist self-awareness is one of the most basic and essential underlying skills in emotion-focused therapy. It is also the most global and pervasive. It refers to therapists’ way of being rather than something they are doing and involves (a) being grounded in oneself while receptively taking in the verbal and nonverbal expression of the client’s in-the-moment experience (Geller & Greenberg, 2012) and (b) being present in one’s own experience while simultaneously staying attuned to the client’s experience. It can also be viewed as a way for therapists to monitor their own experiences in therapy. This may, in turn, provide valuable information on the therapeutic relationship and work. This exercise is different from the other exercises in that trainees are not practicing what to say out loud to clients in real therapy sessions. Rather, trainees practice self-awareness by observing and labeling their internal process out loud so it will be easier for them to do when sitting with a real client. (Self-disclosure or revealing of one’s experience to clients in therapy can be a powerful technique that should be used carefully and only in certain situations, as indicated by a supervisor.)

https://doi.org/10.1037/0000227-003 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Special Instructions for Exercise 1 This exercise follows a different procedure from the other exercises in this book. One trainee will role-play a client who talks about an emotionally arousing topic. The other trainee will not role-play; instead, their task is to monitor their internal thoughts, feelings, and bodily felt responses as they are listening to the client and to disclose only those internal experiences that they feel comfortable sharing. A trainer (professor or supervisor) observes and provides feedback. In this task, the therapist does not respond to the client but instead describes their experience out loud. The therapist should try not to think about the appropriate clinical interventions or responses to the client’s words. Instead, the focus is fully on gradually heightening the therapist’s awareness of their own internal processes. The client reads the first client statement to the therapist. The therapist monitors their own internal experience and reactions (thoughts, feelings, bodily reactions, and urges) while listening to the client. When the client is finished reading the client statement, the therapist describes out loud any feelings or bodily felt experiences that they feel comfortable disclosing. For example, the therapist could say, “As I hear this, I feel a big smile crossing my lips,” “I start to breathe deeper,” “I feel warmth in my chest,” “I feel joy,” or “I feel very sad, and I get an urge to hug the client.” The Deliberate Practice Reaction Form provides common responses, but you may notice your own bodily felt responses that are not listed on this form. Try to notice and describe at least one aspect of your experience. It may be a feeling or sensation you are aware of internally, such as a pit in your stomach or a closing of your throat. It may also involve an externally felt experience, such as flushing of your face or a smile coming across your lips. The goal is to continually scan for inner experiences, although at first many trainees may only notice or have trouble identifying an experience at all. Only describe responses that you feel comfortable disclosing. It is important that trainees have the right not to reveal responses they wish to keep private.

Examples of Therapist Self-Awareness Example 1 CLIENT: I was playing with my dog the other day and I just became so aware of how much

I love him. He’s an incredible partner through all my hard times, and honestly, I don’t know where I’d be without him. It feels like every time I was sad, anxious, or self-critical, he would kind of notice and be there for me. I really feel blessed that despite all the things going on in my life, I have such a beautiful creature that is so unconditionally there for me. THERAPIST: I feel a strong warmth in my chest when I hear you talk about your dog.

Example 2 CLIENT: I’m excited about starting therapy with you, but I’m also kind of nervous. I’ve

never been in therapy before. THERAPIST: As you talk about your nervousness, I can feel the pitter-patter in my stomach.

Therapist Self-Awareness

Example 3 CLIENT: Last night I had the strangest dream. I was in the house where I grew up.

A monster was chasing me room to room. I was scared, so I hid under a bed. Then you appeared under the bed and said that you’d help me! I was surprised to see you but also relieved. We started planning what to cook for dinner, which felt strange and a bit uncomfortable. Then I woke up. THERAPIST: As I listen to you describe your dream, I can feel my heart racing.

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INSTRUCTIONS FOR EXERCISE 1 Step 1: Role-Play and Feedback • The client either says the first beginner client statement or uses it as an improvisation prompt (i.e., there is no need to repeat every word, but the client needs to convey the general content and tone of the statement). • The therapist tracks their internal experience in reaction to this client statement and then discloses only those reactions that they feel comfortable disclosing. • The trainer or client can provide brief feedback based on the skill criteria. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (see Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

SKILL CRITERIA FOR EXERCISE 1 1. The therapist tracks their internal experience while simultaneously listening to the client. 2. The therapist discloses reactions that they feel comfortable sharing. 3. The therapist protects their privacy and boundaries by not disclosing reactions that they don’t want to disclose. (The trainer should ask the therapist if they were able to do this.) 4. If the therapist has any reactions in the “too hard” category, they can ask the trainer to make the role-play easier, in a way that feels safe and self-respectful.

Therapist Self-Awareness

➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of this exercise is for the trainee playing the therapist to disclose their personal, genuinely felt inner experience in reaction to the client statements. We do not provide sample therapist responses to the client statements because, unlike the other exercises, this one does not focus on developing the most appropriate response to the client. Instead, the main goal of this exercise is for trainees to explore and communicate their own genuine internal reactions. Trainees can refer back to the examples of therapist self-awareness if needed.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 1 Beginner Client Statement 1 [Loving] I was playing with my dog the other day, and I just became so aware of how much I love him. He’s been an incredible partner through all my hard times, and honestly, I don’t know where I’d be without him. It feels like every time I was sad, sick, anxious, or selfcritical, he would kind of notice and be there for me. I feel really blessed that despite all the hard things going on in my life, I have such a beautiful creature that’s so unconditionally there for me. Beginner Client Statement 2 [Nervous] I’m excited about starting therapy with you, but I’m also kind of nervous. I’ve never been in therapy before. I’m not even sure how therapy works. I’m also a bit worried that my problems are maybe just all in my head and talking about them could make it worse? Beginner Client Statement 3 [Anxious] I’m coming to therapy because I just moved here, and I’m having some trouble adjusting. The people here are very different than where I grew up. Everyone here talks faster and seems kind of rude. Where I grew up, people are very calm and polite. Can you help me with this? Beginner Client Statement 4 [Uncomfortable] Last night I had the strangest dream. I was in the house where I grew up. A monster was chasing me room to room. I was scared, so I hid under a bed. Then you appeared under the bed and said you’d help me! I was surprised to see you but also relieved. We started planning what to cook for dinner, which felt strange and a bit uncomfortable. Then I woke up. Beginner Client Statement 5 [Hopeful] I’m very excited to start therapy again. My last therapist was very helpful. She taught me how to calm myself down when I had panic attacks and also how to have more positive thoughts about myself. I’m coming back to therapy because my work has gotten tough and I’m having some frustration with my boss. Can you help me with this?

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 1 Intermediate Client Statement 1 [Ashamed] Today I tried to cook something new and it turned out terrible. I always mess up these things. I guess my mother was right: Why do I even bother with pretending to be an adult? I guess I’m just much more dependent than I ever thought I would be at this age. Does this mean that I’m never going to be successful in my career? Intermediate Client Statement 2 [Concerned] Before we start therapy, can you answer some questions about yourself? Are you religious? If so, what religion? If not, do you have any problems with religious people? I am Muslim, I am honestly unsure if a therapist without religious faith could understand my life. My religious faith is a very important part of my life. My last therapist didn’t respect my religious beliefs, so I want to make sure that you will. Intermediate Client Statement 3 [Sad] When my ex broke up with me, I just felt totally lost and abandoned. And I still do. It’s like nothing makes sense, and all I can think about is “what went wrong?” and “why is this happening to me?” We had so many plans for our future together. We spoke of living together, marrying, having kids. (pauses) And now that’s all gone. It’ll never happen, and it’s awful. I lost the most important person in my life. And now I’m scared that I’ll never be able to trust another person again or that I’ll never find anyone who loved me like that. Intermediate Client Statement 4 [Stoned] I’ve got something to tell you that I’ve been hesitant to say, but I think is important for you to know. I’ve smoked pot before coming to our last few sessions, and also today. It helps me relax and feel more comfortable here. I think marijuana can help me find my true self. I hope you are okay with this? Intermediate Client Statement 5 [Angry] I feel really disappointed about not getting that job promotion. It’s so unfair! My supervisor has always been unfair to me about these things. I’m really tired of being treated like I’m second rate. And I just feel like quitting when all my work goes by unnoticed. I mean, what else does he want from me? Sometimes I just fantasize about punching him in the face.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Therapist Self-Awareness

ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 1 Advanced Client Statement 1 [Hopeless] I’m feeling much more depressed this week. I’ve felt so bad for so long, I just don’t know how much more of this I can take. I just feel totally helpless. I don’t even want to get out of bed in the morning. On the drive over here today, I saw a huge truck, and had an image of driving my car into the truck head-on. It would just be such a relief not to be alive and fight this depression anymore. Advanced Client Statement 2 [Skeptical] How much training and experience do you have? To be totally honest, I’m worried about doing therapy with a trainee. Are you sure that you will be able to help me? I’ve got serious trauma in my history, and I don’t know if you can handle it. Advanced Client Statement 3 [Flirty] So there’s something I’ve been thinking about and that I wanted to share with you. I hope it’s okay and that you don’t freak out about it. The thing is, for the longest time I’ve been feeling attracted to you. Maybe you noticed some signs of that? I mean, I think our work together is good, and I think I’ve been helped a lot. But I also wonder what it would be like if we had met under different circumstances. I think about that a lot, actually. I also notice that you dress very well for our sessions and imagine you are trying to look nice for me. I like that outfit you are wearing. Again, I don’t want to freak you out, I just wanted to let you know that I think you’re wonderful and would probably make a great partner. And, well . . . I was wondering if you ever thought about me that way? Advanced Client Statement 4 [Distrusting] I’ve been thinking about our last session, and I don’t think it was helpful. I really don’t understand what we are doing here in therapy or how it can help me. Do you have some kind of agenda or plan that you haven’t told me about? Is this how you help your other clients, or are you treating me differently? Honestly, I feel very frustrated with you right now and I’m not sure if I trust you. Advanced Client Statement 5 [Skeptical] I only came to therapy because my wife made me. She thinks I have a drinking problem. But she’s totally wrong, I just have a few drinks at night to calm down because my job is very hard and stressful. She doesn’t understand this because she’s a woman, and women don’t know what it’s like to work hard jobs. Also, to be totally honest, I think I drink because of her and her nagging. I know that isn’t very politically correct to say, but I hope I can be direct here and that you can handle the truth.

Assess and adjust the difficulty here (see Step 3 in the exercise instructions).   If appropriate, follow the instructions to make the exercise more challenging (see Appendix A).

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EXERCISE

Empathic Understanding Preparation 1. Read instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Beginner This skill is the most basic emotion-focused therapy response mode that the therapist uses throughout therapy. The therapist attunes themself to the client’s frame of reference and emotional experience in a moment-by-moment manner. The goal is to understand the client’s perspective while sensitively and accurately reflecting in both depth and intensity the client’s essential core experience, which are expressions or experiences that the therapist senses are significant for the client based on the client’s manner or voice. The client’s expression may be affect-laden or possess a certain precision or certainty of “this is how I feel.” Responses are symbolic representations of client’s implicit experiences that they may not have stated fully. The therapist attempts to capture a feeling-tone or sense of what the client is expressing. Responses target current or previously felt experiences. For clarification and examples of the differences between different empathy skills, see Appendix B.

https://doi.org/10.1037/0000227-004 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Examples of the Therapist’s Empathic Understanding Example 1 CLIENT: [stressed] I spent my entire day at the unemployment office, and I’m just so fed up. THERAPIST: You feel so worn out and frustrated . . .

Example 2 CLIENT: [worried] I’m so worried that I won’t be able to pay my bills next month, and

I don’t even know what I can do about it. It’s overwhelming. THERAPIST: It’s like you are feeling very scared and lost and not sure which way to turn.

Example 3 CLIENT: [confused] I have been feeling so depressed. I don’t really know why. Nothing

terrible has happened, work is just rolling along, my kids are doing okay, so I don’t know why. THERAPIST: You are very puzzled as to why, but somehow you are feeling so depressed

and down.

Empathic Understanding

INSTRUCTIONS FOR EXERCISE 2 Step 1: Role-Play and Feedback • The client says the first beginner client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provides brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (see Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

Optional Variation for Exercise 2 In the final round of the exercise, the client improvises by talking about an event that was emotionally challenging, difficult, or conflictual for them in real life, and the therapist attempts to express empathic understanding. The client can then tell the trainer whether she felt the therapist’s empathy and felt understood. Note that the client should be careful to only talk about topics that they feel comfortable sharing.

SKILL CRITERIA FOR EXERCISE 2 1. Convey an accurate sense of the client’s main concern—a felt sense or meaning in what the client is expressing. 2. Stay present in the moment. 3. Avoid asking questions, making suggestions, or interpreting the client’s experience. 4. Make sure to match tone of voice to client’s expressed emotion (i.e., if client’s voice is anguished and sad, use a soft tone; if the client is angry, match your voice with solidity and firmness, although not loud and angry).

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➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Beginner Client Statement 1 [Sad] I’m feeling really down today. I just can’t stop thinking about my mother who died last year. Beginner Client Statement 2 [Optimistic] I’d really like to feel better about myself, and I think I’m finally ready to work on some important issues here in therapy. Beginner Client Statement 3 [Stressed] I spent my entire day at the unemployment office, and I’m just so fed up. Beginner Client Statement 4 [Sad] I guess a big part of me died when my brother died, and I still need to find the space to deal with this.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Empathic Understanding

INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Intermediate Client Statement 1 [Hopeless] I get so tired of trying to make my partner take a new job. We’ve had so many fights over it, and nothing good ever comes of it. Intermediate Client Statement 2 [Worried] I’m so worried that I won’t be able to pay my bills next month, and I don’t even know what I can do about it. It’s overwhelming. Intermediate Client Statement 3 [Worried] I’d like to be nicer to my friends, but whenever I feel closer to anyone, I start thinking about how I’ll eventually disappoint them. Intermediate Client Statement 4 [Stressed] I have been trying to stop thinking these negative thoughts because I really do need to work more, but every time I sit down to do something, it’s like they just come back up. Intermediate Client Statement 5 [Angry] I got so mad at my friend the other day. We agreed to meet for lunch, and then she simply disappeared, without saying a thing! She’s done this before, and I just get so mad at her! Intermediate Client Statement 6 [Angry] Whenever I think of my mother, I only remember the bad times we had and all the ways she mistreated me as a child. To this day, I get upset just hearing her name. Intermediate Client Statement 7 [Confused] I have been feeling so depressed. I don’t really know why. Nothing terrible has happened, work is just rolling along, my kids are doing okay, so I don’t know why.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Advanced Client Statement 1 [Worried] I’m trying to let go of alcohol, but I’ve never dealt with my anxiety in any other way in the past. It’s actually been so useful to get drunk and feel fun and spontaneous, and I don’t know if I can manage without it. Advanced Client Statement 2 [Frustrated] I try to convince myself that what my father told me in the past was wrong, that I am worthwhile, that my opinions do matter. But why don’t I feel any different, even if I can now see that he was wrong? Advanced Client Statement 3 [Embarrassed] I am not sure whether to talk about this and I am kind of embarrassed to say so, but I have gained a lot of weight recently. If I don’t get to the gym to work out, then I am really angry at myself. But also, I engage in a lot mindless eating, like I will come home from work hungry, and find myself raiding the pantry, kind of desperate, I don’t know. Advanced Client Statement 4 [Confused] I don’t know what to talk about this week. I was hoping you could guide us. Advanced Client Statement 5 [Scared] I have been having a great deal of anxiety lately and [pauses] I don’t know, everything is affected, my sleep, my eating. My school is shutting down, and I am just so worried that I will lose all the credits and my student loans. [pauses] Is it possible that everything I have worked toward will go up in smoke? I don’t know what to do.

Assess and adjust the difficulty here (see Step 3 in the exercise instructions).   If appropriate, follow instructions to make the exercise even more challenging (see Appendix A).

Empathic Understanding

Example Therapist Responses: Empathic Understanding Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Example Response to Beginner Statement 1 You’re feeling sad over this big loss. Example Response to Beginner Statement 2 So, it’s like now the timing is right to work on some important issues. Example Response to Beginner Statement 3 You feel so worn out and frustrated. Example Response to Beginner Statement 4 Yes, it is hard to grieve this very painful loss.

EXAMPLE RESPONSES TO INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Example Response to Intermediate Client Statement 1 So much back-and-forth bickering, and yet it’s like your efforts seem wasted right now? Example Response to Intermediate Client Statement 2 It’s like you are feeling very scared and lost and not sure which way to turn. Example Response to Intermediate Client Statement 3 So it’s hard to feel close to someone without then having this fear of letting them down. Example Response to Intermediate Client Statement 4 Somehow you are not in a space to work, it’s hard for you to concentrate. Hard to stop thinking [pauses] the thoughts just pop up, and you feel sort of helpless to stop them. Example Response to Intermediate Client Statement 5 Yeah, so she simply disappeared, and this left you feeling so upset! Example Response to Intermediate Client Statement 6 So, there’s this part of you that really feels such strong resentment toward her, and the very mention of her name enrages you. Example Response to Intermediate Client Statement 7 You are very puzzled as to why, but somehow you are feeling so depressed and down.

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EXAMPLE RESPONSES TO ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 2 Example Response to Advanced Client Statement 1 So, it’s like it’s so hard to let go of something that’s been helpful before, and it sounds like you’re afraid of how life would be without it. Example Response to Advanced Client Statement 2 So, despite knowing he was wrong, deep down you still feel not worthwhile. Example Response to Advanced Client Statement 3 So, it is hard to talk about it because you are feeling very bad, but at times you are aware of yourself engaging in sort of “mindless eating.” Example Response to Advanced Client Statement 4 Sounds like you aren’t sure what to talk about right now and you’re hoping you could get some guidance from me. Example Response to Advanced Client Statement 5 So, you are feeling very worried and scared about the situation with your school and somehow fearing all you have worked toward will be lost.

EXERCISE

Empathic Affirmation and Validation Preparation 1. Read instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Beginner Empathic affirmation and validation responses affirm and support the client’s sense of self and situation. The therapist communicates being right beside the client, hearing, seeing, and deeply understanding how good or bad is the client’s situation in its depth and intensity. Therapist responses validate and communicate to clients a sense of “No wonder you feel this way, given what has happened to you in your life” and “It is understandable within your particular context.” In this type of response, therapists are not pushing clients to explore or further deepen their experience but are standing together with clients to see themselves and their situation as they truly are, helping clients to feel felt, seen, and heard. For clarification and examples of the differences between different empathy skills, see Appendix B.

https://doi.org/10.1037/0000227-005 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Examples of the Therapist Using Empathic Affirmation and Validation Example 1 CLIENT: [angry] I just can’t believe the direction our country is taking right now. Watching

the news makes me so angry! THERAPIST:  Yeah, somehow you find the news enraging. So much bad happening.

Example 2 CLIENT: [nervous] Whenever I have to give a presentation at work, I get very nervous. THERAPIST:  Yeah, the expectation and demand, the performance, can leave one feeling so on the spot and shaky inside.

Example 3 CLIENT: [scared] I just feel like my world is falling apart. THERAPIST: No wonder, it just feels so scary right now, like everything around you is

crumbling.

Empathic Affirmation and Validation

INSTRUCTIONS FOR EXERCISE 3 Step 1: Role-Play and Feedback • The client says the first beginning client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provides brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

Optional Variation for Exercise 3 In the final round of the exercise, the client improvises by talking about an event that was emotionally challenging for them in real life, and the therapist attempts to empathically validate and affirm the client’s experience. Clients can then tell the trainee whether they felt the therapist’s empathic validation and even reference where in their body they felt it. Note that clients should be careful to only talk about topics that they feel comfortable sharing.

SKILL CRITERIA FOR EXERCISE 3 1.  Therapist responses capture the depth and intensity of present experiencing. 2. Therapists responses deepen and affirm but do not speculate or push beyond client current experiencing. 3.  Therapist uses a soft, gentle, but affirming, voice.

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➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 3 Beginner Client Statement 1 [Angry] I just can’t believe the direction our country is taking right now. Watching the news makes me so angry! Beginner Client Statement 2 [Guilty] I accidentally hit a pedestrian while driving the other day. The weather was bad and the sun was in my eyes, so I couldn’t see him. He was taken to the hospital with broken bones. I feel so guilty! Beginner Client Statement 3 [Sad] My daughter recently left for college. My husband died last year, so I’m all alone at home. I feel really sad and lonely. Beginner Client Statement 4 [Nervous] Whenever I have to give a presentation at work, I get very nervous. Beginner Client Statement 5 [Scared] I just feel like my world is falling apart.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Empathic Affirmation and Validation

INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 3 Intermediate Client Statement 1 [Ashamed] I just feel so disgusting, like I am disgusting, like a black stain, like how could anyone ever love me? Intermediate Client Statement 2 [Confused] I recently started dating a new guy. He’s amazing. Although we’ve only gone on a few dates, I can already feel myself falling in love with him. I’ve had a pattern of falling for men too quickly in the past, and I’m worried that I’m making the same mistake again. Intermediate Client Statement 3 [Sad] I just moved to a new house. I like my new house, but I’ve also had a lot of grief about memories of my parents from my old house. I didn’t expect this. Intermediate Client Statement 4 [Scared] My son just joined the army. I’m proud of him but also frightened for his safety for when he is deployed. Intermediate Client Statement 5 [Depressed] Sometimes it’s just like I want to go crawl in my bed and just stay in there where nobody will bother me.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 3 Advanced Client Statement 1 [Anger and shame] My father abused me when I was a child. I still have nightmares about it. I feel deeply ashamed and also angry at him. However, my culture and religion say that I should respect my parents, and especially my father. Advanced Client Statement 2 [Overwhelmed and confused] I’m not sure what I’m feeling right now. Advanced Client Statement 3 [Rage and fear] I just got out of prison for hitting my ex-wife a few months ago. It was awful and I don’t want to ever go back. Every time I think of her I feel this intense rage build up inside me. Advanced Client Statement 4 [Very sad and desperate] Sometimes I used to just wish I was in the hospital dying or something so then my mom would finally notice me and notice I was there. Maybe she would give me the last month of my life. Advanced Client Statement 5 [Loving] I am so happy you got assigned as my therapist because I just feel so comfortable with you, so warm, I feel I can just be myself—it’s almost a feeling of love.

Assess and adjust the difficulty here (see Step 3 in the exercise instructions).   If appropriate, follow instructions to make the exercise even more challenging (see Appendix A).

Empathic Affirmation and Validation

Example Therapist Responses: Empathic Affirmation and Validation Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER CLIENT STATEMENTS FOR EXERCISE 3 Example Response to Beginner Client Statement 1 Yeah, somehow you find the news enraging. So much bad happening. Example Response to Beginner Client Statement 2 Oh wow, that sounds very distressing. I am so sorry that happened. No wonder it has left you feeling so bad. Example Response to Beginner Client Statement 3 It has left you feeling really alone, and so sad. Example Response to Beginner Client Statement 4 Yeah, the expectation and demand, the performance, can leave one feeling so on the spot and shaky inside. Example Response to Beginner Client Statement 5 No wonder, it just feels so scary right now, like everything around you is crumbling.

EXAMPLE RESPONSES TO INTERMEDIATE CLIENT STATEMENTS FOR EXERCISE 3 Example Response to Intermediate Client Statement 1 You just feel like there is something wrong with you, like you are just this black stain [pauses] it’s just like, “I feel so unlovable.” That sounds like such a difficult but important experience to acknowledge. Example Response to Intermediate Client Statement 2 So, on the one hand you are worried about a common pattern of rushing in too quickly, but on the other hand, you know there is this feeling of falling deeply in love and it feels very real. Example Response to Intermediate Client Statement 3 Such a loss, and it has left you with a lot of grief and sadness about what you left behind. Example Response to Intermediate Client Statement 4 Of course, it must be very frightening to think of him out there on the frontlines. Example Response to Intermediate Client Statement 5 Understandably, it is like [voicing the client], “I just want to shut my eyes and shut out all the pain” because the pain you are living now feels so unbearable.

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EXAMPLE RESPONSES TO ADVANCED CLIENT STATEMENTS FOR EXERCISE 3 Example Response to Advanced Client Statement 1 That sounds like a difficult feeling. It sounds like you have very strong feelings. Both intense anger and deep, deep shame. Example Response to Advanced Client Statement 2 So, it sounds like a lot of mixed emotion, and you are not sure . . . kind of overwhelmed and confused. And it seems important to just stay with that uncertainty, to just focus inside and see what comes up. Example Response to Advanced Client Statement 3 Wow, it sounds like a very intense rage. I imagine that must be quite frightening and worrying. Example Response to Advanced Client Statement 4 Wow, that sounds so painful. To wish you could just die. That must have been so scary and hard for you. You were just longing for her to notice, longing to be seen by her. Example Response to Advanced Client Statement 5 Feeling so much trust and a kind of love, a wonderful sense of comfort and safety.

EXERCISE

Exploratory Questions Preparation 1. Read instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Beginner Exploratory questions are open-ended and help people explore and deepen experience. They are often focused on bodily felt experience and encourage bodily felt expression.

Examples of the Therapist Asking Exploratory Questions Example 1 CLIENT: [ashamed] You should have seen how she glared at me. It made me feel so little. THERAPIST: Yes, you felt so small. Can you turn your attention inside your body, maybe

your stomach or your chest and tell me what it was like when you felt so little?

https://doi.org/10.1037/0000227-006 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Example 2 CLIENT: [angry] I feel so taken advantage of by her, so used. THERAPIST:  Yes, so used. What is it like inside when you imagine feeling that?

Example 3 CLIENT:  He just put down the phone in the middle of our conversation. I was so hurt. THERAPIST: Yes, you felt so dismissed and hurt. Where do you feel that in your body,

as you talk about it now?

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Exploratory Questions

INSTRUCTIONS FOR EXERCISE 4 Step 1: Role-Play and Feedback • The client says the first beginning client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provide brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

Optional Variation for Exercise 4 In the final round of the exercise, the client improvises by talking about an event that was emotionally challenging for them in real life, and the therapist attempts to ask exploratory questions. The client can then tell the trainer whether they felt the therapist’s empathy and an openness toward further exploration. Note that the client should be careful only to talk about two topics that they feel comfortable sharing.

SKILL CRITERIA FOR EXERCISE 4 1. Questions are nonjudgmental. 2. Questions focus on and are directed to client’s experiences (including perceptions, feelings, thoughts, and emotions), particularly bodily felt experience. 3. Exploratory questions tend to start with “how” or “what,” rather than “why” or “when.” 4. Questions promote open-ended self-exploration and emotional deepening. 5. Therapist uses an exploratory, discovery-oriented vocal style.

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➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 4 Beginner Client Statement 1 [Ashamed] You should have seen how she glared at me. It made me feel so little. Beginner Client Statement 2 [Angry] I feel so taken advantage of by her, so used. Beginner Client Statement 3 [Hurt] He just put down the phone in the middle of our conversation. I was so hurt. Beginner Client Statement 4 [Angry] My son is dating this new girl who is so disrespectful. She really makes my blood boil. Just furious! Beginner Client Statement 5 [Sad] I’m in Alcoholics Anonymous and on the step where we say sorry to people. I’ve been making a list of all people I’ve disappointed and hurt over the decades due to my drinking. There are so many, I don’t know if I can handle it.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Exploratory Questions

INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 4 Intermediate Client Statement 1 [Obsessed] I cannot stop thinking of him. I just haven’t felt this way in a long time. I think it fills some kind of a void inside. Intermediate Client Statement 2 [Worthless] I just feel so worthless. Intermediate Client Statement 3 [Betrayed] My boyfriend has been so unfaithful, I just can’t let myself love him anymore. He cheated on me again this weekend! I need to stop loving him. Intermediate Client Statement 4 [Sad] Even though my father has passed on now, I still cannot let go of some of the resentment. I cannot help but feel there was something missing in our relationship. Intermediate Client Statement 5 [Hopeless] I mean when he starts talking, I feel like I cannot get a word in, and eventually I find myself just giving up, and then I just shut down. Intermediate Client Statement 6 [Unsure] I just wish my father would acknowledge my feelings, or at least look at me once in a while. When he doesn’t, it just leaves me with a strong, empty, churning feeling in my stomach.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 4 Advanced Client Statement 1 [Very sad] I just cannot believe she could just leave and walk away from this relationship after 25 years! Advanced Client Statement 2 [Confused] I am in such a confused, distressed place today. I don’t even know what I feel or where to begin. Advanced Client Statement 3 [Macho] My father was in the army, and he taught me that only weak people have feelings. Advanced Client Statement 4 [Ashamed] I feel like nobody really knows I feel this, but deep inside, I think there is something really wrong with me, like I am rotten to the core.

Assess and adjust the difficulty here (see Step 3 in the exercise   instructions). If appropriate, follow instructions to make the exercise even more challenging (see Appendix A).

Exploratory Questions

Example Therapist Responses: Exploratory Questions Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER CLIENT STATEMENTS FOR EXERCISE 4 Example Response to Beginner Client Statement 1 Yes, you felt so small. Can you turn your attention inside your body, maybe your stomach or your chest, and tell me what it was like when you felt so little? Example Response to Beginner Client Statement 2 Yes, so used. What is it like inside when you imagine feeling that? Example Response to Beginner Client Statement 3 Yes, you felt so dismissed and hurt. Where do you feel that in your body as you talk about it now? Example Response to Beginner Client Statement 4 Can you imagine your son’s girlfriend sitting in front of you and tell her how much you resent her? Example Response to Beginner Client Statement 5 So, a long list of people [pauses] and what feels the worst part of all of that?

EXAMPLE RESPONSES TO INTERMEDIATE CLIENT STATEMENTS FOR EXERCISE 4 Example Response to Intermediate Client Statement 1 What is it that you feel you have been missing? Example Response to Intermediate Client Statement 2 It is like a deep sense of feeling like such a nothing. Where do you feel that in your body when you talk about it? Can you actually put a hand to the place where you feel that and speak from it? Example Response to Intermediate Client Statement 3 It’s so hard for you to stop loving him. What do you feel you are getting from this relationship that makes it so hard to give up? Example Response to Intermediate Client Statement 4 What did you miss getting from your father? Example Response to Intermediate Client Statement 5 Somehow you just shut down. Let’s see how you do that. How do you actually shut yourself down? Where in your body can you feel yourself shutting down? Example Response to Intermediate Client Statement 6 Let’s just stay with the feeling and focus on it, speak from it. What does the churning, empty feeling actually say? Like I am so hurt, or what is it?

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EXAMPLE RESPONSES TO ADVANCED CLIENT STATEMENTS FOR EXERCISE 4 Example Response to Advanced Client Statement 1 And as those important tears begin to fall, let’s pay attention to them. See if you can talk from the tears. What do the tears say? “I am so sad. I miss her”? Example Response to Advanced Client Statement 2 That sounds difficult. Let’s go to your body and see what it may be telling you. See if you can check inside your chest or your stomach. Feel free to put a hand there if you like, and it is okay if you don’t want to, but see if you can get a sense. Ask by checking in from those places, what you would like to focus on today? What comes up when you try to do that? Example Response to Advanced Client Statement 3 What do you feel inside when you tell me the story of your father being in the army right now? Example Response to Advanced Client Statement 4 You feel so rotten inside. What happens as you look over at me and tell me this?

EXERCISE

Providing Treatment Rationale for Emotion-Focused Therapy Preparation 1. Read instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Intermediate Explaining the treatment rationale for emotion-focused therapy (EFT) is an essential skill that therapists draw upon at different stages of treatment. This skill can be helpful for establishing the therapeutic relationship and a plan for work. Therapists use it in response to inquiries from clients related to how EFT works, what methods are used, and what will happen in the sessions. Like much of EFT, treatment rationales are given moment by moment and throughout the course of therapy. The skill is not only used at the beginning of therapy. It is also used to address doubts that may emerge about the various tasks of therapy, such as the value of exploring painful emotions or engaging in chair dialogues, a key aspect of EFT.

https://doi.org/10.1037/0000227-007 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Examples of the Therapist Providing a Treatment Rationale for EFT Example 1 CLIENT: [curious] Can you tell me more about your approach to therapy? THERAPIST:  Of course. In our sessions, we are going to explore your emotions together,

discuss how you feel about things, solve problems, and help you decide on the best course of action for you.

Example 2 CLIENT:  [curious] How does therapy work? THERAPIST:  Therapy helps you explore what is not working for you. Our ultimate goal is to

help you transform those troubling emotions so that you can feel better.

Example 3 CLIENT:  [skeptical] I’m not sure I understand how talking about my feelings will help. THERAPIST:  This is very common concern, and I appreciate you sharing it. You see, at their

core, feelings give us important information, and when we’re comfortable experiencing and expressing feelings, we are usually more able to meet our needs.

Providing Treatment Rationale for Emotion-Focused Therapy

INSTRUCTIONS FOR EXERCISE 5 Step 1: Role-Play and Feedback • The client says the first beginner client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provide brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

SKILL CRITERIA FOR EXERCISE 5 1.  Validate the client’s experience. 2.  Give a rationale for why we work with emotion. 3.  Reformulate the presenting problem in emotional terms.

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➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 5 Beginner Client Statement 1 [Curious] Can you tell me more about your approach to therapy? Beginner Client Statement 2 [Curious] Why does talking about my feelings help me feel better? Beginner Client Statement 3 [Curious] How does therapy work? Beginner Client Statement 4 [Curious] I’ve never been in therapy before. What do we talk about here? Beginner Client Statement 5 [Curious] I’ve never been in therapy before. Should I tell you about my history?

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Providing Treatment Rationale for Emotion-Focused Therapy

INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 5 Intermediate Client Statement 1 [Skeptical] I’m not sure I understand how talking about my feelings will help. Intermediate Client Statement 2 [Hopeful] My friends on Facebook are always happy and positive. I want to be like that. Can you help me with this? Intermediate Client Statement 3 [Skeptical] If I talk about feeling sad or angry, couldn’t I just feel worse? Intermediate Client Statement 4 [Skeptical] I think my feelings are irrational. Won’t talking about them make it worse? Intermediate Client Statement 5 [Ashamed] I’m embarrassed of how sad I feel all the time, and I’m worried that if I start crying here, I won’t be able to stop. I think I look ugly when I cry.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 5 Advanced Client Statement 1 [Very skeptical] I don’t think this is going to work for me because my emotions are part of the problem. That’s what I want you to help me with, to feel less! Advanced Client Statement 2 [Very skeptical] How can you guarantee that if I go into my painful emotions, I am going to feel better afterward? My experience has been that I go in there and get lost and just feel worse. How will this be different? Advanced Client Statement 3 [Afraid] I’ve had bad experiences in therapy before. My last therapist tried to make me talk about my past traumas. How can I know that I am safe with you? Advanced Client Statement 4 [Self-blaming] I hate that I can’t control my feelings. I believe this makes me weak. I want to control my feelings, so I can be strong. Can you help me with this? Advanced Client Statement 5 [Confused] My doctor said I have an anger problem. When I get really angry, I lose control and hit people. Is safe for me to explore my feelings? Shouldn’t I just try to get rid of my anger?

Assess and adjust the difficulty here (see Step 3 in the exercise   instructions). If appropriate, follow instructions to make the exercise even more challenging (see Appendix A).

Providing Treatment Rationale for Emotion-Focused Therapy

Example Therapist Responses: Providing the Treatment Rationale for EFT Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER CLIENT STATEMENTS FOR EXERCISE 5 Example Response to Beginner Client Statement 1 Of course. In our sessions we are going to explore your emotions together, discuss how you feel about things, solve problems, and help you decide on the best course of action for you. Example Response to Beginner Client Statement 2 Talking about your feelings can help you understand what you feel so that you can better identify what you need. Example Response to Beginner Client Statement 3 Therapy helps you explore what is not working for you. Our ultimate goal is to help you transform those troubling emotions so that you can feel better. Example Response to Beginner Client Statement 4 I like to let you decide what you want to focus on. Maybe you could take a moment, check inside, and see what feels most pressing at the moment? Example Response to Beginner Client Statement 5 Maybe you can just start by telling me what brings you here and maybe even what comes up as you sit here now with me. I am interested in your history, and I am sure we will get to that.

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EXAMPLE RESPONSES TO INTERMEDIATE CLIENT STATEMENTS FOR EXERCISE 5 Example Response to Intermediate Client Statement 1 This is very common concern, and I appreciate you sharing it. You see, at their core, feelings give us important information, and when we’re comfortable experiencing and expressing feelings, we are usually more able to meet our needs. Example Response to Intermediate Client Statement 2 It seems to you that everyone around you is so happy. That must feel difficult. We can work toward helping you find more inner satisfaction by focusing on what is getting you down and trying to change that. Example Response to Intermediate Client Statement 3 Sometimes talking about difficult feelings can make you feel temporarily worse, although sometimes it actually makes you feel better. Overall, it is helpful to share your feelings with someone, so you feel less isolated and alone with those feelings. Example Response to Intermediate Client Statement 4 I know it sometimes feels like our feelings don’t make sense, but actually there is often a lot of sense in your feelings. By giving your inner world a voice, we can work together to try to figure out which feelings you want to listen to and which ones are not helping you. Those are the feelings we want to help transform. Example Response to Intermediate Client Statement 5 That sounds like a difficult experience. You somehow feel like your sadness and tears are ugly. I actually think they are so important—and important to listen to. After all, therapy is a place that you can cry, and I imagine this is some of what we will do here together.

Providing Treatment Rationale for Emotion-Focused Therapy

EXAMPLE RESPONSES TO ADVANCED CLIENT STATEMENTS FOR EXERCISE 5 Example Response to Advanced Client Statement 1 I understand your experience tells you that emotions can sometimes feel dangerous or disorganizing. Here we are going to explore your feelings, but in some new ways you might not have done before. This is important as it will give us a sense of what is missing for you and what you need. Remember that I will be on this journey with you. Example Response to Advanced Client Statement 2 Thank you for asking, this is very important, and you’re not alone in that experience. Maybe I could clarify when and why emotions can be healthy and helpful. Emotion motivates and helps you get your needs met because it tells you what is missing. For example, sadness tells you that you have lost something important to you and can allow you to let go and organize to find something new. Anger helps you set boundaries and feel deserving when you have been violated. Loneliness tells you what you need to feel connected and motivates you to reach out. Anxiety and fear tell you that you do not feel safe and that you need protection. So, emotions usually tell us what we need, help us get needs met, help us remember what is important to us, and help us connect. Does that make sense? Example Response to Advanced Client Statement 3 I know it can be difficult to talk about past traumas. And we need to go slow and at a pace that you feel comfortable with. I actually do think it is important to be able to talk about what happened to you and process the feelings around it, in a safe place. How about we take it at a pace you feel comfortable with where you decide how deep you want to go. Example Response to Advanced Client Statement 4 Yes, it can feel very distressing when you feel out of control. And it sounds like that does leave you feeling weak. I don’t believe that controlling feelings makes you stronger, but we can explore that. In many ways, I think it is strong to be able to allow your feelings. You can then have choice over when to express them. But we discuss it. How does it sound to you? Example Response to Advanced Client Statement 5 I think we need to look into your anger a little further. Hitting people is not a good thing, and I agree that we need to work on it. Maybe we need to consider strategies to help you get anger under control. Also, it is important to look at what is driving that anger, what is underneath it. Sometimes it can be helpful to get, to feelings underneath your anger. This refocusing helps you actually get anger under control.

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EXERCISE

Empathic Explorations Preparation 1. Read the instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Intermediate The therapist enters into the client’s frame of reference, attempts to understand and reflect the client’s present experience, and explores the leading edge of the client’s experience. The leading edge may be that which is in the client’s awareness but appears to be on the periphery or that which is not fully in awareness. The goal is to facilitate a new synthesis and create new meaning by focusing on experiential information that was previously not yet figural. This skill also has a quality of coexploration—of the therapist and client searching together for accurate symbolizations. Here the therapist uses a probing, tentative quality that helps clients explore the peripheries and margins of their experience. The response is designed to help clients unpack and illuminate all the different aspects of the client’s experience, including those of which they may not have been previously aware. The therapist should use a discovery-oriented voice and collaborative, exploratory style. The purpose of these interventions is to evoke experience and deepen emotion. For clarification and examples of the differences between different empathy skills, see Appendix B.

https://doi.org/10.1037/0000227-008 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Examples of the Therapist Using Empathic Explorations Example 1 CLIENT:  [confused/lost] I feel so lost, like life has no purpose, and I don’t quite know

which way to turn. THERAPIST:  Just feeling so lost and without meaning, and there is a feeling of wanting to

reach forward but not knowing how, somehow.

Example 2 CLIENT:  [angry] My husband makes me so frustrated. Sometimes I just want to

strangle him. THERAPIST:  He just makes you so angry, maybe even enraged.

Example 3 CLIENT:  [very sad] Both of my parents died last year. It is hard to bear. THERAPIST:  It feels so difficult and sad . . . almost an unbearable feeling.

Empathic Explorations

INSTRUCTIONS FOR EXERCISE 6 Step 1: Role-Play and Feedback • The client says the first beginning client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provide brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

Optional Variation for Exercise 6 In the final round of the exercise, the client improvises by talking about an event that was emotionally challenging for them in real life, and the therapist tries various empathic exploration responses. The client can then tell the trainer whether they felt the therapist’s empathy and felt invited to explore more deeply. Note that the client should be careful only to talk about topics that they feel comfortable sharing.

SKILL CRITERIA FOR EXERCISE 6 1. The therapist has a tentative probing quality exploring the peripheries and margins of the client’s experience. 2.  The therapist softens voice, attending to the leading edge of the client’s experience. 3.  The therapist has a discovery-oriented, collaborative, and exploratory style. 4.  The therapist deepens emotion or elaborates meaning and tone.

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➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 6 Beginner Client Statement 1 [Confused/lost] I feel so lost, like life has no purpose, and I don’t quite know which way to turn. Beginner Client Statement 2 [Angry] My husband makes me so frustrated. Sometimes I just want to strangle him. Beginner Client Statement 3 [Scared] I lost my daughter at the supermarket the other day and couldn’t find her. She was crying when I finally found her 10 minutes later. I feel horrible about this! Beginner Client Statement 4 [Very sad] Both of my parents died last year. It is hard to bear. Beginner Client Statement 5 [Excited] I just started dating a new guy. He’s awesome and super cute, but there is something about him that I question. . . . I am not clear on what or why!

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Empathic Explorations

INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 6 Intermediate Client Statement 1 [Ashamed] It was a difficult relationship. He treated me really badly. I really gave him everything, and he left me with nothing. Intermediate Client Statement 2 [Uncomfortable] I really love my wife, but she has developed some strange behavioral habits. I am not sure what to do. Intermediate Client Statement 3 [Distrusting] My last therapist dropped me after I missed a session. It has left me feeling unsure about trusting any therapist. I mean, I am here today for this session, but . . . Intermediate Client Statement 4 [Confused/detached] I’m not very emotional and don’t really understand feelings. I am not sure what I am going to talk about.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 6 Advanced Client Statement 1 [Dazed] I’m feeling strange right now . . . umm . . . it’s all blurry and foggy inside . . . wow . . . kind of warm, like a balloon floating away. . . . Is this normal? Am I in danger? Advanced Client Statement 2 [Ashamed] You seem like such a confident and healthy person, and I feel that in comparison, I’m a mess. I can’t understand how you could even want to help me. Why can’t I just be normal and healthy like you? Advanced Client Statement 3 [Flirting] Is it okay if I’m attracted to you? Advanced Client Statement 4 [Confused] It is like I don’t know why I stay in the relationship. It is clear that he does not prioritize me and he has much more important people close to him. Advanced Client Statement 5 [Guarded] You’re asking me how I feel right now? I know how this works: If I tell you how I feel, you’re going to want to hospitalize me. I can’t spend another month in the hospital. So, to answer your question, I’m feeling just fine. Thanks for asking.

Assess and adjust the difficulty here (see Step 3 in the exercise   instructions). If appropriate, follow the instructions to make the exercise even more challenging (see Appendix A).

Empathic Explorations

Example Therapist Responses: Empathic Explorations Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER CLIENT STATEMENTS FOR EXERCISE 6 Example Response to Beginner Client Statement 1 Just feeling so lost and without meaning, and there is a feeling of wanting to reach forward but not knowing how, somehow. Example Response to Beginner Client Statement 2 He just makes you so angry, maybe even enraged. Example Response to Beginner Client Statement 3 Such a terrible feeling of fear, and now looking back on it, you just feel so bad inside. Example Response to Beginner Client Statement 4 It feels so difficult and sad . . . almost an unbearable feeling. Example Response to Beginner Client Statement 5 So, you are very excited and also, something makes you feel not sure.

EXAMPLE RESPONSES TO INTERMEDIATE CLIENT STATEMENTS FOR EXERCISE 6 Example Response to Intermediate Client Statement 1 Just the way he treated you after you gave everything you could, it just left you feeling so down, so diminished. Example Response to Intermediate Client Statement 2 So, you really love her and she has been doing some funny things that leave you feeling quite uncomfortable? Example Response to Intermediate Client Statement 3 It sounds like it was quite a difficult experience with your last therapist, and you are feeling really unsure that you can open up and share with me? Example Response to Intermediate Client Statement 4 So, it is difficult for you to sort out what is even a feeling, and that leaves you unsure what it is you are going to talk about here . . . it’s like, “Where do I begin?”

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EXAMPLE RESPONSES TO ADVANCED CLIENT STATEMENTS FOR EXERCISE 6 Example Response to Advanced Client Statement 1 It sounds like a scary feeling, and I don’t think you are in danger, but just feeling so strange, and kind of blurry, as if you are floating and it leaves you wondering if you are normal. [pauses] It sounds hard, but can we stay with that feeling a little longer. Example Response to Advanced Client Statement 2 So, to you it seems like I have it all together. But for you it feels like you are struggling so much. I want to reassure you that I do want to find a way to help you. So, you want to feel alright inside, but it feels like you are just in a mess. Example Response to Advanced Client Statement 3 So, you wonder if feeling attracted to me is okay and how I will react . . . I’m flattered, and I’m pleased you are telling me and maybe you could say more about your fears? Example Response to Advanced Client Statement 4 So, given the way you feel treated, it is hard for you to even understand why you stay in the relationship, but somehow you do . . . it is as if there is something important for you to hold onto here. Example Response to Advanced Client Statement 5 So, I hear very strongly that you don’t want to be hospitalized, and we are going to try to avoid that if we can. And you are saying that you feel fine to stay safe, but maybe we can explore what fine feels like for you. I imagine there are a whole lot of other feelings inside as well.

EXERCISE

Empathic Evocations Preparation 1. Read instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Intermediate These empathic responses are primarily intended to evoke emotion. Here, specifically, the responses bring experience to life through vivid imagery, elaborate description, analogy, or metaphor. The responses may also bring experience into awareness through vocal quality or dramatic, expressive manner. One form of evocative reflection involves therapists speaking dramatically as if they were the client. The therapist is guided by what feels like the most poignant aspect of the client’s message, whether this is conveyed through the client’s words, face, body, or posture. For clarification and examples of the differences between different empathy skills, see Appendix B.

https://doi.org/10.1037/0000227-009 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Examples of the Therapist Using Empathic Evocations Example 1 CLIENT:  [ashamed] You should have seen how she glared at me. It made me feel so little. THERAPIST:  Yeah, just so small, almost as if you weren’t there, you could disappear.

Example 2 CLIENT:  [angry] My son is dating this new girl who is so disrespectful. She really makes

me furious. THERAPIST:  Just the sight of her makes you want to blow up!

Example 3 CLIENT:  [obsessed] I love him so much that it’s hard to think of anything else. THERAPIST:  You are so smitten, he has really rocked your world—just feels like nothing

else matters.

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INSTRUCTIONS FOR EXERCISE 7 Step 1: Role-Play and Feedback • The client says the first beginning client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provides brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

Optional Variation for Exercise 7 In the final round of the exercise, the client improvises by talking about an event that was emotionally challenging for them in real life, and the therapist attempts to express empathic evocations. The client can then tell the trainer whether they felt the therapist’s empathy and whether experience was deepened or evoked. Note that the client should be careful only to talk about topics that they feel comfortable sharing.

SKILL CRITERIA FOR EXERCISE 7 1.  The therapist captures the feeling and meaning quality with connotative language. 2.  The therapist intensifies the client content and meaning. 3.  The therapist uses an evocative, soft voice and manner. 4. The therapist uses vivid language, a dramatic or expressive manner, metaphor, or analogy. 5.  The therapist is guided by the poignancy of the client’s message.

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➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 7 Beginner Client Statement 1 [Ashamed] You should have seen how she glared at me. It made me feel so little. Beginner Client Statement 2 [Angry] I feel so taken advantage of by her, so used. Beginner Client Statement 3 [Frustrated] I really hate it when my wife says I have a drinking problem. She’s one to accuse me! She smokes a lot of dope. Beginner Client Statement 4 [Angry] My son is dating this new girl who is so disrespectful to me. She really makes me furious. Beginner Client Statement 5 [Sad] I’m in Alcoholics Anonymous and on the step where we say sorry to people. I’ve been making a list of all people I’ve disappointed and hurt over the decades due to my drinking. There are so many, I don’t know if I can handle it.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Empathic Evocations

INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 7 Intermediate Client Statement 1 [Obsessed] I love him so much that it’s hard to think of anything else. Intermediate Client Statement 2 [Worthless] I just feel so worthless. Intermediate Client Statement 3 [Betrayed] My boyfriend has been so unfaithful, I just can’t let myself love him anymore. He cheated on me again this weekend! I need to stop loving him. Intermediate Client Statement 4 [Obsessed] I love my girlfriend a lot. She’s always there for me, no matter what I do. I can even sleep with other girls! She’s like the perfect girlfriend. Intermediate Client Statement 5 [Hopeless] I mean, when he starts talking, I feel like I cannot get a word in, and eventually I find myself just giving up, and then I just shut down. Intermediate Client Statement 6 [Shame] I just wish my father would acknowledge my feelings, or at least look at me once in a while. When he doesn’t, it just leaves me with a strong, empty, churning feeling in my stomach.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 7 Advanced Client Statement 1 [In denial] Everything is perfect. I felt suicidal last week when my girlfriend left. But yesterday she came back when she realized how bad I felt. I think everything’s okay now. Maybe we should stop therapy? Advanced Client Statement 2 [Confused] I am in such a confused, distressed place today. I don’t even know what I feel or where to begin. Advanced Client Statement 3 [Macho] My father was in the army, and he taught me that only weak people have feelings. Advanced Client Statement 4 [Ashamed] I feel like nobody really knows I feel this, but deep inside there is really something wrong with me, like I am rotten to the core. Advanced Client Statement 5 [Distrustful] I know you are required to keep our session notes private. If you betray me, I’m going to report you to the board of licensure.

Assess and adjust the difficulty here (see Step 3 in the exercise   instructions). If appropriate, follow instructions to make the exercise even more challenging (see Appendix A).

Empathic Evocations

Example Therapist Responses: Empathic Evocations Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER CLIENT STATEMENTS FOR EXERCISE 7 Example Response to Beginner Client Statement 1 Yeah, just so small, almost as if you weren’t there, you could just disappear. Example Response to Beginner Client Statement 2 You feel kind of jerked around, like a yo-yo. Example Response to Beginner Client Statement 3 Something about her accusing you of having a drinking problem feels like a knife digging into you. Example Response to Beginner Client Statement 4 Just the sight of her makes you want to blow up! Example Response to Beginner Client Statement 5 Like a list a mile wide. It is as if you lose count, with so much sorrow. It is like, “Where do I begin?”

EXAMPLE RESPONSES TO INTERMEDIATE CLIENT STATEMENTS FOR EXERCISE 7 Example Response to Intermediate Client Statement 1 You are so smitten, he has really rocked your world—just feels like nothing else matters. Example Response to Intermediate Client Statement 2 It is like “I feel like such a nothing,” like “I don’t deserve to exist,” like wanting to shrink into the floor. Example Response to Intermediate Client Statement 3 Somehow you feel so betrayed, so taken advantage of, and it is a feeling of “This is where I draw the line!” Example Response to Intermediate Client Statement 4 Somehow it feels like the most perfect relationship. It’s as if there are no boundaries, no walls to bump up against. Example Response to Intermediate Client Statement 5 Yes, it is as if you just fold up like an accordion [therapist slumps down in their chair, blows out air], kind of like “What is the point, why bother?” Example Response to Intermediate Client Statement 6 When you imagine him turning away from you, you feel a churning, buzzy feeling in the pit of your stomach.

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EXAMPLE RESPONSES TO ADVANCED CLIENT STATEMENTS FOR EXERCISE 7 Example Response to Advanced Client Statement 1 When things feel okay, it feels like you have been able to stop the bleeding, but I guess the wounds underneath run really deep.1 Example Response to Advanced Client Statement 2 So, just tangled up as if you are stuck in the mud . . . not even knowing what door to open next. Example Response to Advanced Client Statement 3 So, you just hear your father’s words ringing in your ears . . . only weak people feel . . . Example Response to Advanced Client Statement 4 It is as if you have this beautiful linen cloth, but somehow there is a dark stain spreading across it, and try as you might, you cannot get rid of it, you cannot purify it. Example Response to Advanced Client Statement 5 It sounds like you have been really hurt before, and the wound of betrayal cuts really deep.

1. Expressions such as “I felt suicidal” may reflect an expression of a feeling and not an intent to harm oneself. However, therapists need to use a multitude of contextual client indicators to determine suicidal intent. Trainees should seek close supervision for clients who may be at risk of self-harm or suicide. If a client is at risk of suicide, therapists should consider a suicide-focused treatment, such as the Collaborative Assessment and Management of Suicidality (https://cams-care.com).

EXERCISE

Empathic Conjectures Preparation 1. Read the instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Intermediate In this skill, the therapist attempts to foster client exploration by conjecturing, speculating, or “hunching” with clients about what might be beyond what the client is experiencing. The therapist is helping clients to symbolize new meaning or express that which is unexpressed. Empathic conjectures can be made only with an experience that the client is currently feeling. Conjectures are based on inference that the therapist might make based on the client’s present expressions in voice, face, and body. It should be clear that the conjecture or guess is coming from the client’s frame of reference (e.g., “My hunch is that you might feel . . .”). Therapists should not take an authoritative or more knowing stance when using this response, but rather should make it clear that they are merely guessing. The therapist treads carefully, withdrawing or re­tracting conjecture if the client disagrees or asserts otherwise. The conjecture is about inner experience and not about psychogenetic causes or patterns in behavior experience. This is different from empathic exploration, in which the therapist attempts to explore the leading edge of stated client experience. In conjectural empathic understanding, the therapist hypothesizes or guesses about unstated experience—that which lies beyond stated experience. Although both responses are approached from a querying or unknowing therapist perspective, the latter is a conjecture about what is not explicitly stated. For clarification and examples of the differences between different empathy skills, see Appendix B.

https://doi.org/10.1037/0000227-010 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Examples of the Therapist Using Empathic Conjectures Example 1 CLIENT:  [ashamed] You should have seen how she glared at me. It made me feel so little. THERAPIST:  I imagine just burning with anger, and also . . . feeling diminished and hurt.

Example 2 CLIENT:  [angry] I feel so taken advantage of by her, so used. THERAPIST:  I guess you feel so used, and, I don’t know, maybe even outraged, just

resentful and I imagine feeling taken for granted, and hurt inside.

Example 3 CLIENT:  [angry] My son is dating this new girl who is so rude! She really makes my

blood boil. THERAPIST:  The way she treats you makes you so angry, and I guess you just feel

so rejected!

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INSTRUCTIONS FOR EXERCISE 8 Step 1: Role-Play and Feedback • The client says the first beginning client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provide brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

Optional Variation for Exercise 8 In the final round of the exercise, the client improvises by talking about an event that was emotionally challenging in real life, and the therapist attempts to express empathic conjectures. The client can then tell the trainer whether they felt the therapist’s empathy and felt encouraged to move into a deeper exploration. Note that the client should be careful to talk only about topics that they feels comfortable sharing.

SKILL CRITERIA FOR EXERCISE 8 1. The response is targeted beyond the client’s meaning or experience and explores the experience that underlies what has not yet been said or that which was not previously in awareness. 2.  The response is aimed at deepening emotion or elaborating exploration. 3. The response is not a cloaked interpretation that moves toward explanation as to why, nor does it link past to present experience. 4. It is made clear that the response comes for the therapist’s frame of reference and is a hunch. 5.  The response is said tentatively and is about currently held experience.

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➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 8 Beginner Client Statement 1 [Ashamed] You should have seen how she glared at me. It made me feel so little. Beginner Client Statement 2 [Angry] I feel so taken advantage of by her, so used. Beginner Client Statement 3 [Frustrated] I really hate it when my wife says I have a drinking problem. She’s one to accuse me! She smokes a lot of dope! Beginner Client Statement 4 [Angry] My son is dating this new girl who is so disrespectful. She really makes my blood boil. Beginner Client Statement 5 [Sad] I’m in Alcoholics Anonymous and on the step where we say sorry to people. I’ve been making a list of all people I’ve disappointed and hurt over the decades due to my drinking. There are so many, I don’t know if I can handle it.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Empathic Conjectures

INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 8 Intermediate Client Statement 1 [Obsessed] I love him so much that it’s hard to think of anything else. Intermediate Client Statement 2 [Worthless] Sometimes I just don’t like myself. Intermediate Client Statement 3 [Betrayed] My boyfriend has been so unfaithful. He cheated on me again this weekend! I need to stop loving him. Intermediate Client Statement 4 [Obsessed] I love my girlfriend a lot. She’s always there for me, no matter what I do. I can even sleep with other girls! I don’t know why I want to distance myself from her.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 8 Advanced Client Statement 1 [Hopeless] When my boyfriend starts talking, I feel like I cannot get a word in, and eventually I find myself just giving up, and then I just shut down. Advanced Client Statement 2 [Trapped] I don’t know why I don’t just leave the relationship. I think it is self-destructive, but somehow I can’t leave. Advanced Client Statement 3 [In denial] Everything is perfect. I felt suicidal last week when my girlfriend left. But yesterday she came back when she realized how bad I felt. I think everything’s okay now. Maybe we should stop therapy? Advanced Client Statement 4 [Confused] I am in such a confused, distressed place today. I don’t even know what I feel or where to begin. Advanced Client Statement 5 [Macho] My father was in the army, and he taught me that only weak people have feelings.

Assess and adjust the difficulty here (see Step 3 in the exercise   instructions). If appropriate, follow instructions to make the exercise even more challenging (see Appendix A).

Empathic Conjectures

Example Therapist Responses: Empathic Conjectures Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER CLIENT STATEMENTS FOR EXERCISE 8 Example Response to Beginner Client Statement 1 I imagine just burning with anger, and also . . . feeling diminished and hurt. Example Response to Beginner Client Statement 2 I guess you feel so used, and, I don’t know, maybe even outraged, just resentful and I imagine feeling taken for granted, and hurt inside. Example Response to Beginner Client Statement 3 So, you get so angry when she accuses you because it feels so unfair, but I guess you feel criticized and unfairly treated. Example Response to Beginner Client Statement 4 The way she treats you makes you so angry, and I guess you just feel rejected! Example Response to Beginner Client Statement 5 Something about having to apologize I imagine leaves you feeling so vulnerable, almost unprotected.

EXAMPLE RESPONSES TO INTERMEDIATE CLIENT STATEMENTS FOR EXERCISE 8 Example Response to Intermediate Client Statement 1 So, caught up in this incredible feeling of love, and I guess this is touching a strong longing in you that you have been thirsting for. Example Response to Intermediate Client Statement 2 There is a strong feeling of “I feel so inadequate, so bad about me.” Example Response to Intermediate Client Statement 3 You feel so betrayed and angry. And I imagine that also leaves you feeling so rejected, with a feeling of “Why can’t he love me?” Example Response to Intermediate Client Statement 4 On the one hand, it feels so perfect, and yet something feels uncomfortable, I imagine almost unnerving and you just want to push her away.

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EXAMPLE RESPONSES TO ADVANCED CLIENT STATEMENTS FOR EXERCISE 8 Example Response to Advanced Client Statement 1 So you kind of give up and shut down but you actually feel so intruded upon and maybe angry inside . . . Example Response to Advanced Client Statement 2 Somehow you want to leave, but you cannot. I imagine that it’s like a feeling of “I am so afraid.” Example Response to Advanced Client Statement 3 I guess it feels okay now, but it sounds like this is touching something very deep inside for you, and it’s making it hard to feel like you want to keep going.1 Example Response to Advanced Client Statement 4 Just not knowing where to begin, I guess it is somehow scary to approach your feelings . . . Example Response to Advanced Client Statement 5 So, your father taught you to feel is to be weak. That must leave you feeling very confusing and difficult, and could and perhaps leave you feeling angry?

1. Expressions such as “I felt suicidal” may reflect an expression of a feeling and not an intent to harm oneself. On the other hand, therapists need to use a multitude of contextual client indicators to determine suicidal intent. Trainees should seek close supervision for clients who may be at risk of self-harm or suicide. If a client is at risk of suicide, therapists should consider a suicide-focused treatment, such as the Collaborative Assessment and Management of Suicidality (https://cams-care.com).

EXERCISE

Staying in Contact in the Face of Intense Affect Preparation 1. Read instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Advanced Emotion-focused therapy requires that the therapist remain present and attuned with the client even when the client expresses intense affect, such as rage, deep grief, overwhelming fear and lack of safety, debilitating shame, strong feelings of desire and sexual attraction, closeness and affection, exuberant joy, and strong admiration. This can be difficult for many trainees, although what proves challenging for one trainee may not be for another: One therapist may find it challenging to stay present with clients’ rage especially if it is directed at them, another with grief, another with desire. Therapists may find intense affect challenging for a variety of reasons, including their own emotional history, culture, personal preferences, and so on. Trainees may be tempted to push away affect that makes them uncomfortable. However, this tends to limit their effectiveness. Thus, the goal of this skill is to help trainees develop the capacity to be effective with a broad range of strong affect. Skill 1: Therapist Self-Awareness started this process by building the intrapersonal skill of therapists’ self-awareness of their internal processes. The current skill takes the next step and helps therapists to first identify and turn toward affect they are tempted to avoid, and then make a clinically relevant intervention. Thus, this skill involves two components: one intrapersonal (within the therapist) and one interpersonal (with the client).

https://doi.org/10.1037/0000227-011 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Intrapersonal (Inner) Skill TASK: The therapist first tracks their internal experience and completes the Reaction

Form. GOAL: Build self-awareness of internal sensitive areas with patience and self-compassion.

Interpersonal Skill TASK: While staying in contact with the client and their own internal experience, the

therapist attempts to intervene using one of the previously trained empathic responses or a self-disclosure. GOAL: Build the ability to stay present and attuned with clients while intervening clinically.

Note About Exercise 9 Of all the exercises in this book, this exercise is most likely to elicit shame, embarrassment, or self-doubt. These reactions are normal and common, like how athletes sweat or breathe hard during tough workouts. If these reactions feel manageable, then you should proceed. If the shame, embarrassment, or self-doubt feels severe or unmanageable, then you should pick an easier client statement or return to practicing an easier exercise.

Staying in Contact in the Face of Intense Affect

INSTRUCTIONS FOR EXERCISE 9 Step 1: Role-Play and Feedback • The client either says or uses the example scripts as improvisation prompts (i.e., there is no need to repeat every word, but the response needs to convey the general content and tone of the client script). • The therapist first takes time to track their internal experience in reaction to this client statement. They may choose to share some of these inner experiences, but only those they are comfortable disclosing. • The therapist then improvises a clinically relevant response (e.g., empathic intervention or self-disclosure). • The trainer (or, if not available, the client) provides brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

SKILL CRITERIA FOR EXERCISE 9 1.  Before intervening, track your own experience. 2. When you have a strong urge to push away, try to stay self-compassionate and patient with yourself. (The trainer should ask the trainee if they were able to do this. Note that the criterion is only for trainees to try to stay patient and compassionate with themselves—many therapists find this to be a challenging, lifelong process!) 3. Try to intervene with a clinically relevant response, even while experiencing urges to push away from the client or your own internal experiencing. 4. Work on protecting privacy and boundaries by not disclosing inner experiences you don’t want to disclose or that do not feel comfortable.

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➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 9 Beginner Client Statement 1 [Warmly] You remind me of my daughter. I love her so much! She is perfect in every way. Beginner Client Statement 2 [Depressed] Ever since I was fired from my last job, I have felt so depressed and hopeless. I have nothing to look forward to. Beginner Client Statement 3 [Guilty] When my children were very young, I couldn’t control my anger, and I hit them a lot. I can tell it’s traumatized them because they are always nervous around me and other people. I feel really guilty about this, but I also feel like they should move on and forgive me already. Beginner Client Statement 4 [Sad] My mother and sister both died this year. I don’t have any immediate family left alive. Beginner Client Statement 5 [Angry] I’ve been thinking a lot about my uncle who abused me when I was young. Previously I tried to forget about him, but recently I’ve been feeling incredibly angry at him!

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Staying in Contact in the Face of Intense Affect

INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 9 Intermediate Client Statement 1 [Loving] I’m starting therapy with you because my last therapist retired. She was amazing. I saw her for over a decade, and we became real friends. I think of her every day. Intermediate Client Statement 2 [Sad and guilty] I think I am going to put my dog to sleep tomorrow. My veterinarian says I should do it because he is so old and sick. But he has been my best friend for a decade, and I can’t even imagine life without him. How could I have my best friend killed? It’s so hard to even say this out loud. Intermediate Client Statement 3 [Angry] Whenever I read about politics these days, I become enraged. How can people be so blind? I think we just need to blow up the whole system and start over. Intermediate Client Statement 4 [Shameful] I have to confess that I have been having an affair for 20 years with another woman. I never told my wife. I find myself wracked with guilt. It is unbearable. Intermediate Client Statement 5 [Sad] My wife and I are getting divorced. I don’t think I can live without her. I just don’t see the point. I think I should just kill myself.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 9 Advanced Client Statement 1 [Flirty] We’ve only had a few sessions, but I can already tell that you are an amazing therapist. It’s like you can read my thoughts. How do you understand me so well? Sometimes I wonder what it would be like if we dated. Can you tell what I’m thinking right now? Advanced Client Statement 2 [Sad] Most of my parents’ family died in the Holocaust. I watched a movie about it the other day. I can’t believe how many millions of people were killed, including children. It makes me sick just to think about it. Advanced Client Statement 3 [Guilty] When my sister was very young, I touched her sexually. I was a teenager. I don’t think she’s ever told anyone, and neither have I. I think it really disturbed her. She looked up to me so much. I feel so awful about this. Advanced Client Statement 4 [Angry] Last week I discovered that my wife has been cheating on me. I found pictures of the guy on her phone. I am so angry! I feel like smashing his face with a baseball bat. I could just beat him to a pulp. Advanced Client Statement 5 [Disappointed and angry] I need to tell you that therapy isn’t working. You just don’t understand me. I feel worse than when I started. I think it’s because you’re a trainee and don’t have much experience.

Assess and adjust the difficulty here (see Step 3 in the exercise instructions).   If appropriate, follow instructions to make the exercise even more challenging (see Appendix A).

Staying in Contact in the Face of Intense Affect

Example Therapist Responses: Staying in Contact in the Face of Intense Affect Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER CLIENT STATEMENTS FOR EXERCISE 9 Example Response to Beginner Client Statement 1 Thank you for saying that. I feel touched to hear that. Example Response to Beginner Client Statement 2 Somehow you just feel so hopeless, with nothing to look forward to. Example Response to Beginner Client Statement 3 So, it is hard and there is this incredible feeling of guilt and maybe shame, like “What did I do?” Example Response to Beginner Client Statement 4 That sounds incredibly sad and hard. Example Response to Beginner Client Statement 5 Just feeling so angry at him for abusing and mistreating you!

EXAMPLE RESPONSES TO INTERMEDIATE CLIENT STATEMENTS FOR EXERCISE 9 Example Response to Intermediate Client Statement 1 It sounds like you had a very special relationship with her and that you were really close. She is still very present for you. Example Response to Intermediate Client Statement 2 It is just so painful to think about putting him down Example Response to Intermediate Client Statement 3 So, you find yourself feeling incredibly angry. Example Response to Intermediate Client Statement 4 I appreciate you sharing this with me. It is just this huge secret that you kept all these years, and now you find yourself wracked with an unbearable guilt. Example Response to Intermediate Client Statement 5 It is just unimaginable to live life without her.1

1. Expressions such as “I should just kill myself” may reflect an expression of a feeling and not an intent to harm oneself. On the other hand, therapists need to use a multitude of contextual client indicators to determine suicidal intent. Trainees should seek close supervision for clients who may be at risk of selfharm or suicide. If a client is at risk of suicide, therapists should consider a suicide-focused treatment, such as the Collaborative Assessment and Management of Suicidality (https://cams-care.com).

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EXAMPLE RESPONSES TO ADVANCED CLIENT STATEMENTS FOR EXERCISE 9 Example Response to Advanced Client Statement 1 I am glad that you feel comfortable and understood by me. The truth is, I cannot tell what you are thinking right now. It might be important for us to discuss the limits of our relationship, though, because this is a therapeutic relationship and not a romantic one. Example Response to Advanced Client Statement 2 I am really sorry to hear that. It is horrible. And it sounds like it is really eating away at you right now, like just a strong feeling of disgust and maybe abhorrence? Example Response to Advanced Client Statement 3 This must be very difficult to say out loud, and I appreciate you sharing it with me. It sounds like something you feel really bad about and we need to explore it further. Example Response to Advanced Client Statement 4 That must have been horribly shocking and disturbing to find out! Your rage is very understandable.2 Example Response to Advanced Client Statement 5 I really appreciate you telling me how you have been feeling. And it must be difficult to feel worse than when you started. Let’s discuss this further. I am a trainee, although I have a few years of experience. I feel that I can help you and would like to find a way, but if this does not feel like a good fit for you, we can discuss alternatives.

2. Trainees should seek close supervision for clients who may be at risk of harming others. Note that although statements such as “I want to smash his face with a baseball bat” and “I want to beat him to a pulp” may be no more than strong expressions of anger and not actual statements of intent, if the therapist assesses that a client is actually homicidal, the therapist should consider breaking informed consent and notifying relevant parties or a homicide-focused treatment. If therapists are unsure what to do, it is recommended that they consult a colleague or supervisor.

EXERCISE

Self-Disclosure Preparation 1. Read instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Advanced Self-disclosures are statements in which therapists reveal something about themselves. This is considered a more advanced skill because therapists are often challenged to know when, what, and how much to disclose; are concerned about crossing boundaries; and worry about the impact of such statements on the client. In general with self-disclosure, it is important to remain present and aware in the moment and be prepared to discuss the immediate impact on the client. In emotion-focused therapy (EFT), therapists most often nonblamingly disclose or reveal currently felt or immediate experience, although they may also disclose about personal information or experiences. This exercise will help you practice how to perform self-disclosures correctly, although it will not teach the timing of self-disclosures (i.e., when to use self-disclosures in therapy). With respect to timing, one criteria EFT therapists often use is to consider whether the self-disclosure will be therapeutically beneficial. Beyond this, the timing of self-disclosures can be subtle. This is a skill on which your supervisor or professor will guide you.

https://doi.org/10.1037/0000227-012 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Examples of the Therapist Providing Self-Disclosures Example 1 CLIENT:  [hesitant] I’m Christian, and my faith is a big part of my life. Is that okay with you? THERAPIST:  Yes, I feel open to working with people of varying faiths and spiritual belief

systems.

Example 2 CLIENT:  [self-blaming] Wow, I’m such a mess. You must think that I’m totally crazy, right? THERAPIST:  I do not see you as crazy at all. Actually, I feel a lot of concern and empathy

for you.

Example 3 CLIENT:  [sad] I feel so vulnerable and alone, talking about this. THERAPIST:  I feel moved to hear you share your vulnerable feelings with me now.

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Self-Disclosure

INSTRUCTIONS FOR EXERCISE 10 Step 1: Role-Play and Feedback • The client says the first beginning client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provides brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

SKILL CRITERIA FOR EXERCISE 10 1.  Self-disclosures begin with “I” statements. 2.  Self-disclosures refer to therapist self-experience. 3.  Self-disclosures do not include blame or judgment. 4. Self-disclosures are made for the purpose of advancing client self-exploration, deepening emotion, or gaining a new awareness. 5.  Self-disclosures are deemed by the therapist to be therapeutically beneficial.

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➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 10 Beginner Client Statement 1 [Beginning of first session] [Hesitant] So should I just start anywhere or . . .? Beginner Client Statement 2 [Curious] Are you married? Beginner Client Statement 3 [Hesitant] I’m Christian, and my faith is a big part of my life. Is that okay with you? Beginner Client Statement 4 [Self-blaming] Wow, I’m such a mess. You must think that I’m totally crazy, right? Beginner Client Statement 5 [Sad] I feel so vulnerable and alone, talking about this.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Self-Disclosure

INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 10 Intermediate Client Statement 1 [Uncomfortable] I’ve seen you yawn a few times today. Am I boring you? Intermediate Client Statement 2 [Uncomfortable] Just coming to therapy and sitting here with you makes me feel really uncomfortable. Intermediate Client Statement 3 [Very sad] I really feel like there is something wrong with me. I cannot stop crying. I really didn’t see this coming. I just can’t stop crying after losing my father. Intermediate Client Statement 4 [Slightly annoyed] Sometimes I think you get bored listening to me talk about my problems every week. Is that true? Intermediate Client Statement 5 [Very sad] I had to put my dog to sleep this weekend. She was so sick, and I know it was the best thing to do, but my heart is just broken into a million pieces.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 10 Advanced Client Statement 1 [Client arrives 20 minutes late to session for the fourth time in a row] [Rushed, aloof] Hi, how are you? I know I’m late, I just got distracted with work. Where should we start? Advanced Client Statement 2 [Fearful] I’ve always been self-conscious about how I look. Other kids teased me and said I was ugly. Do you think that I am attractive? Advanced Client Statement 3 [Angry, clenching fists] I hate it when you get that look of pity in your eyes. Don’t look down at me! Advanced Client Statement 4 [Skeptical] I think I can tell you don’t have a lot of experience as a therapist. I wanted to work with a very experienced therapist. How can I be sure you can help me?

Assess and adjust the difficulty here (see Step 3 in the exercise instructions).   If appropriate, follow instructions to make the exercise more challenging (see Appendix A).

Self-Disclosure

Example Therapist Responses: Self-Disclosure Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER CLIENT STATEMENTS FOR EXERCISE 10 Example Response to Beginner Client Statement 1 I am very excited to begin our work together and to hear what brought you in today. Example Response to Beginner Client Statement 2 Yes, I am married, and I have two children. I am curious about what that means to you? or No, I am not married. I am curious about what that means to you? Example Response to Beginner Client Statement 3 Yes, that is definitely okay. I feel open to working with people of varying faiths and spiritual belief systems. Example Response to Beginner Client Statement 4 I do not see you as crazy at all. Actually, I feel a lot of concern and empathy for you. Example Response to Beginner Client Statement 5 I feel moved to hear you share your vulnerable feelings with me now.

EXAMPLE RESPONSES TO INTERMEDIATE CLIENT STATEMENTS FOR EXERCISE 10 Example Response to Intermediate Client Statement 1 Oh, I am really sorry. I am a bit tired today, but it does not reflect on how I am feeling about you or what you are talking about. Example Response to Intermediate Client Statement 2 I am sorry to hear you are uncomfortable, although I really appreciate you telling me that. Maybe we can explore what makes you feel uncomfortable. Example Response to Intermediate Client Statement 3 That sounds very painful. When my father died, I cried for days. Example Response to Intermediate Client Statement 4 Wow, it must have been hard to ask me that. I do appreciate you sharing that concern. I want to address that directly. I do not feel bored all. At times, though, I have felt we are a little stuck. I would like to work together to figure out how to deepen your emotional experiencing during sessions. Example Response to Intermediate Client Statement 5 As you’re telling me this, I just feel so sad, moved to tears.

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EXAMPLE RESPONSES TO ADVANCED CLIENT STATEMENTS FOR EXERCISE 10 Example Response to Advanced Client Statement 1 It is hard for me to tell you this, but when you come late, I actually feel annoyed, and kind of diminished inside. Example Response to Advanced Client Statement 2 No, I do not find you ugly at all. I find you to be an attractive person. [After a few seconds, checking in] What do you feel when you hear me say that? Example Response to Advanced Client Statement 3 Thank you for sharing with me how you really feel. It must be hard to do that. Actually, I do not feel pity for you. I do feel moved and concerned, but not pity. [After a few seconds, checking in] What do you feel when you hear me say that? Example Response to Advanced Client Statement 4 I do understand your concern. I have 3 months of experience. I really do want to try to help you out. Perhaps we can explore what it is you are looking for in therapy and see whether this might be a good fit for you.

EXERCISE

Marker Recognition and Chair Work Task Setup Preparation 1. Read instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Advanced Markers in emotion-focused therapy (EFT) are in-session verbal and nonverbal indicators of emotional processing difficulties that signal to the therapist that they can suggest a task intervention. There are many markers for subsequent tasks that might emerge. We will focus here, however, on three main task markers: • A marker for a self-evaluative split: when one part of self is critical of, or coercive toward, another aspect of self • A marker for a self-interruptive split: when one part of the self interrupts, blocks, or constricts expression of emotional feelings and needs • A marker for unfinished business: when the client describes a lingering unresolved bad feeling toward a significant other The goal of this exercise is to learn how to (a) recognize a marker and (b) initiate and set up a corresponding therapeutic task. Once a task is set up and begins, it will often continue for at least 20 minutes and up to a whole therapy session. The actual client processes and therapist response interventions have been specified and mapped elsewhere (Elliott et al., 2004; Greenberg et al., 1993). The tasks outlined here all have specified resolution points. EFT therapists are trained to facilitate a task from start to

https://doi.org/10.1037/0000227-013 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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finish. By studying and practicing the processes and steps of the tasks, therapists can learn to facilitate a task through to its resolution point. However, the skills that are focused on in this skill exercise are only the initial steps: marker recognition and subsequent task setup. Processes that ensue past the point of task setup, including middle- and end-state resolutions, and their associated therapist interventions and client processes, are beyond the scope of what is covered in this book. This exercise is not focused on achieving those end goals but rather how to recognize a marker and set up a corresponding therapeutic chair-work task. The skills required for chair-work tasks are complex and nuanced. If readers wish to learn how to facilitate these tasks further, they are referred to other EFT books, such as Elliott et al. (2004), Learning Emotion-Focused Therapy. It is also recommended that learners participate in EFT workshops, where the tasks are specifically taught. Practice and supervision of tasks is also necessary and required to achieve full competency. It is important to note that EFT chair work is designed to help deepen and process emotions, but it is not always the most clinically appropriate strategy (see Table E11.1). For instance, it is not appropriate to deepen or process some emotions with clients who are already highly emotionally dysregulated, psychotic, or suicidal. Learning to recognize and intervene with specific markers must take into consideration the conceptualization and overall state of the client to ensure safe and effective clinical work.

Special Instructions for Exercise 11 Do not set up a specific chair technique in advance. The therapist moves the chairs and guides the client during the role-play in response to the task marker they think is being presented by the client. Arrange the task role-play so that the client faces an empty chair, with the therapist between the two chairs to the side, facing the client. When undertaking the self-critical chair work, set a chair in front of the client (see Figure E11.1). Ask the client to move and sit in the chair placed across from them and imagine themselves as, or to be, their critical or coercive part. Have the client move into that chair and start from this position. Ask them to express from the critical or coercive side first, back to the imaginary self now pictured in the original chair the client was sitting in. When undertaking self-interruptive work, bring a chair and set it up in front of the client. Ask the client to move and sit in the chair that you have placed across from them and imagine themselves as their interrupting part. Have the person start the dialogue as the interrupting part expressing back to the other part or self.

TABLE E11.1.  Task Markers and Chair-Dialogue Task Interventions Task Marker Self-evaluative split

Task Intervention

End Goal

Two-chair dialogue

Self-acceptance, integration

Self-interruption split

Two-chair enactment

Self-expression of emotions and needs

Unfinished business

Empty chair work

Letting go of unmet needs, holding the other accountable, and understanding the other

Worry/catastrophizing split

Marker Recognition and Chair Work Task Setup

FIGURE E11.1.  How to Set Up the Chairs for Exercise 11

Note. Reprinted from Case Formulation in Emotion-Focused Therapy: Addressing Unfinished Business (screenshot of DVD), by R. N. Goldman, 2013, American Psychological Association (https://www.apa.org/ pubs/videos/4310916). Copyright 2013 by the American Psychological Association.

Ask them to interrupt the imagined part sitting in the other chair. In other words, “do the thing they do.” Thus, if the therapist and client identify that they tighten, squeeze, or shut themself down, they will be asked to actually tighten or squeeze or shut themself down in the chair. Ask them to imagine the developmentally significant other (i.e., mother, father, grandparent) sitting in the empty chair in front of them, and ask them to express to the other to begin the dialogue.

Sample Responses: Therapist Recognizes Marker and Initiates Task Setup Example 1 CLIENT:  I am just too fat and ugly. I should lose weight, but I don’t. [Marker = Self-

evaluative split] THERAPIST:  It sounds like you are being very hard on yourself and criticizing yourself for

being too fat. Can we help you become aware of how you criticize yourself? Can you come over to this chair here [move chair across from client] and tell yourself you are too fat?

Example 2 CLIENT:  [tense and weepy] I can feel tears coming up but I just tighten up. It’s really hard

for me to cry. [Marker = Self-interruptive split] THERAPIST:  So, it is hard for you to cry, and you just tighten up. Would it be okay for us to

work on this a little? Can you come over to this chair [point to other chair]. [Once person is in interrupter’s chair] Imagine yourself over there [point back to original chair] crying?

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Try telling her why she shouldn’t cry. How do you stop her from crying? What do you say or do to her to stop her? Imagine her over there and let’s see if you can actually do it. See if you can do it now.

Example 3 CLIENT:  [scared] My father used to beat us. That was his way of disciplining us. You sure

knew something was wrong when he got home. Just the way he would slam the door and put his keys on the table. We would all run for cover. [Marker = Unfinished business] THERAPIST:  Wow, that sounds very scary and painful. [Pull chair up in front of client] How

would you feel about bringing him here in imagination and having a dialogue with him now so that you can let him know how you feel about that?

Marker Recognition and Chair Work Task Setup

INSTRUCTIONS FOR EXERCISE 11 Step 1: Role-Play and Feedback • The client says the first beginning client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provide brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

SKILL CRITERIA FOR EXERCISE 11 1.  The therapist hears and recognizes the marker. 2.  The therapist reflects back key aspects of the marker. 3.  The therapist initiates and sets up the appropriate task intervention. 4.  The therapist engages the client, garners implicit consent, and addresses any concerns.

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➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 11 Beginner Client Statement 1 [Sad] I am just too fat and ugly. I should lose weight, but I don’t. Beginner Client Statement 2 [Sad] I don’t know why I bothered going to law school. I am just not smart enough, not up to the task. Beginner Client Statement 3 [Anxious] I am aware that I shut down. I just think why bother expressing myself because well, what’s the point? Beginner Client Statement 4 [Tense and weepy] I can feel tears coming up, but I just tighten up. It’s really hard for me to cry. Beginner Client Statement 5 [Sad] My mother used to make me feel bad about being overweight. And I really took it on. She also made me feel like I would never succeed. Even though I don’t think she meant any harm, I feel scarred by it. Beginner Client Statement 6 [Scared] My father used to beat us. That was his way of disciplining us. You sure knew something was wrong when he got home. Just the way he would slam the door and put his keys on the table. We would all run for cover.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Marker Recognition and Chair Work Task Setup

INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 11 Intermediate Client Statement 1 [Sad] My mother died years ago, and I feel bad about it now, that I never got to say goodbye. But she is gone, and I don’t think there is any point in revisiting the past. Intermediate Client Statement 2 [Very sad and anxious] My wife and I are getting divorced. I can’t imagine life without her. I am finding it really painful, and I blame myself for it. I think I really screwed up, and I cannot imagine how I can go on. Intermediate Client Statement 3 [Sad and guilty] I just feel like I am not a good person. I don’t know how anyone can love me. Intermediate Client Statement 4 [Shameful] I have to confess something. When my wife was alive, I had an affair and I never told her. Even though my wife has died, I am left with this horrible sense of guilt about it, and I just can’t stop thinking about it these days. Intermediate Client Statement 5 [Slow and flat] When bad things happen to me, I don’t feel anything. For example, when my husband left me I did not feel anything. I feel like I should be angry or hurt, but I just feel numb.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 11 Advanced Client Statement 1 [Sad] Most of my grandfather’s family died in the Holocaust. I watched a movie about it the other day. I can’t believe how many millions of people were killed, including children. You know my grandfather survived the Holocaust at great expense, but he really did a number on my mother. I think that is why she was so cold to me. Even though I feel sorry for her, I still don’t forgive her for how she was with me. I still find myself hating her. Advanced Client Statement 2 [Guilty] I left my abusive husband 5 years ago. I had to sneak out of our house in the middle of the night with my 5- and 2-year-olds. I don’t regret leaving, but I can’t believe how stupid I was to have ever married him. I am so depressed. Advanced Client Statement 3 [Angry] You know, even though it has been a couple years and we are divorced now, I am still so angry that my wife cheated on me. I still have images of her with him in bed. I am feeling so betrayed and angry! I hate her! Advanced Client Statement 4 [Angry] I find myself worrying about everything these days. I worry about my kids now that they are both away from home and that something will happen to them. I worry about these pains in my stomach and think maybe I have cancer. I worry about the government and think we might be heading for the next world war. It is overwhelming. I just worry about everything! Advanced Client Statement 5 [Tense and nervous] I am so angry with my father. I really hate him, but I could never say that to him, even in this imaginary dialogue.

Assess and adjust the difficulty here (see Step 3 in the exercise instructions).   If appropriate, follow instructions to make the exercise even more challenging (see Appendix A).

Marker Recognition and Chair Work Task Setup

Example Therapist Responses: Marker Recognition and Chair Work Task Setup Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER CLIENT STATEMENTS FOR EXERCISE 11 Example Response to Beginner Client Statement 1 [The therapist recognizes a marker of a self-evaluative split.] It sounds like you are being very hard on yourself and criticizing yourself for being too fat. Can we help you become aware of how you criticize yourself? Can you come over to this chair here [moves the chair across from the client] and tell yourself you are too fat?1 Example Response to Beginner Client Statement 2 [The therapist recognizes a marker of a self-evaluative split.] It sounds like you are really beating up on yourself. Can we work with this a little? Can you come over to this chair [moves the chair across from the client] and tell yourself you are not smart enough?1 Example Response to Beginner Client Statement 3 [The therapist recognizes a marker of a self-interruptive split.] So, it sounds as if you are really shutting yourself down. Let’s work with this a little, to help you become aware of how you shut yourself down. Can you come over here [points to the other chair] and get a sense of how you do that? [Once the client is in the interrupter’s chair] Imagine yourself over there [points back to the original chair the client was in] and see if you can shut yourself down. What do you do to silence him?2 Example Response to Beginner Client Statement 4 [The therapist recognizes a marker of a self-interruptive split.] So, it is hard for you to cry and you just tighten up. Would it be okay for us to work on this a little? Can you come over to this chair [points to the other chair]? [Once the client is in the interrupter’s chair] Imagine yourself over there crying [points back to the original chair]. Try telling her why she shouldn’t cry. How do you stop her from crying? What do you say or do to her to stop her? Maybe you squeeze back her tears or choke her. Imagine her over there and let’s see if you can actually do it now.2

1. The therapist trainee should remember that it may feel awkward at first to suggest that someone criticize or put themselves down. By doing chair work, however, clients gain awareness and take ownership for how they criticize themselves. Remember that the aim of the dialogue is to become aware of the critic so that clients can assert themselves back to it, softening and transforming the critic. 2. The therapist trainee should remember that the goal of the self-interruptive dialogue is to gain awareness of how clients block or interrupt themselves so that they can take internal responsibility for the process and make choices in favor of self-expression.

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Example Response to Beginner Client Statement 5 [The therapist recognizes a marker of unfinished business.] So, you have, in a sense, really taken on those messages and brought them inside as your own. How would you feel about working with your mother in imagination and telling her this? How about bringing her here in imagination [pulls the chair up in front of the client] and having a dialogue with her?3 Example Response to Beginner Client Statement 6 [The therapist recognizes a marker of unfinished business.] Wow, that sounds very scary and painful. [Pulls the chair up in front of the client] How would you feel about imagining him here now, having a dialogue with him and telling him how you felt about that?3

EXAMPLE RESPONSES TO INTERMEDIATE CLIENT STATEMENTS FOR EXERCISE 11 Example Response to Intermediate Client Statement 1 [The therapist recognizes a marker of unfinished business.] So, it is hard because you did not get a chance to say goodbye. And even though it feels like there is nothing you can do about it now, it is still hard to live with that feeling. [Pulls the chair up in front of the client] Maybe we could try bringing her here in imagination so you could have a dialogue with her and say goodbye and maybe get to tell her some of the things you would have like to have told her.3 Example Response to Intermediate Client Statement 2 [The therapist recognizes a marker of a self-evaluative split.] That sounds very painful. It also sounds like you are giving yourself a very hard time about it and really coming down heavily on yourself. Can we try to get at how you blame yourself? Because it does seem like you are really beating up on yourself and that leaves you feeling very bad. As a way of trying to deal with that and to help you fight back from inside yourself, can we try to get a sense of how you put yourself down? Can you come over here [moves the client to the other chair] and give yourself a hard time? See if you can do it now.1 Example Response to Intermediate Client Statement 3 [The therapist recognizes a marker of a self-evaluative split.] So, it is hard to imagine someone truly loving you. I get a strong sense of the negative messages you give yourself, how you put yourself down and make yourself feel like you are not worth loving. Will you come over here to this chair [points to the other chair] and make her feel like she is not lovable [points back to the original chair the client was sitting in]. What do you say to yourself to make yourself feel not lovable?1

3. The therapist trainee should remember that the goal of the unfinished business dialogue is to stand up for the self, self-validate, hold the developmentally significant other accountable, and let go of unmet needs or forgive the other.

Marker Recognition and Chair Work Task Setup

Example Response to Intermediate Client Statement 4 [The therapist recognizes a marker of unfinished business.] That sounds very painful. It also sounds very much unresolved. Perhaps we could try something around this to help you come to terms with what you did. Would you be willing to bring your wife here [pulls up chair in front of client], in imagination, and have a dialogue with her and maybe tell her your feelings about what happened, what you did?3 Example Response to Intermediate Client Statement 5 [The therapist recognizes a marker of a self-interruptive split.] It sounds like you are blocking some pretty painful feelings. Let’s get a sense of how you do this. Can you come to this other chair? [Once the client is sitting in the other chair] Imagine yourself over there [points back to the original chair], and can you actually try to stop your feelings? Imagine you over there [points again to the chair across from the client], and what do you do to numb yourself, and can you actually do it now? How do you stop her from feeling angry or hurt? Do you sit on her? Do you stuff a sock in her mouth? Put a big steel door in front of her? In imagination, what would you actually do?2

EXAMPLE RESPONSES TO ADVANCED CLIENT STATEMENTS FOR EXERCISE 11 Example Response to Advanced Client Statement 1 [The therapist recognizes a marker of unfinished business.] It sounds like you have a lot of strong feelings toward your mother, though you also feel sorry for her at the same time, being the child of a Holocaust survivor. [Pulls the chair up in front of the client] Perhaps we can try having a dialogue with her where we bring her here in imagination and tell her about how you feel about how she was with you.3 Example Response to Advanced Client Statement 2 [The therapist recognizes a marker of a self-evaluative split.] Yes, you left 5 years ago, and you carry all this guilt about ever marrying him in the first place. I wonder what you feel when you blame yourself. It must hurt. Can we try to work on this though so you can come to terms with it? Can you come over to this chair here and blame yourself? How do you do that? [Moves the client to the other chair and asks them to blame themself]1 Example Response to Advanced Client Statement 3 [The therapist recognizes a marker of unfinished business.] Yes, it does sound like you still have a lot of feelings about what happened. Perhaps we can work on this to try to get help you get through this and move forward. [Pulls the chair up in front of the client] Can we try having a dialogue with your wife so you can actually tell her about your feelings and how you feel about it what she did?3

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Example Response to Advanced Client Statement 4 [The therapist recognizes a marker of a self-evaluative (catastrophizing/worry) split.4] Wow, that does sound like a lot of worrying. It must be very overwhelming. And maybe even paralyzing. How about if we work with this a little, so we can get a sense of how you worry yourself? Can we try something with the chairs? [asks the client to sit in the other chair set up across from them] I want you to imagine yourself over there, [points back to the original chair the client was sitting in] and just try to get an image or a picture, and I want you to worry yourself now. How do you do that? What do you tell yourself? I want you to actually do it now. Worry her. What would you say? “Your kids are not going to be okay, something terrible will happen to them”? “Maybe you have cancer and you will die in the next 6 months”? Try doing it now. Example Response to Advanced Client Statement 5 [The therapist recognizes a marker of a self-interruptive split.] So it is hard to imagine actually saying “I hate you” to your father even if you know it is an imaginary dialogue and he is not really here and you would not have to say it in real life. Let’s work on it a little though to get a sense of how you stop yourself from allowing or expressing your actual feelings to your father. [Brings the client to the chair across from the one they are sitting in] Can you look over to this chair [points back to the other chair across from the client] and imagine yourself over there and try telling yourself not to be angry? What do you say to this part of you? “Don’t be angry,” “Don’t let it out,” “You mustn’t be angry.” Really make a case for why he should not get angry with his father.2

4. The catastrophizing/worry-split is a particular form of a the self-critical/self-evaluative split that is often used with anxious clients who worry and pressure themselves very strongly. The goal of such a dialogue is to understand and take ownership for how the person creates their own worry and anxiety as a way of taking hold of it. The worry dialogue eventually evolves into a self-critical dialogue where the person becomes aware of how they are criticizing and weakening themselves. Eventually, they are able to fight back and transform the critic, leading to self-assertion, self-support, and compassionate self-soothing. For a fuller description and explanation of how to work with the catastrophizing/worry-split, see Timulak and McElvaney (2018).

EXERCISE

Addressing Ruptures and Facilitating Repair Preparation 1. Read instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A).

Skill Description Skill Difficulty Level: Advanced This is a complex skill that combines many of the other emotion-focused therapy skills. An alliance rupture is defined as deterioration in the therapeutic alliance, manifested by a disagreement between the client and therapist on treatment goals, a lack of collaboration on therapeutic tasks, or a strain in their emotional bond (Eubanks et al., 2015). As a general rule, when confronted with an alliance rupture, the therapist strives to listen, explore, and validate the client’s concern; stay in a receptive mode; remain nondefensive and responsive; and avoid proposing any solutions or engaging in any premature problem-solving. The therapist should stay present with, and empathically attune themselves to, the client’s experience, even under challenging circumstances, such as the client expressing negative judgment or disregard for the therapist. If the client is expressing, for example, rejecting anger, the therapist works to understand the underlying primary (sometimes maladaptive) emotion that is behind the client’s words or stance. This involves the therapist being actively present and genuine, staying in a receptive mode and attempting to radically understand, empathize, and accept the client wherever they are (Greenberg, 2014). It often involves the therapist validating the client’s experience in a genuine, meaningful manner,

https://doi.org/10.1037/0000227-014 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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for example, by self-disclosing the therapist’s own experience (e.g., “I did not understand,” “I feel bad hearing you felt criticized by me”). It may involve an apology on the part of therapist (e.g., “I am sorry that I hurt you”). Before the therapist responds to client’s concerns, they need to take a step back, hear, understand, and validate what the client is needing or missing. Occasionally, the therapist can offer responses designed to address the client’s concern directly. This may sometimes involve the therapist nondefensively explaining the treatment rationale and why they responded in the manner they did or tentatively offering suggestions to address the concern. This must be done with caution so that the client does not feel invalidated or that the concern is being “explained away.” In more intense ruptures, the therapist can also discuss the option of referral to another therapist or introduce the idea of moving to a different treatment model. This should also be done carefully and with your supervisor’s guidance because clients may experience such interventions as a form of rejection or abandonment.1 Each therapist response is divided into two stages. In Phase 1, the therapist empathically stays with the client. Then, in Phase 2, the therapist empathically moves forward with the client.

Examples of Therapists Providing Alliance Repairs Example 1 CLIENT:  [distrustful] Sometimes I think I see you getting bored with me. I know I repeat

myself a lot, but I want you to pay attention to what I say. THERAPIST:  Thank you for bringing this to my attention! Your reactions to me and our

work are extremely important, and I very much appreciate you letting me know. I have not been feeling bored. I find what you say interesting and important. Can I ask you to please let me know when you feel I am not paying attention?

Example 2 CLIENT:  [annoyed] To be honest, I don’t even see the point of talking about my mother.

That was a painful relationship, and I would prefer just not to remember it. THERAPIST:  Yeah, it was such a difficult relationship in so many ways, and I imagine your

experience of talking about it in the past didn’t feel very productive. I can really understand why you’d prefer to “not go there.” I also know it is very scary to remember those painful childhood feelings. Although you may not be able to change the past, you can change how you carry those feelings you were left with inside of yourself. You see, our goal is not to change the past or to change your mother, because that is unlikely to happen. But what we can change is some of the heartache you were left with, including feelings of worthlessness and pain.

1. Additional alliance-repairing skills can be found, for example, in Watson and Greenberg (2000) and Muran et al. (2010).

Addressing Ruptures and Facilitating Repair

Example 3 CLIENT:  [angry] You know, last week I got really mad at how you laughed when I told

you that story with my father. The one where I sarcastically told him that “I never asked to be born.” THERAPIST:  I really appreciate you telling me this. I am sorry I laughed in that moment.

And I understand why you felt badly about it. I know how painful your relationship with your father has been for you. It was a momentary lapse for me, and I didn’t mean it. I will make sure to not let it happen again. And I hope that you continue to let me know if I do something that leaves you feeling bad.

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INSTRUCTIONS FOR EXERCISE 12 Step 1: Role-Play and Feedback • The client says the first beginning client statement. The therapist improvises a response based on the skill criteria. • The trainer (or, if not available, the client) provides brief feedback based on the skill criteria. • The client then repeats the same statement, and the therapist again improvises a response. The trainer (or client) again provide brief feedback. Step 2: Repeat • Repeat Step 1 for all the statements in the current difficulty level (beginner, intermediate, or advanced). Step 3: Assess and Adjust Difficulty • The therapist completes the Deliberate Practice Reaction Form (see Appendix A) and decides whether to make the exercise easier or harder or to stay at the same difficulty level. Step 4: Repeat for Approximately 15 Minutes • Repeat Steps 1 to 3 for at least 15 minutes. • The trainees then switch therapist and client roles and start over.

SKILL CRITERIA FOR EXERCISE 12 1. The therapist takes a step back: empathically “stays with”—listens, explores, hears, and actively validates—the client’s concern, remaining nondefensive and making clear that they are emotionally available to the client. 2. The therapist then empathically “moves forward,” tentatively offering coherent, cogent ideas and suggestions about how to address the client’s concern. 3. The therapist again steps back to listen and actively validate the client, processing the impact of the therapist’s response to see if client feels validated and understood.

Addressing Ruptures and Facilitating Repair

➔ Now it’s your turn! Follow Steps 1 and 2 from the instructions. Remember: The goal of the role-play is for trainees to practice improvising responses to the client statements in a manner that (a) uses the skill criteria and (b) feels authentic for the trainee. Example therapist responses for each client statement are provided at the end of this exercise. Trainees should attempt to improvise their own responses before reading the example responses.

BEGINNER-LEVEL CLIENT STATEMENTS FOR EXERCISE 12 Beginner Client Statement 1 [Distrustful] Sometimes I think I see you getting bored with me. I know I repeat myself a lot, but I want you to pay attention to what I say. Beginner Client Statement 2 [Worried] My previous therapist asked me about my feelings a lot, and it never helped. One day I got so upset, she had to send me to the hospital. I’d really prefer that we don’t talk about my feelings. Beginner Client Statement 3 [Hesitant] I see you are student therapist. Do you think you have enough experience to help me? Beginner Client Statement 4 [Guilty] We’ve been meeting for a few months, but I’m honestly not feeling any better. I think maybe I am doing therapy wrong. What do you think?

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

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INTERMEDIATE-LEVEL CLIENT STATEMENTS FOR EXERCISE 12 Intermediate Client Statement 1 [Annoyed] To be honest, I don’t even see the point of talking about my mother. That was a painful relationship, and I would prefer to just not remember it. Intermediate Client Statement 2 [Angry] You know, last week I got really mad at how you laughed when I told you that story with my father. The one where I sarcastically told him that “I never asked to be born”? I felt like you were laughing at me. Intermediate Client Statement 3 [Worried] Sometimes I feel like you don’t understand me. I am 85 years old. I know that you are a lot younger and still in graduate school. Do you think that you are the right therapist for me? Intermediate Client Statement 4 [Ashamed] I have a feeling that you aren’t really interested in me. You sometimes seem bored or tired. If this is true, please be honest and tell me.

Assess and adjust the difficulty before moving to the next difficulty level   (see Step 3 in the exercise instructions).

Addressing Ruptures and Facilitating Repair

ADVANCED-LEVEL CLIENT STATEMENTS FOR EXERCISE 12 Advanced Client Statement 1 [Stern and angry] I don’t think this therapy is working for me. Every week I come back and tell you the same thing over and over again, and I just don’t feel like I am making progress. I still feel quite down and depressed. I wonder if, like, I am wasting my time and your time, to be honest. Advanced Client Statement 2 [Very uncomfortable] This is uncomfortable to ask, but I wonder if you are attracted to me romantically? Last week, when I mentioned that I hooked up with a random guy I met at a bar, you asked me a lot of questions about my sexual relationships. Are you interested in me like that?

Assess and adjust the difficulty here (see Step 3 in the exercise instructions).   If appropriate, follow instructions to make the exercise even more challenging (see Appendix A).

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Example Therapist Responses: Addressing Rupture and Facilitating Repair Remember: Trainees should attempt to improvise their own responses before reading the example responses. Do not read the following responses verbatim unless you are having trouble coming up with your own responses!

EXAMPLE RESPONSES TO BEGINNER CLIENT STATEMENTS FOR EXERCISE 12 Example Response to Beginner Client Statement 1 Thank you for bringing this to my attention! Your reactions to me and our work are extremely important, and I very much appreciate you letting me know. I have not been feeling bored. I find what you say interesting and important. Can I ask you to please let me know when you feel I am not paying attention? Example Response to Beginner Client Statement 2 Wow, that must have been really stressful for you. Thank you for letting me know about this. It’s really important. It sounds like talking about feelings has been difficult for you and led you to some pretty deep and distressing places. I can only imagine how hard that must have been. Let’s work out a way together to talk about and focus on what has been painful for you without it leaving you feeling so desperate. Example Response to Beginner Client Statement 3 That’s a very common concern, thank you for sharing it. It makes a lot of sense that you’d have some doubts or questions about it. I am a student therapist in training. I am working under supervision of a clinical psychologist. I do hope and believe I can be of help to you, and I’d like to explore your concerns around this, if you think that could be helpful. Example Response to Beginner Client Statement 4 I am so glad you are bringing this up so we can discuss it. And I am sorry you have not been feeling any better. I want to let you know that I don’t think there is any such thing as “doing therapy wrong.” Let’s talk about what is not working for you and what you imagine could be more helpful. There may be something different I could be doing.

Addressing Ruptures and Facilitating Repair

EXAMPLE RESPONSES TO INTERMEDIATE CLIENT STATEMENTS FOR EXERCISE 12 Example Response to Intermediate Client Statement 1 Yeah, it was such a difficult relationship in so many ways, and I imagine your experience of talking about it in the past didn’t feel very productive. I can really understand why you’d prefer to “not go there.” I also know it is very scary to remember those painful childhood feelings. Although you may not be able to change the past, you can change how you carry those feelings you were left with inside of yourself. You see, our goal really is not to change the past or to change your mother because that is unlikely to happen, but what we can change is some of the heartache you were left with, including feelings of worthlessness and pain. Example Response to Intermediate Client Statement 2 I really appreciate you telling me this. I am really sorry that I laughed in that moment. And I understand why you felt badly about it. I know how painful your relationship with your father has been for you. It was a momentary lapse for me, and I didn’t mean to put you down. I am sorry I hurt you. I will make sure to not let it happen again. And I hope that you continue to let me know if I do something that leaves you feeling bad. Example Response to Intermediate Client Statement 3 First, thank you so much for letting me know your concern. It makes a lot of sense. And you’re very right—we do have a considerable age difference, and I’m sure I’ve sometimes failed to fully understand your experiences. I imagine this is really frustrating for you. And I’m glad we can talk about it openly. I’m committed to you, and believe I can be of help. What matters most is how you feel, and I want to make sure we take this seriously. If, over time, you don’t feel like I am giving you what you need, I can help you find someone that could be a better fit. In the meantime, I want you to know that I feel I can relate to your stories and struggles. If you feel that I somehow don’t understand something, I hope you can tell me like you did just now. Example Response to Intermediate Client Statement 4 I am very pleased you brought this up. I am sorry that I seem tired or bored. I am not aware of feeling that, but I’m sure that’s not a pleasant experience for you. It could very naturally bring up some feelings toward me or our work. It’s really great that you told me. I want you to know that I do feel interest and concern for you. But I think you may have picked up on something important: Sometimes it feels to me that we aren’t talking about the difficult feelings that really brought you here. Does that make sense? Could we maybe talk about those feelings for a bit?

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EXAMPLE RESPONSES TO ADVANCED CLIENT STATEMENTS FOR EXERCISE 12 Example Response to Advanced Client Statement 1 I am sorry you feel that. It must be really hard to feel this cycle each week. And I imagine it leaves you feeling a bit trapped or hopeless. I am so glad you brought that to me. I really feel honored that you are sharing this and risking telling me your truth of your experience. First, I want to be clear that if you ever want to discuss the option of trying another therapist or therapy model, I can help you with a few referrals. From my perspective you have been doing some very courageous and difficult work. I also want to make sure you know that I don’t feel like you are wasting my time. I understand that therapy can be a difficult process, and it sometimes means revisiting painful things more than once. I also think that perhaps it has been hard for you to get to some of those painful feelings because they are both scary and distressing. That is understandable. Now that you are bringing this up, though, if you like, I feel that we can work together to find a way to get down into those feelings. Example Response to Advanced Client Statement 2 I really appreciate you bringing this up. And I’m sorry if I made you feel uncomfortable or on the spot. These are sensitive topics, and I appreciate that we can talk about them openly. I’m sure it took a lot of courage on your part to bring this up. I want to tell you directly that I do not have romantic feelings toward you and that for me, this is clearly a professional therapeutic relationship. I asked you questions about your relationship because I felt it was important for me to better understand you and your experience. How do you feel hearing this now? I’d like to talk about it.

EXERCISE

Annotated Emotion-Focused Therapy Practice Session Transcript It is now time to put all the skills you have learned together! This exercise presents a transcript from one of Rhonda Goldman’s typical therapy sessions. Each therapist statement is annotated to indicate which emotion-focused therapy (EFT) skill from Exercises 1 to 12 is used. The transcript provides an example of how therapists can interweave many EFT skills in response to clients.

Instructions As in the previous exercises, one trainee can play the client while the other plays the therapist. As much as possible, the trainee who plays the client should try to adopt an authentic emotional tone as if they were a real client. The first time through, both partners can read verbatim from the transcript. After one complete run-through, try it again. This time, the client can read from the script, while the therapist can improvise to the degree that they feel comfortable. At this point, you may also want to reflect on it with a supervisor and go through it again. Before you start, it is recommended that both therapist and client read the entire transcript through on their own, to the end. The purpose of the sample transcript is to give trainees the opportunity to try out what it is like to offer the EFT responses in a sequence that mimics live therapy sessions.

https://doi.org/10.1037/0000227-015 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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Note to Therapists Remember to be aware of your vocal quality. Match your tone to the client’s presentation. Thus, if the clients present vulnerable, soft emotions behind their words, soften your tone to be soothing and calm. If, on the other hand, clients are aggressive and angry, match your tone to be firm and solid. If you choose responses that are prompting client exploration, such as Skill 6: Empathic Exploration, remember to adopt a more querying, exploratory tone of voice. If you choose responses such as empathic affirmation, remember to adopt a validating tone. Throughout the transcript, the most appropriate tone for some therapist responses is indicated alongside the skill itself. However, we encourage trainees to use whichever tone they think is best and most appropriate.

Note that throughout this transcript the therapist is using Skill 1: Therapist SelfAwareness. At moments when the therapist has particularly strong emotional reactions, she uses Skill 9: Staying in Contact in the Face of Intense Affect. Also note that there are several points in the transcript where the client cries, sometimes with several seconds of silence. At these points, the trainee playing the client can express sad anguish but should not feel pressured to have to produce tears.

Annotated EFT Transcript THERAPIST 1:  Hello, I am excited to get to you know you. I thought we’d just take this first

session for you to tell me what brought you here and what you’ve been feeling, how you got to be feeling depressed. (Skill 4: Exploratory Question) CLIENT 1:  Do you want me to start in any particular order? THERAPIST 2:  Well, there is no specific agenda. Maybe you can just breathe and pay

attention inward to your stomach or chest and just say what comes to your mind, when you consider what you want to talk about. What comes up when you do that? (Skill 4: Exploratory Question; said in a soft, solid tone) CLIENT 2:  I have been struggling with depression most of my adult life, I’d say from about

my early 20s on. I am 52 now. THERAPIST 3:  Mmmhmm. So, you’re saying it’s been up and down, but right now you are

really feeling depressed. (Skill 2: Empathic Understanding) CLIENT 3:  Yeah, it’s been a struggle. I’m afraid it’s hereditary. I believe my mother’s

bipolar. She’s never been diagnosed as such, but I remember her struggling with depression all the time and really seeing her go up and down when I was a kid. So, it’s a real fear of mine. THERAPIST 4:  So, you saw your mother go through it, and somehow it’s scary for you.

(Skill 6: Empathic Exploration; said in a discovery-oriented tone) CLIENT 4:  Yeah. And, uh, it’s also very discouraging that every time you go through it

and you read the self-help books and you get counseling (Therapist: Mm hmm) and, you know, I thought I had beat it, but then it just came back, kind of feels out of the blue.

Annotated Emotion-Focused Therapy Practice Session Transcript

THERAPIST 5:  It’s as if things were looking up and somehow it crept back up on you.

(Skill 7: Empathic Evocation) CLIENT 5:  It seems like it’s just . . . it seems like it’s something you can’t get away from.

It’s not, it’s not like you’ve got a cold and you take a medicine and you’re all better. (Therapist: Mmm) THERAPIST 6:  Right, like it’s sort of like it comes back to haunt you . . . (Skill 7: Empathic

Evocation; said in a gentle evocative tone) CLIENT 6:  And, um, what brought on my last one was, I have a 17-year-old daughter, and

she and I used to be really close and we have always had such a good time together, you know she was so great, we did everything together and I have always felt so lucky to have her. She has been a model child. But lately she has been kind of withdrawn and nonresponsive and, well, then I found out she has been cutting and like maybe she has an eating disorder, she has been throwing up her food a lot, and she has kind of got involved with the wrong crowd at school and well maybe there is drugs. To be perfectly honest it has really thrown me, and I have to tell you that those awful feelings have just been coming back again. THERAPIST 7:  So, it has brought you back into that same spiral again. Like a painful kind of

tailspin. (Skill 7: Empathic Evocation; said in a gentle, evocative tone) CLIENT 7:  Yes, [crying] and this is when I start getting so down and feeling like I am no

good, I am a bad parent and yeah just angry at her but feeling really down. THERAPIST 8:  And you are angry with her but also find yourself sort of asking, “What have

I done wrong?” and maybe, “I have failed as a mother,” and that is leaving you feeling so down. (Skill 6: Empathic Exploration; said in an understanding but discoveryoriented tone) CLIENT 8:  Well, I do feel like a failure. I do think it is my fault. How can it not be? I am

her main caretaker and well, somewhere along the line I screwed up at the mothering thing! Yeah, and I realize that I am very hard on myself but basically, I do think it’s all my fault. THERAPIST 9:  Yes, so you find yourself being really hard on yourself and beating up on

yourself for this. (Skill 11: Marker Recognition. The therapist recognizes the marker for a self-evaluative/self-critical split, which could lead to a two-chair dialogue. However, this being a first session, the therapist chooses to store knowledge away rather than initiate a task setup. The therapist instead responds with Skill 5: Empathic Exploration.) CLIENT 9:  Yes, but I also feel angry at her and sad that I have invested all this time. THERAPIST 10:  Yeah, so somehow you feel so sad. (Skill 3: Empathic Affirmation and Vali-

dation; said in a gentle, soft, and sad tone) CLIENT 10:  [crying] I was doing fine until I got here [weak laugh]. I am sorry that I am cry-

ing so much. I was not expecting to, and I feel kind of awkward. THERAPIST 11:  Well, you know, this really is a place that you can cry, and this is some of

what we will do in here. It is helpful for us to be able to get down into some of the stuff that is really bothering you and to what has left you feeling pretty down and depressed. (Skill 5: Providing Treatment Rationale) CLIENT 11:  Right. Well, yeah, I guess that’s okay.

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THERAPIST 12:  Yeah, yeah. Yeah, so somehow that really touches something very painful.

This feeling of “I’ve failed” or “I haven’t done it right” or “What did I do wrong again?” It’s lingering, it stays with you. (Skill 3: Empathic Affirmation and Validation; said in a gentle, soft, and slow tone) CLIENT 12:  Yes, it is painful, and I have learned I cannot trust her (daughter), or anyone

else for that matter. I have been sitting with this for a few months and I think, I don’t trust people very easily. And all of this has shown me that I really can’t rely on anybody. It’s only been my daughter, and there’s never really been anybody I can rely on. THERAPIST 13:  There’s just a feeling of disappointment, I guess, and loneliness. Feeling so

alone. (Skill 8: Empathic Conjecture; said in a soft but exploratory voice) CLIENT 13:  Alone, yes, but I’m too busy being angry at the whole thing. [Client laughs

weakly] THERAPIST 14:  Yeah, and you find yourself feeling, um, blaming or angry at people?

Like when you say you’re angry . . .? (Skill 6: Empathic Exploration; said in a discoveryoriented tone) CLIENT 14:  [big sigh] That’s a really hard one to explain. I kind of shut down when people

let me down. Fine, whatever (Therapist: Mm hmm). I can do it by myself. THERAPIST 15:  Oh, I see. So, it’s kind of like I’ll just take my marbles and go home. (Skill 7:

Empathic Evocation) CLIENT 15:  Yeah, I just kind of shut right down. (Therapist: Mm hmmm) And I guess that’s

partially anger, like I don’t get angry. I don’t yell at anybody. I don’t lose my temper at anybody. I think I just shut down. THERAPIST 16:  Yes, like you just say, “Fine” and pull away, kind of shut right down. (Skill 2:

Empathic Understanding) CLIENT 16:  Yeah [laugh]. And so, I won’t make the first step towards people. It’s like I don’t

want to open myself to . . . THERAPIST 17:  Be hurt by them. (Skill 3: Empathic Affirmation and Validation) CLIENT 17:  Yeah. (Therapist: Mm hmmm) So I just kind of close off. And, I guess I’ve done

that gradually over the years more and more. And I’m really aware of how closed off I really am. (Therapist: Mmm) When it comes to personal things, that is. I mean I can talk about things (Therapist: Mmm), but it doesn’t matter when you don’t let anybody in. THERAPIST 18:  Yes, so you say to yourself, “I’m not gonna let anyone too close to me,

‘cause they could hurt me. I don’t want to go through that pain.” (Skill 8: Empathic Conjecture; said softly and slowly) CLIENT 18:  Yeah. [silently cries for about 5–10 seconds] THERAPIST 19:  It’s so hard to feel so . . . sad and alone. (Skill 3: Empathic Affirmation and

Validation; said in a low, slow voice) CLIENT 19:  [cries for 10 seconds] I’d rather be angry than sad. (Therapist: Mm hmmm)

Cause when I get sad, I get depressed, and then I don’t function. I don’t have the luxury of not being able to function. [breathes] THERAPIST 20:  Yes, you don’t have the luxury of not being able to function. (Skill 3:

Empathic Affirmation and Validation; said in a gentle, soft tone)

Annotated Emotion-Focused Therapy Practice Session Transcript

CLIENT 20:  I have to take care of myself, and I have to take care of my daughter.

(Therapist: Mm hmmm) So I can’t afford [tears and sniffling] to fall apart. THERAPIST 21:  Mm hmmm. So, it’s that there’s never any time or place for you to just be

sad and cry. (Skill 3: Empathic Affirmation and Validation) CLIENT 21:  I don’t like it ‘cause I don’t think it solves anything [crying]. THERAPIST 22:  Mm hmm. Feels unproductive. (Skill 3: Empathic Affirmation and Validation;

said in a soft, solid tone of familiarity) CLIENT 22:  [sigh] Uh, absolutely. Its feels counterproductive. I’d rather just, if I’m really

angry, I can clean my house in like a half an hour [laughs]. If I feel sad, I don’t want to get out of bed. THERAPIST 23:  Mm hmmm. So, it’s like sadness leads to more sadness. (Skill 6: Empathic

Exploration; said in a soft, discovery-oriented tone) CLIENT 23:  Sadness makes me very lethargic. THERAPIST 24:  So, it’s like a sad, hopeless feeling. (Skill 8: Empathic Conjecture) CLIENT 24:  Yes. Yeah. THERAPIST 25:  Yes, so that sounds really difficult but important, and I really want you to

know how touched I am that you have shared this feeling of sadness and vulnerability with me, because I imagine that it is not easy to do that and with what you are telling me, it has been hard, so thank you for sharing this now. (Skill 10: Self-Disclosure; said in genuine, direct, solid tone) And I hear that the sadness is difficult and leaves you feeling very hopeless. And at the same time those are important tears, and that’s some of what we will do in here is explore those tears, because even though they are difficult, they are your tears and what we want to do is explore what they are saying and meaning and what is painful and help you find a different way through so that you don’t have to feel so alone and hopeless. Does that make sense? (Skill 5: Providing Treatment Rationale)

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Mock Emotion-Focused Therapy Sessions In contrast to highly structured and repetitive deliberate practice exercises, a mock emotion-focused therapy (EFT) session is an unstructured and improvised role-play therapy session. Like a jazz rehearsal, mock sessions let you practice the art and science of appropriate responsiveness (Hatcher, 2015; Stiles & Horvath, 2017), putting your psychotherapy skills together in way that is helpful to your mock client. This exercise outlines the procedure for conducting a mock EFT session. It offers different client profiles you may choose to adopt when enacting a client. The last recommendation gives you the option to play yourself, a choice we have found to be highly rewarding. Mock sessions are also an opportunity for trainees to practice the following: • using psychotherapy skills responsively • navigating challenging choice-points in therapy • choosing which responses to use • tracking the arc of a therapy session and the overall big-picture therapy treatment • guiding treatment in the context of the client’s preferences • knowing how to proceed when the therapist is unsure, lost, or confused • recognizing and recovering from therapeutic errors • discovering your personal therapeutic style • building endurance for working with real clients

Mock EFT Session Overview For the mock session, you will perform a role-play of an initial therapy session. As is true with the exercises to build individual skills, the role-play involves three people: One trainee role-plays the therapist, another trainee role-plays the client, and a trainer (a professor or supervisor) observes and provides feedback. This is an open-ended role-play, as is commonly done in training. However, this differs in two important ways from the role-plays used in more traditional training. First, the therapist will use their

https://doi.org/10.1037/0000227-016 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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hand to indicate how difficult the role-play feels. Second, the client will attempt to make the role-play easier or harder to ensure the therapist is practicing at the right difficulty level.

Preparation 1. Read instructions in Chapter 2. 2. Download the Deliberate Practice Reaction Form at http://pubs.apa.org/books/supp/ deliberate-practice (also available in Appendix A). 3. Designate one student to role-play the therapist and one student to role-play the client. The trainer will observe and provide corrective feedback. 4. Every student will need their own copy of the Deliberate Practice Reaction Form on a separate piece of paper so they can access it quickly.

Mock EFT Session Procedure 1. The trainees will role-play an initial (first) therapy session. The trainee role-playing the client selects a client profile from the end of this exercise. 2. Before beginning the role-play, the therapist raises a hand to their side, at the level of their chair seat (see Figure E14.1). They will use this hand throughout the role-play to indicate how challenging it feels to them to help the client. The therapist’s starting hand level (chair seat) indicates that the role-play feels easy. By raising a hand, the therapist indicates that the difficulty is rising. If the therapist’s hand rises above neck level, it indicates that the role-play is too difficult. FIGURE E14.1.  Ongoing Difficulty Assessment Through Hand Level

Start / Easy

Too Hard

Note. Left: Start of role-play. Right: Role-play is too difficult.

Mock Emotion-Focused Therapy Sessions

3. The therapist begins the role-play. The therapist and client should engage in the roleplay in an improvised manner, as they would engage in a real therapy session. The therapist keeps their hand out at their side throughout this process. (This may feel strange at first!) 4. Whenever the therapist feels that the difficulty of the role-play has changed significantly, they should move their hand up if it feels more difficult, and down if it feels easier. If the therapist’s hand drops below the seat of the chair, the client should make the role-play more challenging; if the therapist’s hand rises above neck level, the client should make the role-play easier. Instructions for adjusting the difficulty of the roleplay are described in the “Varying the Level of Challenge” section.

Note to Therapists Remember to be aware of your vocal quality. Match your tone to the client’s presentation. Thus, if clients present vulnerable, soft emotions behind their words, soften your tone to be soothing and calm. If clients, are aggressive and angry, match your tone to be firm and solid. If you choose responses that are prompting of client exploration, such as Skill 6: Empathic Exploration, remember to adopt a more querying, exploratory tone of voice.

5. The role-play continues for at least 15 minutes. The trainer may provide corrective feedback during this process if the therapist gets significantly off track. However, trainers should exercise restraint and keep feedback as short and tight as possible because this will reduce the therapist’s opportunity for experiential training. 6. After the role-play is finished, the therapist and client switch roles and begin a new mock session. 7. After both trainees have completed the mock session as a therapist, the trainer provides an evaluation, the trainees do a self-evaluation, and the three discuss the experience.

Varying the Level of Challenge If the therapist indicates that the mock session is too easy, the person enacting the role of the client can use the following modifications to make it more challenging (see also Appendix A): • The client can improvise with topics that are more evocative or make the therapist uncomfortable, such as expressing currently held strong feelings (see Figure A.2). • The client can use a distressed voice (e.g., angry, sad, sarcastic) or unpleasant facial expression. This increases the emotional tone. • Blend complex mixtures of opposing feelings (e.g., love and rage). • Become confrontational, questioning the purpose of therapy or the therapist’s fitness for the role.

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If the therapist indicates that the mock session is too hard: • The client can be guided by Figure A.2 to – present topics that are less evocative, – present material on any topic but without expressing feelings, or – present material concerning the future or the past or events outside therapy. • The client can ask the questions in a soft voice or with a smile. This softens the emotional stimulus. • The therapist can take short breaks during the role-play. • The trainer can expand the “feedback phase” by discussing EFT or psychotherapy theory.

Mock Session Client Profiles Following are six client profiles for trainees to use during mock sessions, presented in order of difficulty. After these profiles is a third advanced profile, where clients have the option of playing themselves. Trainees playing as themselves can be very challenging and should only be done if they are comfortable doing so and only after completing the other profiles. The choice of client profile may be determined by the trainee playing the therapist, the trainee playing the client, or assigned by the trainer. The most important aspect of role-plays is for trainees to convey the emotional tone indicated by the client profile (e.g., “angry,” “sad”). The demographics of the client (e.g., age, gender) and specific content of the client profiles are not important. Thus, trainees should adjust the client profile to be most comfortable and easy for the trainee to role-play. For example, a trainee may change the client profile from female to male or from 45 to 22 years old.

Beginner Profile: Processing Grief With a Receptive Client Laura is a 28-year-old Latinx waitress whose mother died from cancer about 6  months ago. Laura has been experiencing sadness about losing her mother. Her grief is complicated by feelings of anger she has about her mother not being very attentive or loving during Laura’s childhood. Her father left the family when Laura was very young. Laura’s mother was very busy when she was growing up, caring for the family while trying to hold multiple jobs; however, Laura feels her mother was both abandoning and hard on her. Laura also misses her two siblings, who were forced to go back to Mexico because they were undocumented. Laura wants help processing her grief and anger about her mother. • Symptoms: Grief, anger, and loneliness. • Client’s goals for therapy: Laura wants to process her complex feelings about her mother and reconnect with her siblings. • Attitude toward therapy: Laura previously had good experiences in therapy when she was in high school and is optimistic about therapy helping again. • Strengths: Laura is very motivated for therapy and is emotionally open with the therapist.

Mock Emotion-Focused Therapy Sessions

Beginner Profile: Addressing Loneliness With Engaged Client Susan is a 25-year-old accountant who recently moved across the country for a new job. She loves her new job, but she has had trouble making friends. She is coming to therapy because she is feeling lonely. She recently went on a date and was dis­­ appointed when it didn’t go well. She’s worried that she will get demoralized and stop trying to make new friends. • Symptoms: Loneliness, sadness, and demoralization. • Client’s goals for therapy: Susan wants to build motivation to make more friends and go on more dates. • Attitude toward therapy: Susan has had positive experiences in therapy before. She is hopeful that this therapy will help as well. • Strengths: Susan is emotionally open and motivated to engage in the therapy tasks.

Intermediate Profile: Addressing Anxiety With a Nervous Client Bob is a 35-year-old electrician who suffers from extreme anxiety, panic attacks, and shame. He feels like he has been a “loser” his whole life. He was bullied in high school and thinks that people still judge him. He tries to avoid contact with people except through online computer games. He was referred to therapy by his boss, who noticed that Bob would sometimes not show up for work or would leave work early. Bob has trouble identifying any of his feelings except anxiety. • Symptoms: Anxiety, panic attacks, and social isolation. • Client’s goals for therapy: Bob wants to feel more confident socially so he can engage in work more reliably. • Attitude toward therapy: Bob didn’t want to come to therapy because he felt very nervous about it and thinks that the therapist will judge him. Bob’s boss convinced him to try therapy. • Strengths: Underneath his anxiety and shame, Bob really wants to connect with other people, including the therapist.

Intermediate Profile: Helping a Sarcastic and Skeptical Client Jeff is a 45-year-old engineer who was referred to therapy by his employer because he has been getting angry at work. He is very smart and gets frustrated quickly when his colleagues do not understand his decisions. When he gets frustrated, Jeff is sarcastic or mean. He understands that this is a problem and wants to be more friendly, but he has been unable to change his behavior. He knows that his colleagues do not like him, so he feels socially isolated at work. • Symptoms: Outbursts of sarcasm and meanness that cover loneliness and social isolation. • Client’s goals for therapy: Jeff wants to learn how to be more patient and relate better to his colleagues.

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• Attitude toward therapy: Jeff has never been in therapy before and is skeptical whether it will help. He came to therapy because his employer asked him to. • Strengths: Jeff wants to be more prosocial.

Advanced Profile: Helping a Very Distrustful Client Betty is a 27-year-old African American graduate student in law school. She wants to become a public defender when she graduates. Betty is the oldest of four siblings. Betty and her siblings were sexually and physically abused by her father when she was a child. Her father also beat her mother frequently. She also feels she has been very hurt and traumatized by systematic racism and discrimination. Betty has fought hard to achieve her current status. She does not generally trust the system because she does not feel her interests have been prioritized or protected. Betty feels a lot of anger toward her father, but also toward her mother for not protecting her and her siblings. Betty’s youngest sister recently committed suicide due to the abuse. Betty feels very guilty about not protecting her siblings from her father. • Symptoms: Anger at parents, guilt about not protecting siblings, and grief about her sister’s suicide. • Client’s goals for therapy: Betty wants to resolve her guilt about her sister. • Attitude toward therapy: Betty went to therapy in grade school but had a bad experience: When she told her therapist about her father’s abuse, the therapist didn’t believe her and told the father what Betty had said. (Betty found out later that the therapist was a friend of the father.) Thus, Betty is distrustful of therapists, particularly non–African American therapists. • Strengths: Betty is focused and dedicated to improving her mental health. She is extremely resilient. She has strong convictions about social justice and is fiercely loyal to her friends and family.

Advanced Profile: Helping a Client With Mood Lability and Self-Harm Jane is a 20-year-old college student who is having problems in her relationship where she cycles between being deeply in love with her boyfriend and then hating him when he does something that disappoints her, like forgetting her birthday. When Jane is disappointed by her boyfriend, she feels betrayed and abandoned, gets very angry and depressed, and cuts herself. Jane has a similar pattern with her family and friends, where she cycles between liking them a lot and then feeling betrayed and abandoned when they disappoint her. • Symptoms: Mood lability, self-harm (cutting), and relationship instability. • Client’s goals for therapy: Jane wants to find stability in herself and her relationships. • Attitude toward therapy: Jane was in therapy before, which was helpful until the therapist disappointed Jane by missing a session, after which Jane felt betrayed and abandoned and quit therapy. Jane is worried that you (her new therapist) may betray or abandon her. • Strengths: Jane is very open to what the therapist says (when she feels safe in therapy).

Mock Emotion-Focused Therapy Sessions

Advanced Profile: Play Yourself The last example suggests that therapists-in-training play themselves. This follows in the tradition of EFT training. From an EFT perspective, this is the most productive way to learn to be an EFT therapist. When you choose to draw on your actual experience as a client, you learn an immense amount about what is helpful (or not). You also have an opportunity to explore your own experience and recognize your own emotions in a productive manner. This is also highly beneficial to therapists-in-training (trainee seated across from you) because they get an opportunity to feel the impact of the various responses and evaluate from moment to moment whether they are achieving their aim. It also provides an opportunity for them to read and perceive actual experience and base their next response on it. When the client presents a real issue, the therapist can decide, in each moment, which response would be most fitting to achieve their given aim. Very often in EFT, the momentary aim is to deepen or explore emotional experience, and thus the therapist can decide whether it is best to use an empathic affirmation response to validate the client’s experience, provide an empathic exploration to foster further exploration of experience, or try an empathic conjecture to deepen emotional experiencing. One important note here is that the person playing client should choose a personal issue or topic that they feel comfortable exploring and deepening. “Clients” need to monitor their own experience and choose how deep they wish to go. Finally, in this particular exercise, it is not recommended for the therapist to use their hand because it could be distracting to the client and prevent exploration.

Instructions Work in pairs. Trainees playing the client choose an issue from their own life that they wish to discuss that feels comfortable to explore in the training setting. Trainees may choose an issue that they have been struggling with recently and want to emotionally explore, or something into which they wish to gain insight. If you are playing yourself as client, you may want to think over in advance (a) what relational problems or issues, symptoms, or behaviors you wish to discuss; (b) what your goal for the session might be (exploration as a goal is valid!); and (c) what attitude toward your therapist you wish to convey (curiosity about your own experience is very valid).

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Strategies for Enhancing the Deliberate Practice Exercises Part III consists of a single chapter—Chapter 3—that provides additional advice and instructions for trainers and trainees so that they can reap more benefits from the deliberate practice exercises in Part II. Chapter 3 offers six key points for getting the most out of deliberate practice, evaluation strategies, methods for ensuring trainee well-being and respecting their privacy, and advice for monitoring the trainer–trainee relationship.

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How to Get the Most Out of Deliberate Practice: Additional Guidance for Trainers and Trainees In Chapter  2 and in the exercises themselves, we provide instructions for completing these deliberate practice exercises. This chapter provides guidance on big-picture topics that trainers will need to successfully integrate deliberate practice into their training program. This guidance is based on relevant research and the experiences and feedback from trainers at more than a dozen psychotherapy training programs who volunteered to test the deliberate practice exercises in this book. We cover topics including six points for getting the most from deliberate practice, trainee well-being, respecting trainee privacy, trainer self-evaluation, responsive treatment, and the trainee–trainer alliance.

Six Key Points for Getting the Most From Deliberate Practice Following are six key points of advice for trainers and trainees to get the most benefit from the emotion-focused therapy (EFT) deliberate practice exercises. The following advice is gleaned from experience vetting and practicing the exercises, sometimes in different languages, with many trainees across many countries.

Key Point 1: Create Realistic Emotional Stimuli A key component of deliberate practice is using stimuli that provoke similar reactions to challenging, real-life work settings. For example, pilots train with flight simulators that present mechanical failures and dangerous weather conditions; surgeons practice with surgical simulators that present medical complications with only seconds to respond. Training with challenging stimuli will increase trainees’ capacity to perform therapy effectively under stress—for example, with clients they find challenging. The stimuli used for EFT deliberate practice exercises are role-plays of challenging client statements in therapy. It is important that the trainee who is role-playing the client perform the script with appropriate emotional expression and maintain eye contact with the therapist. For example, if the client statement calls for sad emotion, the trainee should

https://doi.org/10.1037/0000227-017 Deliberate Practice in Emotion-Focused Therapy, by R. N. Goldman, A. Vaz, and T. Rousmaniere Copyright © 2021 by the American Psychological Association. All rights reserved.

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try to express sadness eye-to-eye with the therapist. We offer the following suggestions regarding emotional expressiveness: • The emotional tone of the role-play matters more than the exact words of each script. Trainees role-playing the client should feel free to improvise and change the words if it will help them be more emotionally expressive. Trainees do not need to stick 100% exactly to the script. In fact, to read off the script during the exercise can sound flat and prohibit eye contact. Rather, trainees in the client role should first read the client statement silently to themselves and then, when ready, say it in an emotional manner while looking directly at the trainee playing the therapist. This will help the experience feel more real and engaging for the therapist. • Trainees whose first language isn’t English may particularly benefit from reviewing and changing the words in the client statement script before each role-play so they can find words that feel congruent and facilitate emotional expression. • Trainees role-playing the client should try to use tonal and nonverbal expressions of feelings. For example, if a script calls for anger, the trainee can speak with an angry voice and make fists with their hands; if a script calls for shame or guilt, the trainee could hunch over and wince; if a script calls for sadness, the trainee could speak in a soft, deflated voice. • If trainees are having persistent difficulties acting believably when following a particular script in the client role, it may help to first do a “demo round” by reading directly from paper and then, immediately after, dropping the paper to make eye contact and repeating the same client statement from memory. Some trainees reported this helped them “become available as a real clients” and made the roleplay feel less artificial. Some trainees did three or four demo rounds to get fully into their role as a client.

Key Point 2: Customize the Exercises to Fit Your Unique Training Circumstances Deliberate practice is less about adhering to specific rules than it is about using training principles. Every trainer has their own individual teaching style and every trainee their own learning process. Thus, the exercises in this book are designed to be flexibly customized by trainers across different training contexts within different cultures. Trainees and trainers are encouraged to continually adjust exercises to optimize their practice. The most effective training will occur when deliberate practice exercises are customized to fit the learning needs of each trainee and culture of each training site. In our experience with more than a dozen EFT trainers and trainees across many countries, we found that everyone spontaneously customized the exercises for their unique training circumstances. No two trainers followed the exact same procedure. For example, • One supervisor used the exercises with a trainee who found all the client statements to be too hard, including the “beginning” stimuli. This trainee had multiple reactions in the “too hard” category, including nausea and severe shame and self-doubt. The trainee disclosed to the supervisor that she had experienced extremely harsh learning environments earlier in her life and found the role-plays to be highly evocative. To help, the supervisor followed the suggestions offered earlier to make the stimuli progressively easier until the trainee reported feeling “good challenge” on the Reaction Form. Over many weeks of practice, the trainee developed a sense of safety and was able to practice with more difficult client statements. (Note that if

How to Get the Most Out of Deliberate Practice

the supervisor had proceeded at the too hard difficulty level, the trainee might have complied while hiding her negative reactions, become emotionally flooded and overwhelmed, leading to withdrawal and thus prohibiting her skill development and risking dropout from training.) • Supervisors of trainees for whom English was not their first language adjusted the client statements to their own primary language. • One supervisor used the exercises with a trainee who found all the stimuli to be too easy, including the advanced client statements. This supervisor quickly moved to improvising more challenging client statements from scratch by following the instructions on how to make client statements more challenging.

Key Point 3: Discover Your Own Unique Personal Therapeutic Style Deliberate practice in psychotherapy can be likened to the process of learning to play jazz music. Jazz musicians pride themselves in their skillful improvisations, and the process of “finding your own voice” is a prerequisite for expertise in jazz musicianship. Yet improvisations are not a collection of random notes but the culmination of extensive deliberate practice over time. Indeed, the ability to improvise is built on many hours of dedicated practice of scales, melodies, harmonies, and so on. Much in the same way, psychotherapy trainees are encouraged to experience the scripted interventions in this book not as ends in themselves but as a means to promote skill in a systematic fashion. Over time, effective therapeutic creativity can be aided, instead of constrained, by dedicated practice in these therapeutic “melodies.”

Key Point 4: Engage in a Sufficient Amount of Rehearsal Deliberate practice uses rehearsal to move skills into procedural memory, which helps trainees maintain access to skills even when working with challenging clients. This only works if trainees engage in many repetitions of the exercises. Think of a challenging sport or musical instrument you learned: How many rehearsals would a professional need to feel confident performing a new skill? Psychotherapy is no easier than those other fields!

Key Point 5: Continually Adjust Difficulty A crucial element of deliberate practice is training at an optimal difficulty level: neither too easy nor too hard. To achieve this, do difficulty assessments and adjustments with the Deliberate Practice Reaction Form in Appendix A. Do not skip this step! If trainees don’t feel any of the “Good Challenge” reactions at the bottom of the Reaction Form, then the exercise is probably too easy; if they feel any of the “too hard” reactions, then the exercise could be too difficult for the trainee to benefit. Advanced EFT trainees and therapists may find all the client statements too easy. If so, they should follow the instructions in Appendix A on making client statements harder to make the role-plays sufficiently challenging.

Key Point 6: Put It All Together With the Practice Transcript and Mock Therapy Sessions Some trainees may feel a need for greater contextualization of the individual therapy responses associated with each skill, wishing to integrate the disparate pieces of their

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training in a more coherent manner with a simulation that mimics a real therapy session. The practice therapy transcript (Exercise 13) is offered after the skill exercises because it brings all the skills together to provide trainees with the possibility of practicing different responses in a sequence that mimics an actual therapy session. The mock therapy sessions outlined in Exercise 14 serve the same function, allowing therapists to put their skills training into practice.

Responsive Treatment The exercises in this book are designed to help trainees not only to acquire specific skills of EFT but also to use them in ways that are responsive to each individual client (Goldman & Greenberg, 2015; Greenberg & Goldman, 2019). Across the psychotherapy literature, this stance has been referred to as appropriate responsiveness, wherein the therapists exercise flexible judgment, based on their perception of the client’s emotional state, needs, and goals, and integrates techniques and other interpersonal skills in pursuit of optimal client outcomes (Hatcher, 2015; Stiles et al., 1998). The effective therapist is responsive to the emerging context. As Stiles and Horvath (2017) argued, therapists are effective because they are appropriately responsive. Doing the “right thing” may be different each time and means providing each client with an individually tailored response. Appropriate responsiveness counters a misconception that deliberate practice rehearsal is designed to promote robotic repetition of therapy techniques. Psychotherapy researchers have shown that overadherence to a particular model while neglecting client preferences reduces therapy effectiveness (e.g., Castonguay et al., 1996; Henry et al., 1993; Owen & Hilsenroth, 2014). Therapist flexibility, in contrast, has been shown to improve outcomes (e.g., Bugatti & Boswell, 2016; Kendall & Beidas, 2007; Kendall & Frank, 2018). We recommend, therefore, that trainees practice their newly learned skills in a manner that is flexible and responsive to the unique needs of a diverse range of clients (Hatcher, 2015; Hill & Knox, 2013). Beyond deliberate practice, trainees must develop the necessary perceptual skills to attune to what the client is experiencing in the moment and form their response based on the moment-by-moment client context (Greenberg & Goldman, 1988). To reach strong EFT proficiency, deliberate practice must be combined with one-on-one process supervision to learn the more advanced perceptual skills of what to do, when. Supervisors must help supervisees to specifically attune themselves to the unique and specific needs of clients during sessions. Process supervision (Greenberg & Tomescu, 2017), the practice of supervisor and supervisee listening to tapes, stopping at particular poignant moments to consider the client’s feelings and meanings, lends itself to teaching appropriate responsiveness. The supervisor can stop the recording, ask the supervisee to reflect on the client’s current feelings and meanings, and help the supervisee consider which response would be best in that moment. For example, would it have been best to offer an empathic exploratory response (Exercise 6) or an empathic conjecture (Exercise 8)? By enacting responsiveness with the supervisee, the supervisor can demonstrate its value and make it more explicit. In these ways, attention can be given to the larger picture of appropriate responsiveness. Here the trainee and supervisor can work together to help the trainee master not just the techniques but also how therapists can use their judgment to put the techniques together and foster positive change. Helping trainees keep this overarching goal in mind while reviewing

How to Get the Most Out of Deliberate Practice

the therapy process is a valuable feature of supervision that is difficult to obtain otherwise (Hatcher, 2015). It is also important that deliberate practice occur within a context of wider EFT learning. As noted in Chapter 1, training should be combined with supervision of actual therapy recordings, theoretical learning, observation of competent EFT psychotherapists, and personal therapeutic work. When the trainer or trainee determines that the trainee is having difficulty acquiring EFT skills, it is important to carefully assess what is missing or needed. Assessment should then lead to the appropriate remedy, as the trainer and trainee collaboratively determine what is needed to succeed.

Being Mindful of Trainee Well-Being Although negative effects that some clients experience in psychotherapy have been well documented (Barlow, 2010), negative effects of training and supervision on trainees have received less attention (Ellis et al., 2014). EFT has a strong tradition of creating and sustaining safety in training and supervision (Greenberg & Goldman, 2019; Greenberg & Tomescu, 2017). In keeping with the humanistic tradition, the super­visory and training relationship is built on warmth, empathy, and a validating bond. The trainer must be present (Geller & Greenberg, 2012) with the trainee and attentive to feelings and needs. Collaboration on goals and tasks of training and supervision is founded on such core relational conditions. To support strong self-efficacy, trainers must ensure that trainees are practicing at a correct difficulty level. The exercises in this book feature guidance for frequently assessing and adjusting the difficulty level, so trainees can rehearse at a level that precisely targets their personal skill threshold. Trainers and supervisors must be mindful to provide an appropriate challenge. One risk to trainees that is particularly pertinent to this book occurs when using role-plays that are too difficult. The Reaction Form in Appendix A is provided to help trainers ensure that role-plays are done at an appropriate challenge level. Trainers or trainees may be tempted to skip the difficulty assessments and adjustments out of their motivation to focus on rehearsal, make fast progress, and quickly acquire skills. But across all our test sites, we found that skipping the difficulty assessments and adjustments caused problems and hindered skill acquisition more than any other error. Thus, trainers are advised to remember that one of their most important responsibilities is to remind trainees to do the difficulty assessments and adjustments. Additionally, the Reaction Form serves a dual purpose of helping trainees develop the important skills of self-monitoring and self-awareness. This will help trainees adopt a positive and empowered stance regarding their own self-care and should facilitate career-long professional development.

Respecting Trainee Privacy The deliberate practice exercises in this book may stir up complex or uncomfortable personal reactions within trainees, including, for example, memories of past traumas. Exploring psychological and emotional reactions may make some trainees feel vulnerable. Therapists of every career stage, from trainees to seasoned therapists with

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decades of experience, commonly experience shame, embarrassment, and self-doubt in this process. Although these experiences can be valuable for building trainees’ selfawareness, it is important that training remain focused on professional skill development and not blur into personal therapy (e.g., Ellis et al., 2014). Therefore, one trainer role is to remind trainees to maintain appropriate boundaries. Trainees must have the final say about what to disclose or not disclose to their trainer. Trainees should keep in mind that the goal is for trainees to expand their own self-awareness and psychological capacity to stay active and helpful while experiencing uncomfortable reactions. The trainer does not need to know the specific details about the trainee’s inner world for this to happen. Trainees should be instructed to share only personal information that they feel comfortable sharing. The Reaction Form and difficulty assessment process are designed to help trainees build their self-awareness while retaining control over their privacy. Trainees can be reminded that the goal is for them to learn about their own inner world. They do not necessarily have to share that information with trainers or peers (Bennett-Levy & Finlay-Jones, 2018). Likewise, trainees should be instructed to respect the confidentiality of their peers.

Trainer Self-Evaluation The exercises in this book were tested at a wide range of training sites around the world, including graduate courses, practicum sites, and private practice offices. Although trainers reported that the exercises were highly effective for training, some also said that they felt disoriented by how different deliberate practice feels compared with their traditional methods of clinical education. Many felt comfortable evaluating their trainees’ performance but were less sure about their own performance as trainers. The most common concern we heard from trainers was “My trainees are doing great, but I’m not sure if I am doing this correctly!” To address this concern, we recommend trainers perform periodic self-evaluations along the following five criteria: 1. Observe trainees’ work performance 2. Provide continual corrective feedback 3. Ensure rehearsal of specific skills is just beyond the trainees’ current ability 4. Ensure that the trainee is practicing at the right difficulty level (neither too easy nor too challenging) 5. Continuously assess trainee performance with real clients

Criterion 1: Observe Trainees’ Work Performance Determining how well we are doing as trainers means first having valid information about how well trainees are responding to training. This requires that we directly observe trainees practicing skills to provide corrective feedback and evaluation. One risk of deliberate practice is that trainees gain competence in performing therapy skills in role-plays, but those skills do not transfer to trainees’ work with real clients. Thus, trainers will ideally also have the opportunity to observe samples of trainees’ work with real clients, either live or via recorded video. Supervisors and consultants rely heavily— and, too often, exclusively—on supervisees’ and consultees’ narrative accounts of their

How to Get the Most Out of Deliberate Practice

work with clients (Goodyear & Nelson, 1997). Haggerty and Hilsenroth (2011) described this challenge: Suppose a loved one has to undergo surgery and you need to choose between two surgeons, one of whom has never been directly observed by an experienced surgeon while performing any surgery. He or she would perform the surgery and return to his or her attending physician and try to recall, sometimes incompletely or inaccurately, the intricate steps of the surgery they just performed. It is hard to imagine that anyone, given a choice, would prefer this over a professional who has been routinely observed in the practice of their craft. (p. 193)

Criterion 2: Provide Continual Corrective Feedback Trainees need corrective feedback to learn what they are doing well or poorly and how to improve their skills. Feedback should be as specific and incremental as possible. Examples of specific feedback are “Your voice sounds rushed. Try slowing down by pausing for a few seconds between your statements to the client” and “That’s excellent how you are making eye contact with the client.” Examples of vague and nonspecific feedback are “Try to build better rapport with the client” and “Try to be more open to the client’s feelings.”

Criterion 3: Rehearse Specific Skills Just Beyond the Trainees’ Current Ability (Zone of Proximal Development) Deliberate practice emphasizes skill acquisition via rehearsal. Trainers should endeavor not to get caught up in client conceptualization at the expense of focusing on skills. For many trainers, this requires significant discipline and self-restraint. It is simply more enjoyable to talk about psychotherapy theory (e.g., case conceptualization, treatment planning, nuances of psychotherapy models, similar cases the supervisor has had) than watch trainees rehearse skills. Trainees have many questions, and supervisors have an abundance of experience; the allotted supervision time can easily be filled sharing knowledge. The supervisor gets to sound smart, while the trainee doesn’t have to struggle with acquiring skills at their learning edge. Although answering questions is important, trainees’ intellectual knowledge about psychotherapy can quickly surpass their procedural ability to perform psychotherapy, particularly with clients they find challenging. Here’s a simple rule of thumb: The trainer provides the knowledge, but the behavioral rehearsal provides the skill (Rousmaniere, 2019).

Criterion 4: Practice at the Right Difficulty Level (Neither Too Easy nor Too Challenging) Deliberate practice involves optimal strain: practicing skills just beyond the trainee’s current skill threshold so that he or she can learn incrementally without becoming overwhelmed (Ericsson, 2006). Trainers should use difficulty assessments and adjustments throughout deliberate practice to ensure that trainees are practicing at the right difficulty level. Note that some trainees are surprised by their unpleasant reactions to exercises (e.g., disassociation, nausea, blanking out) and may be tempted to “push through” exercises that are too hard. This can happen out of fear of failing a course, fear of being judged as incompetent, or the trainee’s negative self-impressions (e.g., “This shouldn’t be so hard”).

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Trainers should normalize the fact that there will be wide variation in perceived difficulty of the exercises and encourage trainees to respect their own personal training process.

Criterion 5: Continuously Assess Trainee Performance With Real Clients The goal of deliberately practicing psychotherapy skills is to improve trainees’ effectiveness at helping real clients. One of the risks in deliberate practice training is that the benefits will not generalize: Trainees’ acquired competence in specific skills may not translate into work with real clients. Thus, it is important that trainers assess the impact of deliberate practice on trainees’ work with real clients. Ideally, this is done through triangulation of multiple data points: 1. Client data (verbal self-report and routine outcome monitoring data) 2. Supervisor’s report 3. Trainee’s self-report If the trainee’s effectiveness with real clients is not improving after deliberate practice, the trainer should do a careful assessment of the difficulty. If the supervisor or trainer feels it is a skill acquisition issues, they may want to consider adjusting the deliberate practice routine to better suit the trainee’s learning needs or style. Therapists are held to process accountability (Markman & Tetlock, 2000; see also Goodyear, 2015): being responsible for demonstrating particular target behaviors (e.g., fidelity to a particular treatment model) regardless of the impacts of those behaviors on clients. Achieving clinical effectiveness means moving beyond competence to more reliably improve client outcomes. Learning objectives shift at this point from normative ones that others have declared to be desirable for all therapists to achieve (i.e., competence) to highly individualized goals informed by the learner’s objectives and performance feedback. Outcome accountability (Goodyear, 2015) becomes especially salient. Outcome accountability concerns the extent to which the therapist is able to achieve intended client changes, independent of how the therapist might be performing expected tasks. Of course, the reasonable question in any discussion of accountability concerns “accountability to whom?” In this case, it is ultimately to clients.

Guidance for Trainees The central theme of this book has been that skill rehearsal is not automatically helpful. Deliberate practice must be done well for trainees to benefit (Ericsson & Pool, 2016). In this chapter and in the exercises, we offer guidance for effective deliberate practice. We would also like to provide additional advice specifically for trainees. That advice is drawn from what we have learned at our volunteer deliberate practice test sites around the world. We cover how to discover your own training process, active effort, playfulness and taking breaks during deliberate practice, your right to control your self-disclosure to trainers, monitoring training results, monitoring complex reactions toward the trainer, and your own personal therapy.

Individualized EFT Training: Finding Your Zone of Proximal Development Deliberate practice works best when training targets each trainee’s personal skill thresholds. Also termed the zone of proximal development, a term first coined by

How to Get the Most Out of Deliberate Practice

Vygotsky in reference to developmental learning theory (Zaretskii, 2009); this is the area just beyond the trainee’s current ability but that is possible to reach with the assistance of a teacher or coach (Wass & Golding, 2014). If a deliberate practice exercise is either too easy or too hard, the trainee will not benefit. To maximize training productivity, elite performers follow a “challenging but not overwhelming” principle: Tasks that are too far beyond their capacity will prove ineffective and even harmful, but it is equally true that mindlessly repeating what they already can do confidently will prove equally fruitless. Because of this, deliberate practice requires ongoing assessment of the trainee’s current skill and concurrent difficulty adjustment to consistently target a “good enough” challenge. Thus if you are practicing empathic conjecture (Exercise 8) and it just feels too difficult, consider moving back to a more comfortable skill, such as Exploratory Question or Empathic Understanding that trainees may feel they have already mastered.

Active Effort It is important for trainees to maintain an active and sustained effort while doing the deliberate practice exercises in this book. Deliberate practice really helps when trainees push themselves up to and past their current ability. This is best achieved when trainees take ownership of their own practice by guiding their training partners to adjust role-plays to be as high on the difficulty scale as possible without hurting themselves. This will look different for every trainee. Although it can feel uncomfortable or even frightening, this is the zone of proximal development where the most gains can be made. Simply reading and repeating the written scripts will provide little or no benefit. Trainees are advised to remember that their effort from training should lead to more confidence and comfort in session with real clients.

Stay the Course: Effort Versus Flow Deliberate practice works only if trainees push themselves hard enough to break out of their old patterns of performance, which then permits growth of new skills (Ericsson & Pool, 2016). Because deliberate practice constantly focuses on the current edge of one’s performance capacity, it is inevitably a straining endeavor. Indeed, professionals are unlikely to make lasting performance improvements unless there is sufficient engagement in tasks that are just at the edge of one’s current capacity (Ericsson, 2003, 2006). From athletics or fitness training, many of us are familiar with this process of being pushed out of our comfort zones, followed by adaptation. The same process applies to our mental and emotional abilities. Many trainees might be surprised to discover that deliberate practice for EFT feels harder than psychotherapy with a real client. This may be because when working with a real client, a therapist can get into a state of flow (Csikszentmihalyi, 1997), in which work feels effortless. As a young EFT therapist in training, instructed not to ask questions (something she felt she knew how to do well) but only to provide empathic reflections (something she did not feel proficient at), the first author often felt exhausted after psychotherapy sessions. EFT therapists in training may find it difficult to continually offer empathic understanding responses, feeling they are “just repeating themselves” or have captured the experience as best they can and are ready to move forward. In such cases, therapists may want to move back to offering response formats with which they are more familiar and feel more proficient and try those for a short time, in part to increase a sense of confidence and mastery.

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Discover Your Own Training Process The effectiveness of deliberate practice is directly related to the effort and ownership trainees exert while doing the exercises. Trainers can provide guidance, but it is important for trainees to learn about their own idiosyncratic training processes over time. This will let them become masters of their own training and prepare for a career-long process of professional development. The following are a few examples of personal training processes trainees discovered while engaging in deliberate practice: • One trainee noticed that she is good at persisting when an exercise is challenging, but also that she requires more rehearsal than other trainees to feel comfortable with a new skill. This trainee focused on developing patience with her own pace of progress. • One trainee noticed that he can acquire new skills rather quickly, with only a few repetitions. However, he also noticed that his reactions to evocative client statements could jump quickly and unpredictably from the “good challenge” to “too hard” categories, so he needed to attend carefully to the reactions listed on the Reaction Form. • One trainee described herself as “perfectionistic” and felt a strong urge to “push through” an exercise even when she had anxiety reactions in the “too hard” category, such as nausea and disassociation. This caused the trainee not to benefit from the exercises and risk getting demoralized. This trainee focused on going slower, developing self-compassion regarding her anxiety reactions, and asking her training partners to make role-plays less challenging. One reason the exercises in this book feature self-evaluations is to facilitate the process of trainee self-discovery. Trainees are encouraged to reflect deeply on their own experiences using the exercises to learn the most about themselves and their personal learning processes.

Playfulness and Taking Breaks Psychotherapy is serious work that often involves painful feelings. However, practicing psychotherapy can be playful and fun (Scott Miller, personal communication, 2017). Trainees should remember that one of the main goals of deliberate practice is to experiment with different approaches and styles of therapy. If deliberate practice ever feels rote, boring, or routine, it probably isn’t going to help advance trainees’ skill. In this case, trainees should try to liven it up. A good way to do this is introduce an atmos­ phere of playfulness. For example, trainees can • use different vocal tones, speech pacing, body gestures, or other languages. This can expand trainees’ communication range. • practice while simulating being blind (with a cloth) or deaf. This can increase sensitivity in the other senses. • practice while standing up or walking around outside. This can help trainees get new perspectives on the process of therapy. The supervisor can also ask trainees if they would like to take a 5- to 10-minute break between questions, particularly if the trainees are dealing which difficult emotions and are feeling stressed out.

How to Get the Most Out of Deliberate Practice

Monitoring Training Results While trainers will evaluate trainees using a competency-focused model, trainees are also encouraged to take ownership of their own training process and look for results of deliberate practice themselves. Trainees should experience the results of deliberate practice within a few training sessions. A lack of results can be demoralizing for trainees and result in trainees applying less effort and focus in deliberate practice. Trainees who are not seeing results should openly discuss this problem with their trainer and experiment with adjusting their deliberate practice process. Results can include client outcomes and improving the trainee’s own work as a therapist, their personal development, and their overall training.

Client Outcomes The most important result of deliberate practice is an improvement in trainees’ client outcomes. This can be assessed via routine outcome measurement (Lambert, 2010), qualitative data (McLeod, 2017), and informal discussions with clients. However, trainees should note that an improvement in client outcome due to deliberate practice can sometimes be challenging to achieve quickly, given that the largest amount of variance in client outcome is due to client variables (Bohart & Wade, 2013). For example, a client with severe chronic symptoms may not respond quickly to any treatment, regardless of how effectively a trainee practices. For some clients, an increase in patience and self-compassion regarding their symptoms may be a sign of progress, rather than an immediate decrease in symptoms. Thus, trainees are advised to keep their expectations for client change realistic in the context of their client’s symptoms, history, and presentation. It is important that trainees not try to force their clients to improve in therapy in order for trainees to feel like they are making progress in their training (Rousmaniere, 2016).

Trainee’s Work as a Therapist One important result of deliberate practice is change within trainees regarding their work with clients. For example, trainees at test sites reported feeling more comfortable sitting with evocative clients, more confident addressing uncomfortable topics in therapy, and more responsive to a broader range of clients.

Trainee’s Personal Development Another important result of deliberate practice is personal growth within the trainee. For example, trainees at test sites reported becoming more in touch with their own feelings and gaining increased self-compassion and enhanced motivation to work with a broader range of clients.

Trainee’s Training Process Improvement in trainees’ training process is another valuable result of deliberate practice. For example, trainees at test sites reported becoming more aware of their personal training style, preferences, strengths, and challenges. Over time, trainees should grow to feel more ownership of their training process. Training to be a psychotherapist is a complex process that occurs over many years. Experienced, expert therapists still report continuing to grow well beyond their graduate school years (Orlinsky & Ronnestad, 2005). Furthermore, training is not a linear process. In my personal experience (R. Goldman) of

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learning to be a psychotherapist, I recall feeling, at times, that I was making excellent progress—that I had really turned a corner and would not look back—after a client had had a breakthrough, only to be confronted the next day with a huge feeling of disappointment and setback when confronted with a new client and a new problem. Remember, be easy on yourself. And trust the process!

The Trainee–Trainer Alliance: Monitoring Complex Reactions Toward the Trainer Trainees who engage in hard deliberate practice often report experiencing complex feelings toward their trainer. For example, one trainee said, “I know this is helping, but I also don’t look forward to it!” Another trainee reported simultaneously feeling both appreciation and frustration toward her trainer. Trainees are advised to remember intensive training they have done in other fields, such as athletics or music. When a coach pushes a trainee to the edge of their ability, it is common for trainees to have complex reactions toward the coach. This does not necessarily mean that the trainer is doing anything wrong. In fact, intensive training inevitably stirs up reactions toward the trainer, such as frustration, annoyance, disappointment, or anger, that coexist with the appreciation they feel. In fact, if trainees do not experience complex reactions, it is worth considering whether the deliberate practice is sufficiently challenging. But what we asserted earlier about rights to privacy apply here as well. Because professional mental health training is hierarchical and evaluative, trainers should not require or even expect trainees to share complex reactions they may be experiencing toward them. Trainers should stay open to their sharing, but the choice always remains with the trainee.

Trainee’s Own Therapy When engaging in deliberate practice, many trainees discover aspects of their inner world that may benefit from attending their own psychotherapy. For example, one trainee discovered that her clients’ anger stirred up her own painful memories of abuse, another trainee found himself disassociating while practicing empathy skills, and another trainee experienced overwhelming shame and self-judgment when she couldn’t master skills after just a few repetitions. Although these discoveries were unnerving at first, they ultimately were beneficial because they motivated the trainees to seek out their own therapy. Many therapists attend their own therapy. In fact, in their review of 17 studies, Norcross and Guy (2005) found that about 75% of more than 8,000 therapist participants attended their own therapy. Orlinsky and Ronnestad (2005) found that more than 90% of therapists who attended their own therapy reported it as helpful.

QUESTIONS FOR TRAINEES 1. Are you balancing the effort to improve your skills with patience and self-compassion for your learning process? 2. Are you attending to any shame or self-judgment that is arising from training? 3. Are you being mindful of your personal boundaries and also respecting any complex feelings you may have toward your trainers?

APPENDIX

Difficulty Assessments and Adjustments Deliberate practice works best if the exercises are performed at a good challenge level that is neither too hard nor too easy. To ensure that trainees are practicing at the correct difficulty, they should do a difficulty assessment and adjustment after each level of client statement is completed (beginner, intermediate, and advanced). To do this, use the following instructions and the Deliberate Practice Reaction Form (Figure A.1), which is also available at http://pubs.apa.org/books/supp/deliberatepractice. Do not skip this process!

How to Assess Difficulty The therapist completes the Deliberate Practice Reaction Form (Figure A.1). If they • answer either Question 1 or 2 on the Reaction Form as “too hard,” follow the instructions to make the exercise easier; • answer both Questions 1 and 2 as “too easy” and “no,” proceed to the next level of harder client statements or follow the instructions to make exercise harder; or • answer both Questions 1 and 2 as “good challenge” and “no,” do not proceed to the harder client statements but rather repeat the same level.

Making Client Statements Easier If the therapist ever answers either Question 1 or 2 on the Reaction Form as “too hard,” use the next-level easier client statements (e.g., if you were using Advanced client statements, switch to Intermediate). But if you already were using Beginner client statements, use the following methods to make the client statements even easier: • The person playing the client can use the same Beginner client statements but this time in a softer, calmer voice and with a smile. This softens the emotional tone.

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FIGURE A.1.  Deliberate Practice Reaction Form

Question 1: How challenging was it to fulfill the skill criteria for this exercise?

Question 2: Did you have any reactions in “good challenge” or “too hard” categories? (yes/no)

Good Challenge

Too Hard

Emotions and Thoughts

Body Reactions

Urges

Emotions and Thoughts

Body Reactions

Urges

Manageable shame, self-judgment, irritation, anger, sadness, etc.

Body tension, sighs, shallow breathing, increased heart rate, warmth, dry mouth

Looking away, withdrawing, changing focus

Severe or overwhelming shame, selfjudgement, rage, grief, guilt, etc.

Migraines, dizziness, foggy thinking, diarrhea, disassociation, numbness, blanking out, nausea, etc.

Shutting down, giving up

Too Easy

Good Challenge

Too Hard

Proceed to next difficulty level

Repeat the same difficulty level

Go back to previous difficulty level

• The client can improvise with topics that are less evocative or make the therapist more comfortable, such as talking about topics without expressing feelings, the future–past (avoiding here and now), or any topic outside therapy (see Figure A.2). • The therapist can take a short break (5–10 minutes) between questions. • The trainer can expand the “feedback phase” by discussing emotion-focused therapy or psychotherapy theory and research. This should shift the trainees’ focus toward more detached or intellectual topics and reduce the emotional intensity.

Making Client Statements Harder If the therapist answers both Questions 1 and 2 on the Reaction Form as “too easy,” proceed to next-level harder client statements. If you were already using the Advanced client statements, the client should make the exercise even harder, using the following guidelines: • The person playing the client can use the Advanced client statements again with a more distressed voice (e.g., very angry, sad, sarcastic) or unpleasant facial expression. This should increase the emotional tone.

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FIGURE A.2.  How to Make Client Statements Easier or Harder in Role-Plays

LEAST EVOCATIVE (EASIER)

Talking about events in the future/past, or outside therapy

Talking about anything without expressing feelings (content)

Expressing strong feelings while talking (affect)

Talking about here and now, therapy, or therapist

MOST EVOCATIVE (HARDER)

Note. Figure created by Jason Whipple, PhD.

• The client can improvise new client statements with topics that are more evocative or make the therapist uncomfortable, such as expressing strong feelings or talking about the here and now, therapy, or therapist (see Figure A.2).

Note. The purpose of a deliberate practice session is not to get through all the client statements and therapist responses but to spend as much time as possible practicing at the correct difficulty level. This may mean that trainees repeat the same statements or responses many times, which is okay as long as the difficulty remains in the “good challenge” level.

APPENDIX

Distinguishing Between Empathic Responses At times, it can be difficult to distinguish between the different types of therapist empathic responses. It should be emphasized that the examples given in this book are prototypical of their particular category. Some therapist empathic responses will fall between these categories. For example, there may be a strong degree of overlap between an empathic evocation and exploration, and they can be difficult to distinguish. It is important to remember that in their prototypical form, each response will have a different primary intention. Thus, the main intention behind an empathic understanding response is to convey understanding; the intention behind an affirmation response is to validate how understandable the expressed feeling or experience is and say, “I am here with you” or “Let’s stay right here.” The main intention behind an empathic evocation is to deepen experience and bring it to life, and this is done through the therapist’s use of metaphor, imagery, dramatic language, or vivifying of experience. The main intention behind empathic exploration is to deepen exploration, and this is done by moving the exploration forward toward the leading edges of experience with a discovery-oriented, querying tone. The main intention behind an empathic conjecture is also to deepen exploration, but this is done by “reaching in” to client current experience and hunching or guessing as to the not-yet-said or even experienced that is not yet the focus of client attention. It often has the feel of what is “behind” or “underneath” currently held experience. Conjectures, however, are not interpretations and are not intended to make links to past experiences or causes or address motivation or “reasons why.” Here we present two client statements, each followed by five therapist responses to help learners distinguish among the different types of empathic responses. These are prototypical examples of the five empathic responses to the same client statement prompts. Note that this is not possible with every type of client response because the type of therapist response given is often driven by the type of client statement offered. That is, it is determined by the client response itself and how it is most fitting for an emotion-focused therapist to respond in the moment.

Client Statement 1 [Worried] I’m so worried that I won’t be able to pay my bills next month, and I don’t even know what I can do about it. It’s overwhelming.

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Example Empathic Responses • Empathic Understanding: It’s like you are feeling very scared and lost and not sure which way to turn. • Empathic Affirmation: Yes, it is so understandable that you are scared. And there is a horrible sense of powerlessness. • Empathic Evocation: It’s like a dark shadow looming over you, and it just feels like every which way you turn, there is a wall in front of you. • Empathic Exploration: So, on the one hand, you are very worried, but on the other, feeling so stuck . . . and it’s like when you go to try to take action, say to call or inquire about a job, a sinking feeling just stops you dead in your tracks. • Empathic Conjecture: Feeling very overwhelmed and stuck, almost a feeling of “I am not capable of taking action, I just don’t have inside what it takes.” And then there is just this looming fear, that I am not going to be ok . . .

Client Statement 2 [Worried with moist eyes] I’d like to be nicer to my friends, but whenever I feel closer to anyone, I start thinking about how I’ll eventually disappoint them.

Example Empathic Responses • Empathic Understanding: So, it’s hard to feel close to someone without having this fear of letting them down. • Empathic Affirmation: Yes, it is understandable because you have been hurt, and it’s a strong feeling of “I will disappoint them eventually” that brings the tears. • Empathic Evocation: Whenever you get close to someone. it’s as if a fear washes over you that says, “I will drop the ball and let them down.” • Empathic Exploration: Somehow just a painful feeling of, I don’t know, “Don’t get too close . . . I will let you down, somehow I am just bound to disappoint you . . .” • Empathic Conjecture: Somehow feeling that in the end, it is a given, you will disappoint them, it’s just such a painful feeling of, I don’t know, but “I am not enough, and once they figure it out, they will see me and confirm that I am not enough—that there is somehow something missing, just lacking.”

Sample Emotion-Focused Therapy Syllabus With Embedded Deliberate Practice Exercises This appendix provides a sample one-semester, three-unit course dedicated to teaching emotion-focused therapy (EFT). This course is appropriate for graduate students (master’s and doctoral) at all levels of training, including first-year students who have not yet worked with clients. We present it as a model that can be adopted to a specific program’s contexts and needs. For example, instructors may borrow portions of it to use in other courses, practica, didactic training events at externships and internships, workshops, and continuing education for postgraduate therapists. Course Title: Emotion-Focused Therapy: Theory and Deliberate Practice Suggested Course Description This course teaches theory, principles, and core skills of EFT for individuals. As a course with both didactic and practicum elements, it will review the theory and research on emotion, psychotherapy change processes, and applications of EFT and will foster the use of deliberate practice to enable students to acquire 12 key EFT skills. Course Objectives Students who complete this course will be able to 1. Describe the core theory, research, and skills of EFT 2. Apply the principles of deliberate practice for career-long clinical skill development 3. Demonstrate key EFT skills 4. Evaluate how they can fit EFT skills into their developing therapeutic framework 5. Employ EFT with clients from diverse cultural backgrounds 6. Be emotionally available for their clients as a result of the increased emotional self-awareness and experiential knowledge they gain in the course 7. Describe the ways in which EFT is an evidenced-based practice approach 8. Demonstrate an effective balance of (a) emotional vulnerability/openness and (b) maintaining appropriate personal boundaries

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C

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Date Week 1

Appendix C

Lecture and Discussion Introduction to emotion-focused therapy (EFT)

Skills Lab Video demonstration

Greenberg and Goldman (2019), Clinical Handbook of Emotion-Focused Therapy, Chapters 1 and 2

Overview of EFT theory

Goldman (2015)

History of EFT

Chapter 1

Theory of EFT practice

Videos: Intro to EFT: Greenberg (2007a), Emotion-Focused Therapy for Depression

Principles of deliberate practice

Week 2

Relevant Readings and Videos

Empirical support for EFT: process and outcome research Emotion change principles

Intro to deliberate practice: https://www.dpfortherapists.com Video demonstration Exercise 1: Therapist Self-Awareness

Greenberg and Goldman (2019), Clinical Handbook of Emotion-Focused Therapy, Chapters 3, 4, and 6 Goldman et al. (2006) Ellison et al. (2009)

Case formulation in EFT

Watson et al. (2003)

Therapist self-awareness, therapeutic presence, and related research

Goldman and Greenberg (2015), Case Formulation in Emotion-Focused Therapy Goldman (2017) Exercise 1 Video: Goldman (2013), Case Formulation in Emotion-Focused Therapy

Week 3

The therapeutic relationship in EFT Moment-by-moment empathic attunement to affect and related research

Exercise 2: Empathic Understanding

Greenberg and Goldman (2019), Clinical Handbook of Emotion-Focused Therapy, Chapters 5 and 6 Rogers (1957, 1975) Greenberg (2014) Martin (2015) Exercise 2 Video: Geller (2015), Presence in Psychotherapy

Week 4

Empathic attunement to affect Why focus on emotions and what to listen for (i.e., primary, secondary; adaptive and maladaptive)

Exercise 3: Empathic Affirmation and Validation

Greenberg and Goldman (2019), Clinical Handbook of Emotion-Focused Therapy, Chapters 7–9 Watson et al. (1997) Rogers (1957, 1975)

Empathic affirmation/validation and related research

Martin (2015) Pascual-Leone (2009), Pascual-Leone and Greenberg (2007) Exercise 3

Week 5

Exploratory questions: how and when to use questions in EFT

Exercise 4: Exploratory Questions

Elliott et al. (2004), Chapter 5 Exercise 4 Video: Watson (2013)

Week 6

Week 7

“Hot teaching” in EFT: experiential teaching, emotion coaching, and consolidating change with homework

Greenberg and Goldman (2019), Clinical Handbook of Emotion-Focused Therapy, Chapter 12

Providing treatment rationales

Exercise 5: Providing Treatment Rationale for Emotion-Focused Therapy

Using empathic exploration to explore and deepen emotion

Exercise 6: Empathic Explorations

Elliott et al. (2004), Chapter 6

Greenberg (2015) Exercise 5

Watson et al. (1997) Exercise 6

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Appendix C

Date Week 8

Lecture and Discussion Using empathic evocations to deepen emotion; related research

Skills Lab Exercise 7: Empathic Evocations

Relevant Readings and Videos Greenberg and Goldman (2019), Clinical Handbook of Emotion-Focused Therapy, Chapter 5 Elliott et al. (2004), Chapter 5 Rice (1974) Martin (2015) Exercise 7

Week 9

Empathic conjectures and related research Distinguishing empathic responses

Exercise 8: Empathic Conjectures

Exercise 8 Elliott et al. (2004), Chapter 5 Refer to Appendix B

Week 10

Therapist self-awareness More on cultivating therapeutic presence and related research

Exercise 9: Staying in Contact in the Face of Intense Affect

Integrating a feminist–multicultural perspective into EFT Week 11

Self-disclosure in EFT

Greenberg and Goldman (2019), Clinical Handbook of Emotion-Focused Therapy, Chapters 6 and 19 Geller and Greenberg (2012) Geller (2017) Exercise 9

Exercise 10: Self-Disclosure

Levitt et al. (2016) Elliott et al. (2004), Chapter 5 Exercise 10

Week 12

Marker recognition and chair-work task setup Self-evaluative splits Self-interruptive splits

Exercise 11: Marker Recognition and Chair Work Task Setup

Elliott et al. (2004), Chapters 6, 11, and 12

Exercise 12: Addressing Ruptures and Facilitating Repair

Greenberg and Goldman (2019), Clinical Handbook of Emotion-Focused Therapy, Chapter 5

Empty chair for unfinished business Week 13

Alliance rupture and repair and related research Therapeutic alliance and outcome Theory and research on alliance ruptures in EFT

Week 14

Putting it all together: self-evaluation, skill coaching, and feedback

Exercise 11 Video: Greenberg (2007b), Emotion-Focused Therapy Over Time

Exercise 12 Greenberg (2014) Watson and Greenberg (2000)

Exercise 13: Annotated Emotion-Focused Therapy Practice Session Transcript

Exercises 13 and 14

Exercise 14: Mock Emotion-Focused Therapy Sessions Week 15

Additional EFT tasks including experiential focusing, systematic evocative unfolding for problematic reactions, self-soothing, shame and vulnerability

Lecture, video demonstration, and discussiona

Greenberg and Goldman (2019), Clinical Handbook of Emotion-Focused Therapy, Chapters 10, 13–16, 19, and 20

Applications of EFT

Videos: Goldman (2018), Emotion-Focused Therapy for Couples

EFT for couples

Paivio (2014), Emotion-Focused Therapy for Trauma

Working with specific disorders: depression, anxiety, trauma, eating disorders

Elliott (2018), Resolving Problematic Reactions in Emotion-Focused Therapy Timulak (2020), Facilitating Self-Soothing

Final feedback Note. Specific reading or video suggestions are given related to designated topics. a Given the high volume of material in the last class, professors may choose to cover some of this material at any earlier point in the course or build it into an advanced course. The materials listed here cover a complete course of EFT.

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Format of Class Course time is divided between learning EFT theory, observing video demonstrations, and practicing EFT skills: Skills Labs: Skills labs are for practicing EFT skills using the exercises in this book. The exercises use therapy simulations (role-plays) with the following goals: 1. Build trainees’ skill and confidence for using EFT skills with real clients 2. Provide a safe space for experimenting with different therapeutic interventions, without fear of making mistakes 3. Provide plenty of opportunity to explore and “try on” different styles of therapy so that trainees can ultimately discover their own personal, unique therapy style Practice Sessions: Toward the end of the semester (Week 14), trainees will participate in a skills lab in which they do a practice session using the annotated transcript (Exercise 13) or a mock practice session in which the “client” adopts one of the client profiles listed in Exercise 14 or plays themselves as the client. In contrast to highly structured and repetitive deliberate practice exercises, these are unstructured and improvised role-play therapy sessions. Like a jazz rehearsal, mock sessions let trainees practice the art and science of putting psychotherapy skills together in way that is helpful to clients. Practice sessions let trainees 1. Practice using psychotherapy skills responsively 2. Experiment with clinical decision making in an unscripted context 3. Discover their personal therapeutic style 4. Build endurance for working with real clients EFT Skill Practice Each week, students will be assigned reading and skill practice with an assigned practice partner. For the skills practice, trainees will be asked to repeat the exercise they did for that week’s skills lab. Because the professor will not be there to evaluate performance, trainees should instead perform a self-evaluation. Assignments Students are to write two papers: one due at midterm and one due on the last day of class. Some possible topics for the assignments and papers are as follows: • Ask students to perform a practice session of 30 to 45 minutes in length outside of class. Students should record the session. Students are instructed to become as present as possible, empathically attune to the client, and freely use as many of the skills as they see fit in responding to the “client.” Students may choose to transcribe the session. Students will be asked to review their session, providing an analysis of which EFT theories and skills they applied. Students should specifically identify which EFT deliberate practice skills they used and why. Students may also discuss any difficulties they had in applying the skills or facilitating the process. Professors can decide whether they wish to see the session or have the student transcribe it and turn it in. • Explore one aspect of EFT theory, research, or technique. A partial transcript of one of the trainees’ therapy cases with a real client, with discussion from an EFT perspective as well as an analysis and commentary on the use of EFT deliberate practice skills during the session. • Write a reflection paper discussing a skill practice session.

Appendix C

Vulnerability, Privacy, Confidentiality, and Boundaries This course is aimed at developing therapy skills, self-awareness, and interaction skills in an experiential framework and as relevant to clinical work. Using EFT with clients requires balancing emotional vulnerability and openness and simultaneously maintaining appropriate personal boundaries. We will explore and practice this balance as part of learning EFT together. This course is not psychotherapy or a substitute for psychotherapy. Students should interact at a level of self-disclosure that is personally comfortable and helpful to their own learning. Although becoming aware of internal emotional and psychological processes is necessary for a therapist’s development, it is not necessary to reveal all that information to the trainer. It is important for students to sense their own level of safety and privacy. Students are not evaluated on the level of material that they choose to reveal in the class. Multicultural Orientation This course is taught in a multicultural context, defined as “how the cultural worldviews, values, and beliefs of the client and therapist interact and influence one another to co-create a relational experience that is in the spirit of healing” (Davis et al., 2018, p. 3). Multicultural competencies are included in accreditation requirements and Amer­ ican Psychological Association’s (2017b) Multicultural Guidelines: An Ecological Approach to Context, Identity, and Intersectionality. These include multicultural awareness, knowledge, and skills. Throughout this course, students are encouraged to reflect on their own cultural identity and improve their ability to attune with their clients’ cultural identities (Hook et al., 2017). For further in-depth exploration of integrating feminist–multicultural perspectives in EFT, please see Levitt et al. (2019), Chapter 19, in the Clinical Handbook of Emotion-Focused Therapy. This topic will be discussed in Week 11. Confidentiality Due to the nature of the material covered in class, there are many occasions when personal life (self, friends, or family) experience may be pertinent for the learning environment. It cannot be required to share personal experiences, but some may be inclined to do so. Additionally, the content of client case material is sensitive and demands our ethical consideration. To create a safe learning environment that is respectful of client and counselor information and diversity, and to foster open and vulnerable conversation in class, class members are required to agree to strict confidentiality in the classroom and outside the class as well. Revealing Information About Self In accordance with the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2017a), students are not required to disclose personal information. It is, however, recommended to disclose personal material, within comfortable limits, to learn the most from the exercises. Because this class is about developing both interpersonal and EFT competence, following are some important points so that students are fully informed as they make choices to selfdisclose: • Professional activities are affected by personal experiences, beliefs, and values, and these things have a bearing on students’ professional functioning. • Behaviors are influenced by personal experiences, beliefs, and values. Students may be asked to reflect on this in the specifically defined context of encouraging the growth of professional competence for the work environment only.

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• Students choose how much, when, and what to disclose. Students are not penalized for the choice not to share personal information. This course is not psychotherapy. • The learning environment is susceptible to group dynamics much like any other group space; therefore, students may be asked to share their observations and experiences of the class environment with the singular goal of fostering a more inclusive and productive learning environment. Evaluation Self-Evaluation: At the end of the semester (Week 14), trainees will perform a selfevaluation. This will help trainees track their progress and identify areas for further development. The “Guidance for Trainees” section in Chapter 3 of this book highlights potential areas of focus for self-evaluation. Grading Criteria As designed, students would be accountable for the level and quality of their performance in • Readings and discussion in-class • Skills lab (exercises and practice sessions) • Assignments Instructors who adopt this syllabus have latitude deciding how to assess each of these and the differential weighting to give these. Required Readings and Videos Elliott, R. (2018). Resolving problematic reactions in emotion-focused therapy [Video]. American Psychological Association. Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused therapy: The process-experiential approach to change. American Psychological Association. https://doi.org/10.1037/10725-000 Ellison, J. A., Greenberg, L. S., Goldman, R. N., & Angus, L. (2009). Maintenance of gains following experiential therapies for depression. Journal of Consulting and Clinical Psychology, 77(1), 103–112. https://doi.org/10.1037/a0014653 Geller, S. M. (2015). Presence in psychotherapy [Video]. American Psychological Association. Geller, S. M. (2017). A practical guide to cultivating therapeutic presence. American Psycho­ logical Association. https://doi.org/10.1037/0000025-000 Goldman, R. N. (2013). Case formulation in emotion-focused therapy: Addressing unfinished business [Video]. American Psychological Association. Goldman, R. N. (2015). Emotion-focused therapy. In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of research and practice (2nd ed., pp. 319–350). American Psychological Association. Goldman, R. N. (2017). Case formulation in emotion-focused therapy. Person-centered and experiential psychotherapies, 16(2), 85–105. https://doi.org/10.1080/14779757.2017.1330705 Goldman, R. N. (Guest Expert). (2018). Emotion-focused couple therapy. [Film; educational DVD]. American Psychological Association. https://www.apa.org/pubs/videos/4310997.aspx Goldman, R. N., & Greenberg, L. S. (2015). Case formulation in emotion-focused therapy: Cocreating clinical maps for change. American Psychological Association. https://doi.org/ 10.1037/14523-000 Goldman, R. N., Greenberg, L. S., & Angus, L. (2006). The effects of adding specific emotionfocused interventions to the client-centered relationship conditions in the treatment of depression. Psychotherapy Research, 16(5), 537–549. https://doi.org/10.1080/ 10503300600589456 Goldman, R. N., Greenberg, L. S., & Pos, A. E. (2005). Depth of emotional experience and outcome. Psychotherapy Research, 15(3), 248–260. https://doi.org/10.1080/ 10503300512331385188

Appendix C

Greenberg, L. S. (2007a). Emotion-focused therapy for depression [Video]. American Psychological Association. Greenberg, L. S. (2007b). Emotion-focused therapy over time [Video]. American Psychological Association. Greenberg, L. (2014). The therapeutic relationship in emotion-focused therapy. Psychotherapy: Theory, Research, & Practice, 51(3), 350–357. https://doi.org/10.1037/a0037336 Greenberg, L. S. (2015). Emotion-focused therapy: Coaching clients to work through their feelings. American Psychological Association. Greenberg, L. S., & Goldman, R. N. (2019). Clinical handbook of emotion-focused therapy. American Psychological Association. https://doi.org/10.1037/0000112-000 Levitt, H., Minami, T., Greenspan, S. B., Puckett, J. A., Henretty, J. R., Reich, C. M., & Berman, J. S. (2016). How therapist self-disclosure relates to alliance and outcomes: A naturalistic study. Counselling Psychology Quarterly, 29(1), 7–28. https://doi.org/10.1080/ 09515070.2015.1090396 Levitt, H. M., Whelton, W. J., & Iwakabe, S. (2019). Integrating feminist–multicultural perspectives into emotion-focused therapy. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy (pp. 425–444). American Psychological Association. https://doi.org/10.1037/0000112-019 Martin, D. (2015). Counseling skills and therapy (2nd ed.). Brooks/Cole. Paivio, S. C. (2014). Emotion-focused therapy for trauma [Video]. American Psychological Association. Pascual-Leone, A. (2009). Dynamic emotional processing in experiential therapy: Why the only way out is through. Journal of Consulting and Clinical Psychology, 77(1), 113–126. https://doi.org/10.1037/a0014488 Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional processing in experiential therapy: Why “the only way out is through.” Journal of Consulting and Clinical Psychology, 75(6), 875–887. https://doi.org/10.1037/0022-006X.75.6.875 Rice, L. N. (1974). The evocative function of the therapist. In L. N. Rice & D. A. Wexler (Eds.), Innovations in client-centered therapy (pp. 289–311). John Wiley & Sons. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95–103. https://doi.org/10.1037/h0045357 Rogers, C. R. (1975). Empathic: An unappreciated way of being. The Counseling Psychologist, 5(2), 2–10. https://doi.org/10.1177/001100007500500202 Timulak, L. (2020). Generating self-compassion in emotion-focused therapy [Video]. American Psychological Association. Watson, J. C. (2013). Emotion-focused therapy in practice: Working with grief and abandonment [Video]. American Psychological Association. Watson, J. C., Goldman, R. N., & Vanaerschot, G. (1997). Empathic: A post-modern way of being. In L. S. Greenberg, J. C. Watson, & G. Lietaer (Eds.), Handbook of experiential psychotherapy. Guilford Press. Watson, J. C., Gordon, L. B., Stermac, L., Kalogerakos, F., & Steckley, P. (2003). Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression. Journal of Consulting and Clinical Psychology, 71(4), 773–781. https://doi.org/10.1037/0022-006X.71.4.773 Watson, J. C., & Greenberg, L. S. (2000). Alliance ruptures and repairs in experiential therapy. Journal of Clinical Psychology, 56(2), 175–186. https://doi.org/10.1002/(SICI)10974679(200002)56:23.0.CO;2-5

Optional Reading Greenberg, L. S. (2015). Emotion-focused therapy: Coaching clients to work through their feelings. American Psychological Association. https://doi.org/10.1037/14692-000 Greenberg, L. S., & Goldman, R. N. (2008). Emotion-focused couples therapy: The dynamics of emotion, love, and power. American Psychological Association. https://doi.org/10.1037/ 11750-000 Greenberg, L. S., & Paivio, S. (1997). Working with the emotions. Guilford Press.

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Greenberg, L. S., & Tomescu, L. (2017). Supervision essentials for emotion-focused therapy. American Psychological Association. https://doi.org/10.1037/15966-000 Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression. Guilford Press. https://doi.org/10.1037/11286-000 Greenberg, L. S., Watson, J. C., & Lietaer, G. (Eds.). (1998). Handbook of experiential psychotherapy. Guilford Press. Paivio, S. C., & Pascual-Leone, A. (2010). Emotion-focused therapy for complex trauma. American Psychological Association. Timulak, L., & McElvaney, J. (2018). Transforming generalized anxiety: An emotion-focused approach. Routledge. Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2007). Case studies in emotion-focused treatment of depression. American Psychological Association. Watson, J. C., & Greenberg, L. S. (2017). Emotion-focused therapy for generalized anxiety disorder. American Psychological Association. https://doi.org/10.1037/0000018-000

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and Education in Professional Psychology, 3(Suppl. 4), S5–S26. https://doi.org/10.1037/ a0015832 Geller, S. M. (2015). Presence in psychotherapy [Video]. American Psychological Association. Geller, S. M. (2017). A practical guide to cultivating therapeutic presence. American Psycho­ logical Association. https://doi.org/10.1037/0000025-000 Geller, S. M. (2019). Therapeutic presence: The foundation for effective emotion-focused therapy. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy (pp. 129–146). American Psychological Association. https://doi.org/10.1037/0000112-006 Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: A mindful approach to effective psychotherapy. American Psychological Association. https://doi.org/10.1037/13485-000 Geller, S. M., & Porges, S. W. (2014). Therapeutic presence: Neurophysiological mechanisms mediating feeling safe in therapeutic relationships. Journal of Psychotherapy Integration, 24(3), 178–192. https://doi.org/10.1037/a0037511 Gendlin, E. T. (1981). Focusing. Bantam. Gendlin, E. T. (1996). Focusing-oriented psychotherapy: A manual of the experiential method. Guilford Press. Gendlin, E. T., & Beebe, J. (1968). Experiential groups. In G. M. Gazda (Ed.), Innovations to group psychotherapy (pp. 190–206). Charles C. Thomas. Goldberg, S. B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W. T., Whipple, J. L., Miller, S. D., & Wampold, B. E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy, 53, 367–375. https://doi.org/10.1037/pst0000060 Goldberg, S. B., Rousmaniere, T. G., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology, 63(1), 1–11. https://doi.org/10.1037/cou0000131 Goldman, R. (1991). The experiential therapy adherence measure [Unpublished master’s thesis]. York University, Toronto, Ontario, Canada. Goldman, R. N. (2013). Case formulation in emotion-focused therapy: Addressing unfinished business [Video]. American Psychological Association. Goldman, R. N. (2015). Emotion-focused therapy. In D. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of research and practice (2nd ed., pp. 319–350). American Psychological Association. Goldman, R. N. (2017). Case formulation in emotion-focused therapy. Person-centered and experiential psychotherapies, 16(2), 88–105. https://doi.org/10.1080/14779757.2017. 1330705 Goldman, R. N. (Guest Expert). (2018). Emotion-focused couple therapy. [Film; educational DVD]. American Psychological Association. https://www.apa.org/pubs/videos/4310997. aspx Goldman, R. N., & Greenberg, L. S. (2015). Case formulation in emotion-focused therapy: Co-creating clinical maps for change. American Psychological Association. https:// doi.org/10.1037/14523-000 Goldman, R. N., Greenberg, L., & Angus, L. (2006). The effects of adding specific emotionfocused interventions to the client-centered relationship conditions in the treatment of depression. Psychotherapy Research, 16(5), 537–549. https://doi.org/10.1080/ 10503300600589456 Goldman, R. N., Greenberg, L. S., & Pos, A. E. (2005). Depth of emotional experience and outcome. Psychotherapy Research, 15(3), 248–260. https://doi.org/10.1080/ 10503300512331385188 Goodyear, R. K. (2015). Using accountability mechanisms more intentionally: A framework and its implications for training professional psychologists. American Psychologist, 70(8), 736–743. https://doi.org/10.1037/a0039828 Goodyear, R. K., & Nelson, M. L. (1997). The major formats of psychotherapy supervision. In C. E. Watkins, Jr. (Ed.), Handbook of psychotherapy supervision (pp. 328–344). John Wiley & Sons.

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203

Index

A Accountability, 172 Active effort, 173 Addressing ruptures and facilitating repair (exercise 12), 137–146 advanced-level client statements, 143 beginner-level client statements, 141 difficulty level, 137–138 EFT skills in, 14 examples, 138–139 instructions, 140 intermediate-level client statements, 142 preparation, 137 skill criteria, 140 therapist response examples, 144–146 Advanced-level client statements addressing ruptures and facilitating repair (exercise 12), 143 empathic affirmation and validation (exercise 3), 48, 50 empathic conjectures (exercise 8), 98 empathic evocations (exercise 7), 88, 90 empathic explorations (exercise 6), 78, 80 empathic understanding (exercise 2), 38, 40 exploratory questions (exercise 4), 58, 60 marker recognition and chair work task setup (exercise 11), 130 providing treatment rationale for EFT (exercise 5), 68, 71 for therapist self-awareness (exercise 1), 31 Affect, empathic attunement to, 12 Affirmation. See Empathic affirmation and validation (exercise 3) Afraid client statements, 68. See also Scared client statements Alliance(s) building skills for, 11–12 ruptures in, 137. See also Addressing ruptures and facilitating repair (exercise 12) trainee-trainer, 176 Angry client statements addressing ruptures and facilitating repair (exercise 12), 142, 143 empathic affirmation and validation (exercise 3), 46, 48 empathic conjectures (exercise 8), 96 empathic evocations (exercise 7), 86 empathic explorations (exercise 6), 76 empathic understanding (exercise 2), 37 exploratory questions (exercise 4), 56 marker recognition and chair work task setup (exercise 11), 130

self-disclosure (exercise 10), 118 staying in contact in the face of intense affect (exercise 9), 106–108 therapist self-awareness (exercise 1), 30 Annotated EFT practice session transcript (exercise 13), 149–153 example, 150–153 importance of, 167–168 instructions, 149–150 Annoyed client statements, 117, 142 Anxiety, 159 Anxious client statements in marker recognition and chair work task setup (exercise 11), 128, 129 in therapist self-awareness (exercise 1), 29 Ashamed client statements addressing ruptures and facilitating repair (exercise 12), 142 empathic affirmation and validation (exercise 3), 47 empathic conjectures (exercise 8), 96 empathic evocations (exercise 7), 86, 88 empathic explorations (exercise 6), 77, 78 exploratory questions (exercise 4), 56, 58 providing treatment rationale for EFT (exercise 5), 67 in therapist self-awareness (exercise 1), 30 Attunement to affect, empathic, 12 B Beginner-level client statements addressing ruptures and facilitating repair (exercise 12), 141 empathic affirmation and validation (exercise 3), 46, 49 empathic conjectures (exercise 8), 96 empathic evocations (exercise 7), 86, 89 empathic explorations (exercise 6), 76, 79 empathic understanding (exercise 2), 36, 39 exploratory questions (exercise 4), 56, 59 marker recognition and chair work task setup (exercise 11), 128 providing treatment rationale for EFT (exercise 5), 66, 69 for therapist self-awareness (exercise 1), 29 Betrayed client statements empathic conjectures (exercise 8), 97 empathic evocations (exercise 7), 87 exploratory questions (exercise 4), 57 Body posture, 14–15

205

206

C Chair work. See Marker recognition and chair work task setup (exercise 11) Client outcomes, 175 Client statements. See also specific emotional types advanced-level. See Advanced-level client statements beginner-level. See Beginner-level client statements intermediate-level. See Intermediate-level client statements making, easier, 179–180 making, harder, 180–181 Coexplorations, 73 Coker, Jerry, 7–8 Competence, defined, 5 Conceptual learning, 14 Concerned client statements, 30 Confused client statements empathic affirmation and validation (exercise 3), 47, 48 empathic conjectures (exercise 8), 98 empathic evocations (exercise 7), 88 empathic explorations (exercise 6), 76–78 in empathic understanding (exercise 2), 37, 38 exploratory questions (exercise 4), 58 providing treatment rationale for EFT (exercise 5), 68 Conjectures, empathic. See Empathic conjectures (exercise 8) Corrective feedback, 171 Curious client statements, 66, 116 Customization, exercise, 166–167 D da Vinci, Leonardo, 6 Davis, Miles, 8 Dazed client statements, 78 Declarative knowledge, procedural vs., 8–9 Deliberate practice additional guidance for, 165–176 cycle of, 7 exercises to train for, 4–5. See also EFT deliberate practice exercises and responsive treatment, 168–169 role of, in EFT training, 6–7, 15–16 Deliberate Practice Reaction Form, 26, 167 Depressed client statements, 47 Desperate client statements, 48 Detached client statements, 77 Difficulty assessing, 167, 179–181 continually adjusting, 167 practicing at the right, 171–174 Disappointed client statements, 108 Distrustful clients, 160 Distrustful client statements, 88, 141 Distrusting client statements, 31, 77 E Effort, active, 173 EFT. See Emotion-focused therapy EFT deliberate practice exercises additional guidance for using, 165–176 addressing ruptures and facilitating repair (exercise 12), 137–146 annotated EFT practice session transcript (exercise 13), 149–153 empathic affirmation and validation (exercise 3), 43–50 empathic conjectures (exercise 8), 93–100

Index

empathic evocations (exercise 7), 83–90 empathic explorations (exercise 6), 73–80 empathic understanding (exercise 2), 33–40 exploratory questions (exercise 4), 53–60 instructions for, 19–21 marker recognition and chair work task setup (exercise 11), 123–134 mock EFT sessions (exercise 14), 155–161 providing treatment rationale for EFT (exercise 5), 63–71 self-disclosure (exercise 10), 113–120 staying in contact in the face of intense affect (exercise 9), 103–110 therapist self-awareness (exercise 1), 25–31 EFT skills, 11–16 deliberate practice exercises for, 4, 13–14 rational and alliance building skills, 11–13 technical and process-diagnostic skills, 13 vocal tone, facial expression, and body posture, 14–15 Elliott, R., 11, 16, 124 Embarrassed client statements, 38 Emotion-focused therapy (EFT) role of deliberate practice in training for, 15–16 sample syllabus for teaching, 187–194 skills for, 11–16 theoretical background of, 9–11 Emotion regulation, 10 Emotion transformation, 10 Emotion utilization, 10 Empathic affirmation and validation (exercise 3), 38, 43–50 advanced-level client statements, 48 in annotated EFT practice session transcript (exercise 13), 152–153 beginner-level client statements, 46 difficulty level, 43 EFT skills in, 13 examples, 44, 184 instructions, 45 intermediate-level client statements, 47 optional variation for, 45 preparation, 43 skill criteria, 45 therapist response examples, 49–50 Empathic attunement to affect, 12 Empathic conjectures (exercise 8), 93–100 advanced-level client statements, 98 in annotated EFT practice session transcript (exercise 13), 152–153 beginner-level client statements, 96 difficulty level, 93 EFT skills in, 14 examples, 94, 184 instructions, 95 intermediate-level client statements, 97 optional variation for, 95 preparation, 93 skill criteria, 95 therapist response examples, 99–100 Empathic evocations (exercise 7), 83–90 advanced-level client statements, 88 in annotated EFT practice session transcript (exercise 13), 151 beginner-level client statements, 86 difficulty level, 83 EFT skills in, 14 examples, 84, 184

207

Index

instructions, 85 intermediate-level client statements, 87 optional variation for, 85 preparation, 83 skill criteria, 85 therapist response examples, 89–90 Empathic explorations (exercise 6), 73–80 advanced-level client statements, 78 in annotated EFT practice session transcript (exercise 13), 150, 152, 153 beginner-level client statements, 76 difficulty level, 73 EFT skills in, 14 empathic conjectures vs., 93 examples, 74, 184 instructions, 75 intermediate-level client statements, 77 optional variation for, 75 preparation, 73 skill criteria, 75 therapist response examples, 79–80 Empathic responses, 16, 183–184. See also Therapist response examples Empathic understanding (exercise 2), 33–40 in annotated EFT practice session transcript (exercise 13), 150 beginner-level client statements, 36 difficulty level, 33 EFT skills in, 13 examples, 34, 184 instructions, 35 optional variation for, 35 preparation, 33 skill criteria, 35 therapist response examples, 39 Ericsson, K. Anders, 6 Evocations, empathic. See Empathic evocations (exercise 7) Excited client statements, 76 Explorations, empathic. See Empathic explorations (exercise 6) Exploratory questions (exercise 4), 53–60 advanced-level client statements, 58 in annotated EFT practice session transcript (exercise 13), 150 beginner-level client statements, 56 difficulty level, 53 examples, 53–54 example therapist responses, 59–60 instructions, 55 intermediate-level client statements, 57 optional variation for, 55 preparation, 53 skill criteria, 55 F Facial expression, 14–15 Facilitating repair. See Addressing ruptures and facilitating repair (exercise 12) Fearful client statements, 48, 118. See also Scared client statements Feedback in addressing ruptures and facilitating repair (exercise 12), 140 corrective, 171 elements of, 21 in empathic affirmation and validation (exercise 3), 45 for empathic conjectures (exercise 8), 95 for empathic explorations (exercise 6), 75

in empathic understanding (exercise 2), 35 in exploratory questions (exercise 4), 55 in marker recognition and chair work task setup (exercise 11), 127 for providing treatment rationale for EFT (exercise 5), 65 in self-disclosure (exercise 10), 115 for staying in contact in the face of intense affect (exercise 9), 105 in therapist self-awareness, 28 for trainers, 170–171 Final evaluations, 21 Flat client statements, 129 Flexibility, 166 Flirty client statements empathic explorations (exercise 6), 78 staying in contact in the face of intense affect (exercise 9), 108 in therapist self-awareness (exercise 1), 31 Flow, 173 Frustrated client statements empathic conjectures (exercise 8), 96 empathic evocations (exercise 7), 86 in empathic understanding (exercise 2), 38 G Gladwell, Malcolm, 6–7 Goldman, Rhonda, 11, 15, 16, 21, 149 Greenberg, Leslie, 11, 15 Grief, 158–159 Guarded client statements, 78 Guilty client statements addressing ruptures and facilitating repair (exercise 12), 141 empathic affirmation and validation (exercise 3), 46 marker recognition and chair work task setup (exercise 11), 129, 130 staying in contact in the face of intense affect (exercise 9), 106–108 Guy, J. D., 176 H Haggerty, G., 171 Hesitant client statements, 116, 141 Hilsenroth, M. J., 171 Hopeful client statements, 29, 67 Hopeless client statements empathic conjectures (exercise 8), 98 empathic evocations (exercise 7), 87 in empathic understanding (exercise 2), 37 exploratory questions (exercise 4), 57 in therapist self-awareness (exercise 1), 31 Horvath, A. O., 168 Hurt client statements, 56 I Improvisations, psychotherapy as, 7 In denial client statements, 88, 98 Instrumental emotions, 10 Intense affect. See Staying in contact in the face of intense affect (exercise 9) Intermediate-level client statements addressing ruptures and facilitating repair (exercise 12), 142 empathic affirmation and validation (exercise 3), 47, 49 empathic conjectures (exercise 8), 97 empathic evocations (exercise 7), 87, 89

208

empathic explorations (exercise 6), 77, 79 empathic understanding (exercise 2), 37, 39 exploratory questions (exercise 4), 57, 59 marker recognition and chair work task setup (exercise 11), 129 providing treatment rationale for EFT (exercise 5), 67, 70 for therapist self-awareness (exercise 1), 30 Interpersonal skills, 12, 104 Intrapersonal skills, 12, 104 J Jazz, 7–8, 155, 167 Jordan, Michael, 6 K Kasparov, Garry, 6 Knowledge, procedural vs. declarative, 8–9 L Late clients, 118 Learning conceptual, 14 simulation-based mastery, 8 state-dependent, 8 Learning Emotion-Focused Therapy (Elliott), 124 Loneliness, 159 Lost client statements, 76 Loving client statements empathic affirmation and validation (exercise 3), 48 staying in contact in the face of intense affect (exercise 9), 107 in therapist self-awareness (exercise 1), 29 M Macho client statements empathic conjectures (exercise 8), 98 empathic evocations (exercise 7), 88 exploratory questions (exercise 4), 58 Marker recognition and chair work task setup (exercise 11), 123–134 advanced-level client statements, 130 in annotated EFT practice session transcript (exercise 13), 151 beginner-level client statements, 128 and building technical skills, 13 difficulty level, 123–124 EFT skills in, 14 examples, 125–126 instructions, 124, 127 intermediate-level client statements, 129 preparation, 123 skill criteria, 127 therapist response examples, 131–134 Memory, procedural, 5, 167 Mock EFT sessions (exercise 14), 155–161 about, 155–156 client profiles for, 158–161 evaluation in, 158 importance of, 167–168 preparation, 156 procedure, 156–157 varying level of challenge in, 157–158 Monitoring training results, 175 Mood lability, 160–161 Mozart, 6

Index

N Nervous client statements empathic affirmation and validation (exercise 3), 46 marker recognition and chair work task setup (exercise 11), 130 in therapist self-awareness (exercise 1), 29 Norcross, J. C., 176 O Obsessed client statements empathic conjectures (exercise 8), 97 empathic evocations (exercise 7), 87 exploratory questions (exercise 4), 57 Optimistic client statements, 36 Orientation, 20 Orlinsky, D. E., 176 Outcome accountability, 172 Outliers (Gladwell), 6–7 Overadherence, 168 Overwhelmed client statements, 48 P Personal development, 175 Playfulness, 174 Practice session length, 5 Practice session transcript. See Annotated EFT practice session transcript (exercise 13) Preparation, exercise, 20 Primary adaptive emotions, 10 Primary maladaptive emotions, 10 Procedural knowledge, 8–9 Procedural memory, 5, 167 Process accountability, 172 Process-diagnostic skills, 13 Process supervision, 15, 168 Providing treatment rationale for EFT (exercise 5), 63–71 advanced-level client statements, 68 in annotated EFT practice session transcript (exercise 13), 151, 153 beginner-level client statements, 66 difficulty level, 63 EFT skills in, 13–14 examples, 64 instructions, 65 intermediate-level client statements, 67 preparation, 63 skill criteria, 65 therapist response examples, 69 Proximal development, zone of, 171, 172–173 Psychotherapy training declarative vs. procedural knowledge, 8–9 deliberate practice in, 6–9 simulation-based mastery learning, 8 Q Questions, exploratory. See Exploratory questions (exercise 4) R Rage client statements, 48 Reaction Form, 169, 170, 180 Realistic emotional stimuli, 165–166 Rehearsals, 167, 171 Relational skills, 11–12 Responses, empathic, 16, 183–184. See also Therapist response examples

209

Index

Responsive treatment, 168–169 Rice, Laura, 15 Rogers, C. R., 15 Role-play for addressing ruptures and facilitating repair (exercise 12), 140 for empathic affirmation and validation (exercise 3), 45 in empathic conjectures (exercise 8), 95 in empathic explorations (exercise 6), 75 in empathic understanding (exercise 2), 35 in exploratory questions (exercise 4), 55 goal of, 20–21 making client statements easier or harder in, 181 for marker recognition and chair work task setup (exercise 11), 127 in mock EFT sessions. See Mock EFT sessions (exercise 14) in providing treatment rationale for EFT (exercise 5), 65 realistic emotional stimuli in, 165–166 for self-disclosure (exercise 10), 115 in staying in contact in the face of intense affect (exercise 9), 105 for therapist self-awareness, 26, 28 Ronnestad, M. H., 176 Rousmaniere, T. G., 13 S Sad client statements empathic affirmation and validation (exercise 3), 46–48 empathic conjectures (exercise 8), 96 empathic evocations (exercise 7), 86 empathic explorations (exercise 6), 76 in empathic understanding (exercise 2), 36 exploratory questions (exercise 4), 56–58 marker recognition and chair work task setup (exercise 11), 128–130 self-disclosure (exercise 10), 116, 117 staying in contact in the face of intense affect (exercise 9), 106–108 in therapist self-awareness (exercise 1), 30 Sarcasm, 159–160 Scared client statements empathic affirmation and validation (exercise 3), 46, 47 empathic explorations (exercise 6), 76 in empathic understanding (exercise 2), 38 marker recognition and chair work task setup (exercise 11), 128 Scripted responses, 21 Secondary reactive emotions, 10 Self-awareness, therapist. See Therapist self-awareness (exercise 1) Self-blaming client statements, 68, 116 Self-care, 169 Self-disclosure (exercise 10), 113–120 and addressing alliance ruptures, 138 advanced-level client statements, 118 in annotated EFT practice session transcript (exercise 13), 153 beginner-level client statements, 116 difficulty level, 113 EFT skills in, 14 examples, 114 instructions, 115 intermediate-level client statements, 117 preparation, 113 skill criteria, 115 therapist response examples, 118–119

Self-Evaluation Form, 21 Self-evaluative split, 123, 124 Self-harm, 160–161 Self-interruptive split, 123, 124 Shameful client statements empathic affirmation and validation (exercise 3), 48 empathic evocations (exercise 7), 87 marker recognition and chair work task setup (exercise 11), 129 staying in contact in the face of intense affect (exercise 9), 107 Simulation-based mastery learning, 8 Skeptical clients, 159–160 Skeptical client statements providing treatment rationale for EFT (exercise 5), 67, 68 self-disclosure (exercise 10), 118 in therapist self-awareness (exercise 1), 31 Skill(s) criteria for exercise. See Skill criteria EFT, in deliberate practice, 11–16 interpersonal, 12, 104 intrapersonal, 12, 104 process-diagnostic, 13 relational, 11–12 technical, 13 Skill criteria addressing ruptures and facilitating repair (exercise 12), 140 empathic affirmation and validation (exercise 3), 45 empathic conjectures (exercise 8), 95 empathic evocations (exercise 7), 85 empathic explorations (exercise 6), 75 empathic understanding (exercise 2), 35 exploratory questions (exercise 4), 55 marker recognition and chair work task setup (exercise 11), 127 providing treatment rationale for EFT (exercise 5), 65 self-disclosure (exercise 10), 115 staying in contact in the face of intense affect (exercise 9), 105 therapist self-awareness (exercise 1), 28 Slow client statements, 129 Splits, 123–124 State-dependent learning, 8 Staying in contact in the face of intense affect (exercise 9), 103–110 advanced-level client statements, 108 beginner-level client statements, 106 and building intrapersonal skills, 12 difficulty level, 103–104 EFT skills in, 14 instructions, 105 intermediate-level client statements, 107 preparation, 103 skill criteria, 105 therapist response examples, 109–110 Stern client statements, 143 Stiles, W. B., 168 Stoned client statements, 30 Stressed client statements, 36, 37 Supervision, process, 15, 168 Syllabus, sample, 184–194 T Taking breaks, 174 Technical skills, 13 “10,000-hour rule,” 6–7 Tense client statements, 128, 130 Therapeutic presence, 12 Therapeutic style, 167

210

Therapist response examples addressing ruptures and facilitating repair (exercise 12), 144–146 empathic affirmation and validation (exercise 3), 49–50 empathic conjectures (exercise 8), 99–100 empathic evocations (exercise 7), 89–90 empathic explorations (exercise 6), 79–80 empathic understanding (exercise 2), 39–40 exploratory questions (exercise 4), 59–60 marker recognition and chair work task setup (exercise 11), 131–134 providing treatment rationale for EFT (exercise 5), 69–71 self-disclosure (exercise 10), 118–119 staying in contact in the face of intense affect (exercise 9), 109–110 Therapist self-awareness (exercise 1), 25–31 advanced-level client statements, 31 in annotated EFT practice session transcript (exercise 13), 150 beginner-level client statements, 29 and building intrapersonal skills, 12 difficulty level, 25 EFT skills in, 13 examples, 26–27 intermediate-level client statements, 30 preparation, 25 skill criteria, 28 special instructions, 26 Time frames, exercise, 20 Tone, vocal. See Vocal tone Trainees guidance for, 172–176 privacy of, 169–170 well-being of, 169 Trainee–trainer alliance, 176 Trainer Evaluation Form, 21 Trainers complex reactions toward, 176 role of, in exercises, 20 self-evaluation for, 170–172

Index

“Training in Experiential Therapy” (Greenberg and Goldman), 15 Training results, monitoring, 175 Transcript, annotated EFT practice session. See Annotated EFT practice session transcript (exercise 13) Trapped client statements, 98 Treatment rationale. See Providing treatment rationale for EFT (exercise 5) U Uncomfortable client statements addressing ruptures and facilitating repair (exercise 12), 143 empathic explorations (exercise 6), 77 self-disclosure (exercise 10), 117 in therapist self-awareness (exercise 1), 29 Understanding, empathic. See Empathic understanding (exercise 2) Unfinished business, 123, 124 Unsure client statements, 57 V Validation. See Empathic affirmation and validation (exercise 3) Vygotsky, Lev, 173 Vocal tone, 14–15, 150, 157, 174 W Warm client statements, 106 Watson, J. C., 16 Weepy client statements, 128 Worried client statements addressing ruptures and facilitating repair (exercise 12), 141, 142 in empathic understanding (exercise 2), 37, 38 Worry/catastrophizing split, 124 Worthless client statements empathic conjectures (exercise 8), 97 empathic evocations (exercise 7), 87 exploratory questions (exercise 4), 57

About the Authors Rhonda N. Goldman, PhD, is a professor at The Chicago School of Professional Psychology in Chicago and president of EmotionFocused Therapy, Chicago, where she practices emotionfocused therapy (EFT) for individuals and couples. She also conducts training workshops internationally, having traveled widely in Europe, Asia, and North America. She has authored or edited multiple books on EFT for both individuals and couples with the American Psychological Association (APA), including the Clinical Handbook of Emotion-Focused Therapy (2019) and Case Formulation in Emotion-Focused Therapy (2015), which has a companion instructional video by the same title, and EmotionFocused Couples Therapy (2008), which also has a companion instructional video with the same title (2018). She received the 2011 Carmi Harari Early Career Award from APA Division 32 (Society for Humanistic Psychology). She is a coeditor of the journal Person-Centered and Experiential Psychotherapies. Dr. Goldman is a founding board member of the International Society for Emotion Focused Therapy. Visit http:// www.iseft.org. Alexandre Vaz, MSc, is a clinician, professor, and psychotherapy researcher at the ISPA–University Institute in Lisbon, Portugal, and cofounder of the Deliberate Practice Institute. He has held multiple committee roles for the Society for Psychotherapy Research (SPR) and the Society for the Exploration of Psychotherapy Integration, including serving as editor of The Integrative Therapist newsletter and organizer and host of SPR’s webinar series. Dr. Vaz is also the founder and host of Psychotherapy Expert Talks, an acclaimed interview series with distinguished psychotherapists and therapy researchers.

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Tony Rousmaniere, PsyD, is a licensed psychologist on the clinical faculty at the University of Washington Department of Psychiatry and Behavioral Sciences in Seattle, where he also maintains a private practice. His research focus is clinical supervision and training for psychotherapists and graduate students. He hosts the clinical training website https:// www.dpfortherapists.com/. Dr. Rousmaniere’s work has been featured in mainstream press outlets, such as The Atlantic. In 2018, he won the Early Career Award from the Society for the Advancement of Psychotherapy (American Psychological Association [APA] Division 29) and the Outstanding Publication of the Year Award for the Cycle of Excellence from the Society of Counseling Psychology (APA Division 17).