Early Phase of Therapy: Establishing Emotional Safety and a Rationale to Work on Emotion
In the early phase of treatment in EFT the therapist attends to, empathizes with, and validates the client’s feelings and current sense self. A rationale to working with emotion is also provided in this phase. In these early sessions the therapist encourages an awareness of the client’s internal experience and collaboratively focuses on the underlying origins of the client’s presenting issues as the therapist listens to the client’s stories and learns what brought them to therapyIn this first phase, ensuring that the client feels safe during the therapy and can regulate themselves between sessions is important.
In the first session John speaks about feeling that he does not know how to express himself in a healthy way and believes, “it must be because of my childhood, it was so awful!” In exploring this, John goes into some childhood narratives about his father who was physically abusive and highly critical of him. The therapist provides a rationale about the importance of exploring the impact of John’s childhood on him, given that he expressed that he felt it was the source of his depression and problems. John agrees that this is important, but conveys that he is afraid to go into his past for fear of losing control emotionally and being “engulfed” by it. He states that he needs to know that he was going to be okay to go there. John generally is overcontrolled or regulated in his emotional expression, however when he tries to talk about his father or his painful childhood, he appears overwhelmed and starts to cry. When asked what he is experiencing, he eventually replies through his tears, “I don’t know.” This overwhelming, unclear, and undifferentiated state of emotional pain in which clients are emotionally activated but are not able to identify the cause of their suffering or describe a sense of direction for understanding and resolving their concerns is common of the early phase of therapy. It is viewed as a state of global distress that needs to be regulated. Knowing when to activate and when to regulate emotion is an important skill in EFT and refers to the principle of emotional change called emotion regulation which specifies that an emotion needs to be regulated to use it productively as when emotional activation is too high, emotions can be distressing and interfere with a client’s ability to cope (Pascual-Leone & Greenberg, 2007).
When John shifts into this state of distress when talking about his father, the therapist assesses that he needs some help with regulation and responds empathically to John and offers a lot of relational support as well as a suggestion for deliberate regulation by asking him to breathe: “These are very important tears, and they are welcome here, you are not alone in this. Can you take a few breaths?…. Can I help you put words to what’s happening inside?… I can imagine that there’s so much pain when you think about your childhood…” To this end, the therapist provided experiential teaching about the importance of being able to calm himself when he was feeling distressed and introduced a guided safe place exercise: “Imagine a safe place where you can go to when things feel overwhelming, and no one can hurt you there. You feel safe and protected and relaxed….” This was an interactive intervention as the therapist was checking in with John moment-by-moment, to see how he was doing and once he described feeling calm, relaxed, and safe, the therapist helped John deepen the feeling of safety and calm in his body by getting him to stay with it and describe it. Although John was able to do the intervention successfully and regulate himself, he reported that he was not able to think of a specific safe place to go to because he never had one before, but rather he said that he felt safe and calm because of the intervention. The therapist was encouraging and highlighted how he could find a safe place during the intervention and suggested practice homework alongside experiential teaching in the form of a rationale:
T: It is important to be able to calm yourself when you are feeling shaky or overwhelmed, especially as we go into some of these painful childhood memories that you have identified as being the source of your problems. You were able to experience feeling safe and calm in here with me.
C: Yes, that was helpful.
T: Since you have never had one before, I think it would be very helpful if you could come up with a specific safe place that you can go to when needed, both in our sessions and outside of our sessions. It can be entirely imaginary, but it’s a specific place where you can feel safe, relaxed, and calm. It can be anywhere. Some people think of a place in childhood they have been, others have even used a place they have liked from a favorite movie. Is that something that you think you might be able to do on your own?
C: I think so.
T: Well, see if it fits over the course of the week, and if it doesn’t feel right to do that on your own, then that’s okay, we can work on this together next week. And if you are able to think of a safe place, see if it fits to try this exercise that we did, of imagining bringing that vulnerable part to a safe place. Does it make sense why this would be helpful?
C: Yes, if I could do that on my own that would be good. I am willing to try that.
T: Is there a quiet place you could go to in your house, where you could imagine doing this…
In this example, the proposed homework, was related to the in-session experiential work, naming a specific new safe place. In addition, practice homework of imagining bringing the vulnerable part of him to a safe place was suggested to strengthen and carry forward the in-session work in which John experienced feeling safe. What is notable is that the therapist engaged in experiential teaching prior to proposing homework, giving a rationale about why it was important for John to have a specific safe place. Furthermore, the therapist gave examples of types of safe places to make the proposed exercise more concrete. Finally, the homework was offered in an encouraging and non-imposing manner communicating to John that if it did not feel right for him to do it alone, that he could work on it with the therapist in the next session. Asking for some specificity about how and where between-session work can take place increases success of the task as it is tailored to the unique situation of the client and when the client endeavors to do the task, it seems more feasible. Following the session, John completed a post-session evaluation measure where clients are asked: Was the session helpful? Did anything change or shift? If so, what was it? In response to these questions, John indicated on the post-session form that the session was extremely helpful, and that there was an important change during the session. In writing about what changed, he wrote, “This was the first time that I felt safe, and this felt very significant”.
In the next session, the therapist checked in with John to see what his experience was in approaching the between-session proposed exercise. He reported that he was able to think of a safe place, a peaceful island, which he was able to describe with a lot of detail, and that over the course of the week he imagined going there a few times, and that it felt good. This safe place ended up being a place that John returned to outside of the therapy sessions, often without being directed by the therapist, as well as in-session with the therapist as needed.
In the early sessions, subsequent to exploring John’s emotions with him in-session and providing experiential teaching about the importance of listening to his emotions, it was suggested that he may benefit from trying to be aware of his emotions outside of the sessions and throughout the course of therapy by keeping an emotion diary where he could try to be aware of his feelings and write things down that he may choose to share in therapy. Throughout the therapy, John refers to things that he writes in his emotion diary and shares them with the therapist, sometimes new important feelings, and reflections. An emotion diary is helpful because it increases a client’s awareness of their emotions outside of the sessions.
Additionally, part of promoting work on emotion involves helping clients foster an attitude that is welcoming, curious, and interested in their emotions, recognizing that their emotions can provide them with helpful information. The EFT therapist embodies an attitude towards emotion that is curious, interested, caring, and accepting which is fundamental in helping clients turn their attention to and stay with their internal experiences, especially because it may be difficult if their emotions have been the source of their pain and suffering. Prior to in-session work, the therapist provides John with a rationale about the importance of being curious and accepting towards one’s emotions and guides him in an intervention to pay attention to his emotions in an accepting way. Following this, the therapist suggests that it would be beneficial to try to practice this attitude when he is attending to his emotions outside of the session, particularly when writing in his emotion diary. The emotion diary and the EFT attitude towards emotion fits with the emotion utilization principles of awareness, expression, and reflection of emotion.