Changing Emotion

with Emotion
Changing Emotion
with Emotion
a practitioner’s guide

Leslie S. Greenberg
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Title: Changing emotion with emotion : a practitioner’s guide / by Leslie S. Greenberg.
Description: Washington, DC : American Psychological Association, [2021] |
  Includes bibliographical references and index.
Identifiers: LCCN 2020048842 (print) | LCCN 2020048843 (ebook) |
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Subjects: LCSH: Emotions. | Psychotherapy.
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10 9 8 7 6 5 4 3 2 1
Contents

Introduction: Working With Emotion in Psychotherapy 3

I. UNDERSTANDING THE FUNDAMENTALS 15

1. Emotion Theory 17
2. Research on Emotional Change 39
3. Changing Emotion With Emotion 59
4. Essential Therapist Skills for Practicing Emotion-Based
Approaches 91

II. ARRIVING AT EMOTION 113

5. Empathic Attunement to Affect 115

6. Focusing on Bodily Feelings: When Words Are Not Enough 143
7. Blocks to Emotion 161
8. Unblocking Emotion 187

III. LEAVING EMOTION 217

9. Working With Needs 219

10. Reexperiencing the Past in the Present 243
11. Emotion Regulation 279
12. Narrative and Emotion 309

Looking Ahead:  A Unified Approach to Psychotherapy 323

v
vi • Contents

References 329
Index 353
About the Author 373
Changing Emotion
with Emotion
INTRODUCTION
Working With Emotion in Psychotherapy

There is a burgeoning interest in how to work with emotion in psycho­

therapy. Different schools offer distinct perspectives and have developed
different methods, which were compared in a recent book (Greenberg et al.,
2019). I take a further step in the present book by offering a transdiagnostic,
transtheoretical perspective to working with emotion. This perspective is based
on three main ideas: (a) emotion is central in many forms of psychological
dysfunction, (b) both acceptance and change of emotions are important to
curing suffering regardless of type of emotional disorder, and (c) work on
transforming the underlying emotional cause of psychological dis-ease is
important for enduring change and differs from modification of symptoms
and provision of coping skills.
The intended audience for this book includes mental health clinicians of
all schools and students in all helping disciplines. Other professionals who
work with people suffering from emotional difficulties also should find the
views expressed here informative. How to work with emotions in therapy has
not been explicitly taught in psychology, psychiatry, or social work graduate
programs even though clinicians working on the front lines meet people’s
emotional suffering day in and day out. This book is designed to help you

https://doi.org/10.1037/0000248-001
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

3
4  •  Changing Emotion With Emotion

think clearly about how to work with emotion and to provide you with
methods to do so.
Along with explanations in each chapter of the key steps and skills involved
with emotion change, I provide descriptions of clients and transcripts
excerpted from actual therapy sessions. I have omitted personal details and
changed names to protect all individuals’ privacy. I also have embedded
brief commentary within brackets in the clinical dialogues. These comments
are the result of task analyses I performed on each session to pinpoint the
specific moments when one can perceive—whether through words, silence,
tone, gesture, facial expression, or tears—that a change is occurring or is being
facilitated or acknowledged. By providing analyses of these microevents
within each therapy dialogue, my aim is to help you recognize the processes
described; these analyses may also serve as group discussion topics or as
models for either supervision or deliberate practice.
Until recently, a specific disorder approach has governed diagnosis and
treatment. Growing evidence, however, indicates that similar processes
underlie depressive and anxiety disorders (Kendler, 1996; Kessler et al.,
2005) as well as other disorders. In addition, evidence points to high rates
of comorbidity of up to 40% to 80% in clinical and also in epidemiological
studies (T. A. Brown, Campbell, et al., 2001; Kessler et al., 2005). A major
problem in the field is that interventions that are specific to a disorder pay
relatively limited attention to the aspects of the comorbid disorder. Given these
concerns, clinicians are increasingly in agreement that we need a new way to
classify, and treat, disorders (Barlow et al., 2004). A transdiagnostic approach
needs to identify core, common, maladaptive processes and target them in
treatment (Barlow et al., 2004) as well as delineate where and how these
treatments need to be adjusted depending on the client or diagnostic groups.
People with schizophrenia, for example, may need additional processes.
Different models of psychotherapy think about—and work with—emotion
in distinct ways, but a goal of all treatment approaches is to help people
alleviate emotional suffering. Many features of these diverse approaches are
similar, but they may often be viewed as more different than they really are
because of their various language systems (Abbass, 2015; Fonagy et al., 2002;
Fosha, 2004; Greenberg, 2011; Greenberg & Safran, 1987; Jurist, 2019;
McCullough, 1999; Perls et al., 1951; Rogers, 1957). In this book, I hope to
present a coherent view of emotion to inform an agreed on approach to the
treatment of peoples’ underlying emotional problems. I also hope to propose
a transdiagnostic perspective that specifies underlying principles and methods
for working with deeper emotional pain. I believe that, in the long run, this
proposed approach will improve the treatment of people who suffer from
 Introduction • 5

different disorders. This approach is for working with implicit body-based

emotional states that function beneath levels of awareness and are more
related to right-hemispheric implicit processes than to left-hemispheric
linguistically processed explicit knowledge.

WHY TARGET EMOTION TO CURE SUFFERING?

Early on, Alexander and French (1946) introduced the notion of the cor-
rective emotional experience and claimed that reexperiencing the old diffi­
culties with a new ending was the secret of all therapeutic change. The
proposal was that actual lived experience of a new solution to old problematic
patterns convinces people that new solutions are possible, thus inducing them
to change their old patterns. With repeated novel experience, the corrected
reactions become, over time, automatic and transform into new, higher level
forms of functioning.
Goldfried (1980) suggested that the corrective experience occupies a
central role in the therapy change process across orientations. He proposed
providing the client with new, corrective experiences as a common clinical
strategy. I highlight the importance of corrective experience as a concept
that originated in psychoanalytic circles but has clear relevance to all orien-
tations and perhaps represents a core principle of change (Goldfried, 1980).
In this book, I suggest that the best way to achieve a corrective emotional
experience is to transform one emotion by activating another one; I discuss
how to facilitate this process.
Most people come to therapy because they are in emotional pain. They
may present with symptoms of depression, anxiety, eating disorders, addic-
tion, or personality or interpersonal problems, but they need help dealing with
the underlying sadness, shame, anger, fear, and sometimes even unrestrained
manic pleasure. Several pathologies described in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American
Psychiatric Association, 2013) can be considered as having originated from
emotional difficulties. Individuals with mood disorders, such as depression,
feel trapped in a complex web involving sadness, shame, and guilt; those
with anxiety disorders are taken by dread and fear; and those with border-
line personality disorders experience different alternating emotions that are
always highly intense.
Despite recognizing some differences in varied diagnostic groups, a number
of therapeutic approaches have always treated people, regardless of diag-
nosis, in the same fashion (Goldfried & Davison, 1976). Many that focus on
6  •  Changing Emotion With Emotion

emotion from the start have proposed the curative value of the therapeutic
relationship, specifically the clinician’s empathic responding to feeling and
the use of interventions to access emotion regardless of type of disorder
(Fosha, 2000; Greenberg, Rice, & Elliott, 1993; Perls et al., 1951; Rogers,
1957). From this perspective, the clinician who can master empathy and
emotion eliciting interventions does not need to rely on learning different
protocols for different disorders. Treatment is basically the same, whether
the DSM-5 defines the client’s clinical issue as anxiety, a mood disorder,
posttraumatic stress disorder, addiction, or a personality disorder. This trans-
diagnostic feature of many current emotion-oriented treatments and of both
early, humanistic, and behavioral approaches has been present since the devel-
opment of those treatments because they relied more on problem or process
specification as well as on case formulation than on diagnosis (Fosha, 2000;
Greenberg, 2011; Greenberg & Safran, 1987; McCullough, 1999; Perls et al.,
1951; Rogers, 1957). So, in some fashion, a transdiagnostic approach is going
back to the fundamental principles of these approaches.
Growing evidence shows that activating and working with emotion in
therapy predicts outcome regardless of diagnostic grouping. Recently, the
results of a meta-analysis (Peluso & Freund, 2018) indicated that client
expression of emotion evidences a medium effect size with psychotherapy
outcomes. The results of this meta-analysis generally replicated conclusions
of other systematic reviews and meta-analyses. The magnitude of the effect
sizes observed in the recent analysis (d = .85) was similar to findings in both
the Diener et al. (2007) and A. Pascual-Leone and Yeryomenko (2016) reviews
of the relationship between emotional experience and expression and out-
come. Thus, there is evidence that emotional expression in therapy relates
to outcome—and that it is not diagnosis specific.
Some theoretical views caution against the idea that expressing emotions
is desirable; instead, they champion the value of restraint or suggest different
stages of readiness for change and, by implication, for emotion work (Miller
& Rollnick, 2013; Prochaska & DiClemente, 1983). Others suggest that
emotion work with borderline or traumatized clients and the exploration
of childhood memories can be disorganizing and countertherapeutic. For
example, both transference-focused psychotherapy and mentalization-based
therapy (Bateman & Fonagy, 2004; Yeomans et al., 2015), two psychodynamic
evidence-based approaches for severe personality disorders, question the
activation of childhood memories for certain clients. I agree that clinicians
should exercise some caution about when to activate and when to regulate
emotions, as well as what emotions should be regulated or activated and
when clients should be invited to go back to childhood or to traumatic
experiences. I discuss these caveats throughout the book.
 Introduction • 7

HOW DOES EMOTION TRANSFORMATION WORK?

This book focuses on methods that facilitate the transformation of emotion

by helping clients with all types of disorders arrive at painful maladaptive
emotions and then leave these emotions by accessing new, adaptive emotions.
I suggest that you cannot leave a place until you arrive at it, so one has to feel
an emotion to change an emotion. The focus is on methods for both access-
ing emotion and changing emotion. I discuss generic methods of accessing
emotion, including empathically attuning to affect, focusing on bodily felt
experience, and processing episodic memories to help people reexperience
the past in the present. The importance of new, corrective, emotional expe­
riences and of memory reconsolidation processes is stressed, as well as how
it is the having of new adaptive emotional experiences, in the presence of the
activated old painful experience, that is crucial in transformation. In addition
to generic methods of working with affect, I also discuss more structured
methods for arriving and leaving emotion, such as chair work and imaginal
reentry to past situations.
A key transdiagnostic principle of emotion transformation is that the best
way to change an emotion is with another emotion. To quote Spinoza’s (1967)
Ethics (Part IV): “An emotion cannot be restrained nor removed unless by
an opposed and stronger emotion” (p. 195). This is a fundamental psycho-
logical process that all clinicians need to understand. This form of emotion
transformation differs from emotion regulation, which is itself a rapidly
developing transdiagnostic principle developed mainly within modificational
traditions (Gross, 2013; Linehan, 1993). Emotion regulation involves the
control of emotion—managing unwanted emotions, meaning it is a second-
level process that helps with coping and symptom treatment. Jurist (2019)
pointed to a difference between “emotion regulation” and “emotion modu-
lation”: Emotion modulation involves the transformation of emotion at the
level of emotion generation so that emotion is experienced in a modulated
fashion. Emotion transformation, which produces modulated emotion, occurs
at the basic, first, or primary, level—the level at which the emotion is
generated before it has to be managed. Achieving change at this primary
level makes for change in the underlying dis-ease and is a prerequisite for
the later higher level, more deliberate regulation processes needed for the
complexities of managing emotion in one’s social world. In the therapeutic
context, emotion regulation acts—after the fact—on the primary process of
emotion generation as an aid to coping and symptom. This will be discussed
more fully in Chapter 11 on emotion regulation.
I argue that the royal road to managing emotion is by transforming
emotion at the level of its generation rather than by controlling already
8  •  Changing Emotion With Emotion

generated dysfunctional emotion. For example, in people who have anger

problems, rage is a reaction to, and a way of protecting themselves from, the
hurt and disorganizing effects of their underlying shame or fear. The best
way to manage or regulate dysregulated anger is not by anger management
but by modulation of the anger via transformation of the more primary
underlying shame or fear to which the dysregulated anger is a reaction.
When the person no longer feels ashamed or no longer is afraid, they do not
rage, and their emotion is more modulated (Greenberg, 2015; Jurist, 2019).
In working with emotion, therapists first need to help people arrive at
emotions, which involves staying in contact with their feelings. Doing so
allows feelings to serve their adaptive purpose. However, some painful feelings
are maladaptive; they are responses to past experiences of abandonment,
neglect, or trauma. Once one has accepted these emotions, the emotions need
to be transformed. This is the leaving stage, which is the key thera­peutic
process of changing emotion with emotion. Consider, for example, how the
withdrawal tendencies in shame—of wanting to sink into the ground and
disappear—cannot coexist with the opposing approach tendencies of asser-
tive anger to thrust forward to protect one’s boundaries. Or, consider how
the withdrawal tendency in fear—to run away—can be transformed by the
approach tendency in sadness of reaching out to receive comfort.
Therapists who work with emotion, thus, first facilitate acceptance of
emotion by helping people sit with their difficult feelings in a session.
When a client expresses an emotion, the therapist responds by empathizing
compassionately with the painful aspect of the experience and facilitates
the client’s acceptance and articulation of the meaning of the emotion.
In so doing, therapists pay attention to the client’s moment-by-moment
experience and help the client to not judge their emotions but really accept
them. Therapists at this time also help clients put their emotions into words
because putting feeling into words in and of itself has adaptive and regulating
value (Kircanski et al., 2012). But in addition to acceptance, they also help
clients experience new emotions to change the old emotions (Fredrickson
et al., 2000; Greenberg, 2015; Lane et al., 2015).
Therapists work to help people effectively process their emotions by
getting them to approach, accept, express, regulate, tolerate, understand
and reflect on, and maybe, most importantly, to transform their emotions
(Greenberg, 2002, 2015). These are all important processes, and each is a
basis for a different form of intervention. To help process emotion in this
way, therapists first need to offer a relationship in which the therapist is
present, is empathically attuned to affect moment by moment, and creates a
working alliance. This is a strongly process-oriented approach.
 Introduction • 9

Therapists need to keep their finger on the client’s emotional pulse moment
by moment and follow the client’s shifts and need to respond differentially
to these shifting states. This means, for example, that the therapist may sense
change through the following: a client’s voice as it rises in pitch or volume,
disconnected eye gaze, body postures, or tight facial expressions that reveal
the client is not feeling safe. Doing so helps therapists sense that they may
have said something that led the client to not feel heard; they therefore can
adjust accordingly. Therapists are reading both the client’s and their own
bodily felt sense and action tendencies moment by moment to guide inter-
vention, to intercede to correct any misattunement, or both. They then watch
to see the effect of their intervention: if their responses cause a client’s facial
expression to soften or their breathing to deepen, or, if there had been a mis-
attunement, to see if the client is again feeling safe in the relationship and
that any break in the alliance has been repaired.
A process-oriented approach, central to working with emotion, is funda-
mentally a phenomenological approach that works with a client’s subjective
experience of the world as it emerges for them (Heidegger, 1953/2000;
Merleau-Ponty, 1964, 1968). Working phenomenologically in this way, the
therapist pays attention to the client’s subjective experience and to shifts in the
client’s experience. The therapist views people as dynamic, self-organizing,
emotion-processing systems that change moment by moment, and a crucial
therapist skill involves following and facilitating a next step in emotion
processing. Close attention to the present emotional experience of clients is
central. Perceptual skills of observing what clients are doing and when are
as or more important than intervention skills, which are only as good as
their appropriate timing. From a process orientation, it is not so much what
therapists do but when they do it that is important.

OVERVIEW OF THE BOOK

The book is broken into three parts: Part I, Understanding the Fundamentals
(Chapters 1–4), Part II, Arriving at Emotion (Chapters 5–8), and Part III,
Leaving Emotion (Chapters 9–12). Part I provides the conceptual and research
scaffolding for the emotion-based approach as a transtheoretical, trans­
diagnostic, and transcultural way to conduct therapy.
Chapter 1 covers the theory of emotion and emotional change. It presents
the basic theory of emotion and emotion schematic processing; it also makes
the case for having new emotional experience to change old emotional
experience. The chapter presents the significance of implicit emotional
10  •  Changing Emotion With Emotion

experience, the role of the body and action tendency, and the basics of
memory reconsolidation.
Chapter 2 discusses research on using emotion to change emotion. The
chapter reviews emotion activation and other emotion change processes,
indicating the transdiagnostic nature of these processes.
Chapter 3 elaborates the basic principle of change being proposed in this
book—changing emotion with emotion—and discusses memory reconsoli-
dation in greater depth as a key process in emotional change. It provides
clinical examples of the process of changing emotion with emotion.
Chapter 4 discusses why it is important for therapists to deal with their
own emotions and their fears of emotion. Many therapists and trainees have
some form of fear of both their own and their clients’ emotions; therefore,
learning to become comfortable with their own and their clients’ emotions
is necessary in working with emotion. The chapter moves on to discuss how
different views of self and rules of expression affect emotions across cultures
as well as inform the clinical decisions therapists need to make both in terms
of respecting these differences and of making their proactive choices to
educate about and dismantle systemic racism.
Part II begins with Chapter 5, which introduces the foundational skill for
arriving at and processing emotion: empathic attunement to affect. Flowing
from this skill comes moment-by-moment attunement to affect, a process of
keeping one’s finger on the client’s emotional pulse. The chapter discusses
and demonstrates attunement as well as the importance of responding in
the landscape of feeling rather than in the landscape of action or meaning,
and how focusing internally on feeling influences the client’s next moment.
The chapter also discusses the important differential effects of empathic under-
standing, empathic exploration, and empathic conjecture in helping clients
gain access to their feelings.
Chapter 6 presents the skill of focusing on bodily felt feelings to access
and process emotion. It offers examples of different forms of guiding aware-
ness to bodily felt experience and emphasizes the importance of putting
words to experience. The chapter discusses the difference between emotional
arousal and depth of experience; it also discusses and demonstrates the
differential importance of each in therapeutic change.
Chapter 7 looks at clients’ experience and process of blocking emotion in
sessions, and it highlights the self-protective function of blocking and inter-
rupting emotion. Avoidance and defense are revisioned as self-interruptive
coping strategies coming out of a person’s attempts to protect the self—
to prevent disintegrating or falling apart. It is not that clients are avoiding
the pain of the emotion; rather, it is the fear that they will be overwhelmed,
will drown or fall apart, and will no longer be able to function that they are
 Introduction • 11

protecting against. The chapter presents results of research studies that used
both grounded theory and a task analytic approach to the self-interruption
or blocking of emotion.
Chapter 8 looks at a task analytic study of the unblocking of emotion and
discusses the skills for undoing the blocks to emotion. Highlighted in this
chapter is the importance of key steps in helping people approach dreaded
emotions: validating clients’ fear of emotion and facilitating the realization
of client agency in the blocking process. The chapter presents the use of
a particular form of two-chair dialogue for helping clients experience that
they are agents in their process of self-interruption of emotion.
Part III focuses on the leaving of emotions. The chapters in this part
discuss the processes and skills needed to facilitate transformation.
Chapter 9 discusses the importance of reclaiming previously disclaimed
feelings and mobilizing unmet needs. This chapter highlights not only how to
help clients access previously disallowed needs but also how to facilitate the
feeling of having deserved to get the need met. Once a client feels deserving,
this leads to the automatic emergence of new feelings. Transcripts in this
chapter demonstrate the methods of mobilizing heartfelt needs to generate
new emotions to change old emotions.
Chapter 10 deals with reexperiencing the past in the present through
the activation of episodic memories, and it presents different methods of
accessing episodic memories. The chapter also outlines age regression by
either speaking to the imagined child or going back to become the wounded
child and speaking as if one is the child; it demonstrates this method with
transcripts. The chapter presents other methods, such as going back by
means of an affect bridge, tracking a current feeling to its origins, or using
somatic experience to arouse memories. Going back to the past helps mobilize
clients’ unprocessed emotions and unmet needs to make them amenable
to transformation by the activation of new feelings to change old feelings.
For example, the fear or shame of abuse is changed by the experience of
empowering anger, which comes from the healthy feeling of entitlement to
the need for protection. Likewise, the fear and sadness of lonely abandonment
is changed through grieving what was missed and the internalization of both
self and other compassion.
Chapter 11 focuses on emotion regulation. It looks at deliberate regulation
to enhance coping and at implicit regulation through automatic processes
to enhance transformation at the level of emotion generation. The differ-
ence between emotion regulation (coping and self-soothing of dysregulated
symptomatic feelings) and emotion transformation (transformation of the
client’s core painful emotions by bringing in compassionate soothing) is
discussed. The chapter also addresses the use of different types of imaginal
12  •  Changing Emotion With Emotion

transformation and a variety of chair dialogues that have been developed

for working with transforming emotions.
Chapter 12 focuses on narrative and emotion, specifically, the consol-
idation of emotional change into new narratives. Stories are our primary
way of making meaning, and we make sense of what we feel not only by
labeling what we feel in words but by the way we organize our emotional
experience into narratives. The chapter discusses how an emotion-oriented
therapy facilitates clients’ coming to know and understand their own lived
experience, articulate them as told stories, and create new stories based on
new emotion. It also describes markers of different types of problem-based
stories and change stories.
Following Part III is “Looking Ahead: A Unified Approach to Psychotherapy”
in which I offer concluding thoughts about how adopting an emotion-centric
therapy framework that is transdiagnostic, transtheoretical, and transcultural
will help many more people who need therapy to actually get it. Rather than
providing only symptom reduction, this framework will provide a transfor-
mation of the underlying dis-ease, thus resulting in more enduring change.

WHAT ARE THE ESSENTIALS FOR LEARNING TO WORK WITH

EMOTION IN PSYCHOTHERAPY?

When working with emotion in therapy it is essential to develop clarity about

whether the clinical focus is on having people experience their emotions in
relation to the object or context which activates the emotions, or on helping
the client manage their own emotions more generally. Therapeutic work can
be seen as belonging in one of these two domains, working on emotions
in relation to their objects—say fear of father, or shame about body—or
working on one’s relationship to one’s emotions, such as difficulty in access-
ing emotion or being overwhelmed by emotions. Understanding which of
these forms is the focus of the therapeutic work and when the focus is shifting
helps the therapist and client better formulate what they are doing at any
point in therapy in the treatment. Looking at whether one is focusing on
changing emotion or on changing one’s relationship to the emotion is an
overarching frame that will help readers as they work through the differ-
ent chapters of this book. It will be apparent that Chapter 9 on needs, and
Chapter 10 on experiencing the past in the present, are more centrally
focused on changing emotion, whereas Chapters 7 and 8 on interrupting and
unblocking emotion respectively, and Chapter 11 on regulating emotion are
most centrally about helping people change how they relate to their emotions.
 Introduction • 13

With either of the above clinical goals as the focus of the emotion work,
the therapist will need to develop skills and knowledge in a few key areas. As
I elaborate in Chapter 4, therapists first need to develop an emotion-friendly
attitude; this primarily means being friendly to their own emotions, which
in the long run will help them to be friendly to others’ emotions. Probably
the best way to do this is for therapists to work on their own emotions in
personal therapy or engage in some form of self-experience as part of their
training. The ethic of “know thyself” is better stated as “be aware of and accept
one’s own emotions.” This is a process of paying attention to what one feels
in everyday living and using this information for daily decision making as
well as for transformation. Therapists cannot guide people through terrain
that is totally foreign to them; they need to be able to deal with their own
emotions to help others deal with their emotions.
Therapists also need some knowledge of the nature and function of
emotion at a theoretical level to help clients understand why it is important
to focus on emotion, how feeling bad can lead to feeling good, and how it is
worthwhile to delve into the memory of past experiences rather than bury
them. Clinicians also need to know what research has shown about working
with emotions to know that there is evidence on which to base their work.
Therapists need skills to facilitate both awareness and acceptance of
emotion and emotional change. Four core skills in the arriving phase are
(a) moment-by-moment empathic attunement and the ability to (b) help
people focus on bodily feelings, (c) to focus on the present experience of
emotion, and (d) to overcome blocks to emotion. Leaving emotion by trans-
forming it, as indicated by the preceding chapter summaries, takes place when
clients are able to access their needs, reexperience the past in the present,
regulate emotions, and consolidate their experiences into a new narrative.
I have practiced and supervised now for nearly more than 50 years, and
this book presents my updated, ever-developing learnings on how best to
work with emotion in psychotherapy. Many of the microskills I describe in
this book have developed out of my supervising clinicians from around the
world over the past decade and from task analyses of work on emotion.
My hope for you, the reader, is that this book helps you gain sharper aware-
ness and focus for staying with others as they plunge into painful emotions.
I also hope that the many demonstrations of empathy in action I share in
this book strike a chord and that you learn both the confidence and humility
you need to make your clients feel safe. Finally, it is my sincere hope that you
are able to share in your clients’ joy and help them overcome any trepidation
they have as they create new stories for themselves that are grounded in
emotion transformation.
PART 

I UNDERSTANDING THE
FUNDAMENTALS
 
1 EMOTION THEORY

Emotion, in my view, is the basic datum of human experience. However,

we need to bring cognition to emotion to help us make sense of it and to trans-
late its action tendencies into decisions, behavior, and meaning. Emotion is
not a single category of phenomena but, rather, a complex domain of human
experience. In this chapter, I look at the nature and function of emotion and
describe the role of both emotion schemes and needs in therapeutic change.
Defining “emotion”—and the words used to describe it—is somewhat
controversial because different views exist (Barrett, 2017; Panksepp, 1998;
Panksepp & Biven, 2012; Russell, 2003). Theorists generally agree that
emotion is a complex reaction pattern involving physiological, experiential,
and behavioral and elements (Ekman & Davidson, 1994) and that emotions
help people evaluate the significance of situations for their well-being. In
this book, I use the terms “affect” and “feeling” as well as “emotion” when
discussing emotional processes in therapy. As Damasio (1999) suggested,
a useful way of thinking about these terms is to imagine a tree with a trunk
and roots, major branches, and leafy minor branches.
Affect can be thought of as the physiologically based roots and trunk of
the tree, such as excited or calm; emotions, as the major branches, such as

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Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
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17
18  •  Changing Emotion With Emotion

categorically labeled emotions like anger, sadness, and fear; and feelings
are the small leafy branches, which are the much more socially and cogni­
tively influenced, like annoyed, disappointed, or suspicious. I use these
three terms throughout the book somewhat interchangeably and according to
which word seems to best fit the context. I do so, though, with the sense that
“affect” emphasizes the more implicit physiological aspects; “emotion,” the
more basic categorical labels; and “feelings,” the more finely differentiated
social and cognitive aspects. In addition, to work therapeutically with
emotion, I show that it also is clinically important to discriminate different
types, sequences, and levels of emotion as well as the degree of adaptiveness
and maladaptiveness of emotion.
Emotion serves a number of important evolutionarily derived functions
to aid survival. First and foremost, emotion rapidly provides an action
tendency to help us survive. Second, it simultaneously provides us with
information about what is going on in the situation in relation to our needs,
and it communicates our intentions to others (Greenberg, 2015). Third,
emotion is our primary signaling system. It is embodied; that is, by our
bodily expression of emotion, we communicate our states nonverbally to
others. For example, when fear is activated, it provides us with an action
tendency: to flee. When we feel fear, it tells us that we are in danger, and
our expression or our physical action communicates our state to others. The
appraisal of danger and the fear that is felt is not in words; it is presymbolic.
It is a basic meaning based on an apprehension of an experienced meaningful
pattern that is relevant to our well-being. This fear is not produced by a
thought in language but is a sensing, an orientation, and an inclination that
needs further processing to make sense of it.

ACTION TENDENCY, INFORMATION, AND EXPRESSION

As Frijda (2016) argued, what is most basic in human functioning are

not feelings but modes of action readiness that aim to establish, modify,
maintain, or terminate a given self-object relationship. Action tendencies
prepare us for adaptive action. The action tendency in fear, as mentioned
earlier, is to move away from the dangerous stimulus. Fear motivates us to
seek protection and safety. When the goal is achieved, the emotion cycle ends:
The relationship with the environment changes, and emotion is deactivated.
What is universal across cultures are not emotions as feelings but, rather,
emotions as dispositions for various forms of action readiness. Our feelings
in this view, then, are reflections in consciousness that accompany action
 Emotion Theory  •  19

inclinations. Action tendencies have an aim. If the current situation lends

itself to it, the state of readiness will activate an action or action sequence
from the individual’s repertoire that appears capable of achieving the aim of
modifying or maintaining relationships. Actual actions appear when these
subthreshold activations turn into full-blown action.
Emotion is best understood as fundamentally an action readiness, and
it also is a motive state. Action readiness and the action itself are more basic
than feelings because feelings largely are conscious reflections of states of
action readiness. LeDoux (2012) suggested that, at a neurological level, what
is most basic are survival circuits that mediate a coordinated set of adaptive
brain and behavioral responses. Emotions do not exist in the brain as neuro­
logical entities with specific locations. Instead, what probably are hard-wired
are the brain circuits for survival tendencies, such as defense against harm,
which develop into basic emotions like anger and fear. It is these brain circuits
and their adaptive functions that are conserved across mammals and that,
rather than subjective emotional experience, are universal. In working with
emotion, how we name them and how they feel may vary; however, it is the
action tendencies that are most basic and universal.
Emotions are also our primary meaning system (Forgas, 1995). Evidence
clearly points to the neurological primacy of affect. LeDoux’s (1996) research
on the emotional brain demonstrated that it is possible for our brains to
register the emotional meaning of a stimulus before the perceptual system
has fully processed that stimulus. Thus, the automatic emotional response
has already occurred before one can stop it—be it jumping back from a snake,
snapping at an inconsiderate spouse, or yelling at a disobedient child. The
neocortex, however, also has been found to have fibers leading back to the
amygdala and provides a path for cognitive feedback to the emotion systems.
This is the path by which deliberate conscious cognitive processes can be
used to help regulate emotion. An important consequence of this method
of functioning is that people can respond emotionally without thought
because a situation is perceived to fit a category it activates. The activa-
tion of the amygdala occurs quickly and can be achieved without the inter­
vention of cortical areas, although only for approximately 12 milliseconds
(Markowitsch, 1998).
In addition to action tendency and information, emotional expression,
the third major component of emotion, provides people with their primary
means of communication. An infant’s cry signals to the mother the type of
distress the child is in, and the scowl of the angry father signals disapproval
or danger. Emotional expression qualifies what is expressed verbally, and
it often is more salient than the cognitive content of the communication.
20  •  Changing Emotion With Emotion

The semantic meaning of the words one expresses frequently is not the most
important part of a message. Facial expression, eye and lip expression, direc-
tion of gaze, frown, and tone of voice all are registered by the recipient’s
brain; this plus the context helps interpret what the expresser means and feels.
Bodily expression is an important part of communication. Emotion, therefore,
is not just a feeling but an action tendency, information, and expression.

IMPLICATIONS FOR THERAPY

Research in affective neuroscience suggests that the processing of eco­

logically important stimuli (i.e., emotional and social) is conducted by
dedicated, modular systems that operate rapidly and automatically, and
are largely independent of our conscious awareness (Adolphs & Anderson,
2018; Tamietto & de Gelder, 2010). It has been shown that interference
in the naturally occurring process of emotion activation and completion
underlies development of many major disorders. Disclaiming the action
tendency in emotion, not acknowledging how one feels, and suppressing
emotion are major forms of dysfunctional emotion processing (Foa & Kozak,
1986; Greenberg & Safran, 1987). When activated by a provoking stimulus,
an emotion follows a natural five-phase sequence: (1) emergence, (2) entry
into awareness, (3) ownership by the individual, (4) expression through
action, and (5) completion after which a new emotion emerges and the cycle
begins again. It is only when this process is repeatedly interfered with, such
as when awareness or ownership is prevented, when expression is inter-
rupted, or when action and completion are blocked, that we become stuck
in chronic, painful emotions (Greenberg, 2002; Gross & Levenson, 1997;
Pennebaker, 1990). As a result of this interference, potentially meaningful
implicit information that is necessary for meeting our needs through adaptive
action is kept out of awareness. Accordingly, an important task for thera-
pists is to facilitate the experience and expression of previously disallowed
emotional experiences in clients.
Emotions give people feedback about their reaction to situations, so it is
important to help clients pay attention to what their emotions are telling
them and to use this information to guide their behaviors and get their
needs met (Damasio, 1994). Consciously feeling the emotion in connection
with the object evoking it gives people control over their reactions; they
become agents who are having an emotion rather than passive victims of
emotion. The process of arriving at, allowing, and accepting emotions, how-
ever, is not enough to deal therapeutically with painful emotion. In addition
 Emotion Theory  •  21

to arriving at emotions, therapists also need to help clients leave certain

painful emotions by activating new adaptive emotions that help change the
old emotions. Clients need to consolidate their experiential change in new
narratives consisting of new views of self and world (Greenberg, 2011).
This process of accepting emotion and changing emotion with emotion as
well as creating new narratives involves understanding different types of
emotions and principles of emotional change. The best way to change an
emotion is with an opposing emotion.

Needs

Emotions are embodied connections to our most essential needs (Frijda,

1986). They rapidly alert us to situations important to our well-being.
They tell us if things are going our way and organize us to react adaptively.
Emotion is generated psychologically by the automatic appraisal of situations
in relation to needs, and, therefore, emotions can be seen as carrying needs
within them. As part of the process of providing goal-directed action tenden-
cies, emotion evaluates whether something is good or bad for us; it must
be distinguished from reason, which evaluates if something is true or false.
What is good or bad for us is essentially determined by need or goal attain-
ment. This means the brain is constantly evaluating the state of the organism
and whether, in its interaction with the environment, things are going the
organism’s way—whether its needs are being met.
Emotions and needs are intimately intertwined. Does this mean needs
precede emotion? The answer is no. Needs, rather than being inborn, develop
from basic organismic biases and preferences, such as a preference for light
over dark, soft over hard, warm over cold, maybe even smiles over growls
(Greenberg, 2019). Neonates and all organisms are not born with motivations,
such as attachment, achievement, and control; rather, they are born with an
emotion system designed to aid survival: The infant is an affect-regulating
being designed to move toward those emotions that promote survival and
move away from those that do not. Closeness, tenderness, soothing, hunger
satiation, and so on are sought after because they produce emotions that
feel good, and evolution designed organisms to evaluate whether the envi-
ronment is good or bad for them and to move accordingly. Amoebas,
single-cell organisms, taste the environment, and if it tastes good, they move
forward; if it tastes bad, they spin away. The thing that meets emotions’
goal of survival and growth becomes experienced as good and develops
into desires and needs, which are sought after. The infant, thus, is guided
by an automatic affect-regulation system that is constantly trying to have
22  •  Changing Emotion With Emotion

the feelings they want and not have feelings they do not want. Emotion and
need now exist in an interdependent relationship, both implying the other.
For therapy, this means that empathic understanding of emotion requires
an understanding and articulation of needs. Empathic responses do not
simply offer words for feelings; they include the need embedded in the
emotion. A therapist’s response is not just, “So, this left you feeling sad,”
which often could drop like a lead balloon when the client says, “Yes,” but
that is enhanced by including the unmet need, “So sad. You needed her
comfort, and not getting anything left you so empty and lonely.” This elab-
orated response of feeling and need provides a sense of direction and helps
clients differentiate and deepen their experience. The client may respond
by saying, “Yes, I really need her comfort, and I sort felt hung out to dry—
almost like I didn’t exist.”

The Self

Working with emotion from a process-oriented perspective, it is important

to think of the self as a dynamic self-organizing system. The self in this view is
a constant process in which embodied experience, once felt, can be reflected
on and symbolized by the processes of consciousness and language. Hence,
there is a constant dialectic between experiential and reflective processes
that produces the sensation of who we are and allows for the creation of
narratives by which we live. A lot has been written about the self. William
James (1890) distinguished the self as “Me” and as the self as “I.” Daniel Stern
(1985) described four interrelated senses of “self”: the emergent self, core
self, intersubjective self, and verbal self. Hofmann and Doan (2018) in a
contemporary treatment of emotion and the self also distinguished between
a core self and a social self. In working with emotion in therapy, a person’s
reflective self is seen to be constantly interacting with all emerging affect so
that when people articulate their experience of what they feel and who they
are, it is as much created as discovered. What people feel always involves
how they explain their experience to themselves. People create their final
emotional experience by putting their felt sense, itself a synthesis of more
basic elements, into words.
The self is a process of self-organization constantly being created to take
particular forms. It is a temporal process unfolding in the present in inter-
action with the environment. The self is seen as arising in the moment in
contact with the environment (Perls et al., 1951). It is formed in relation to
others; it is decentralized and unfolds in time, and is organized moment by
moment into different forms, such as happy, self-critical, worthless, cautious,
 Emotion Theory  •  23

or bold. The self is more like a constantly flowing river than a structure in
that it is much more constituted by integrating experiences and reflections
over time than by integrating spatial locations and a situational knowl-
edge. It is a dynamic self-organizing process that creates the person we are
about to become. It is forming and informing forms of being. The person is
constantly putting the self together in the situation. Like touch only exists in
touching, so the self only exists in experiencing something within a situation.
Thus, in therapy, we are concerned with self-organizing processes and the
flexibility of this process rather than with finding a true self.
People organize in different ways at different times, and they develop
some characteristic ways of organizing emotionally, giving a certain stability
to the way personality and character structure are being constructed. People
have certain experiential or reflective patterned sequences and ways of being
that are more likely to occur than others. These more frequently organized
states could be thought of as “self parts.” We all have different self-states
associated with different emotions. We switch states depending on context
and activated emotion. When fear is threatened, a protective self-organization
is triggered automatically. When the threat ceases, the person switches into
another self-state. There is some stability in the dynamic process of self-
formation with different parts that are repeatedly organized; a person may
organize repeatedly as humorous, as timid, as self-critical, or as assertive. Some
therapeutic work involves facilitating how these parts interact. Therapists
need to be aware of the constructive process involved in self-experience:
that people may have many self-organizations, and even these maintain a
constant process of dialectical construction.

EMOTION TYPES

Emotions, their action tendencies, their information processing, and their

expression aspects all developed evolutionarily to help humans survive and
thrive. Emotions and their functions are fundamentally adaptive, but, to aid
clinical work, it is important to make clinical distinctions between different
types of emotion. I have found it most helpful to first distinguish between
“adaptive” and “maladaptive” emotion and between “primary,” “secondary,”
and “instrumental” emotion. Each of these categories implies different gen-
eration processes and calls for differential intervention. In addition, in dis-
cussing working with emotion, it is helpful to distinguish between different
degrees of arousal of too much emotion (dysregulated) and too little emotion
(blocked or intellectualized).
24  •  Changing Emotion With Emotion

Emotions can be seen as healthy (adaptive), or unhealthy (maladaptive),

and as primary or not primary. Primary emotions are the very first emotions
people have in response to internal or external stimuli, that is, their gut
feelings. Secondary emotions are those that come as reactions to primary
emotions. They are more self-protective or defensive, are not adaptive, and
obscure the primary emotions. Instrumental emotions are experienced or
expressed primarily to achieve an aim and often are more manipulative in
nature. Primary emotions can be adaptive, in which case they help us adapt
to the situation by giving us good orientation to the environment and good
information. Or they can be maladaptive and, as a function perhaps of
past trauma or attachment problems, are not responses that help us cope
adaptively with situations. They are reactions in the present to the past and
do not directly seek the attainment of need satisfaction.
Emotional dysregulation refers to poorly modulated emotion responses that
do not lie within the normal range of responding. Dysregulation involves the
inability to control or regulate emotional responses to provocative stimuli.
Primary maladaptive or secondary emotions can become dysregulated.
Primary maladaptive emotions like fear of danger, shame of unworthiness,
or sadness of lonely abandonment can become so intense that they are
intolerably painful. Dysregulated emotions, however, are, more often than
not, secondary symptomatic emotions. These are emotional overreactions
or exaggerated ways of responding to environmental and interpersonal
challenges (e.g., bursts of anger, crying), and may lead to accusing or passive-
aggressive behaviors, or create chaos or conflict.
Primary adaptive emotions, such as sadness at loss, anger at violation,
or fear at threat, are people’s immediate gut response to a situation. They
give people good information about what is important to them. Primary
emotions are not the same as evolutionary basic emotions, which are funda-
mental and universal, and have different action tendencies. “Primary” means
whatever is triggered first in response to a stimulus. So, for example, anger,
sadness, and fear are basic emotions, and could be primary because they
were triggered first, whereas envy, enchantment, admiration, or weariness
are not basic emotions but could be the first complex feelings a person
may have. In addition, we must distinguish between shorter emotion episodes
(like crying at a loss) versus the long-lasting sadness at the loss, which is
better referred to as a mood.
Secondary emotions, such as depressed hopelessness covering shame at
not being good enough, rage covering shame at loss of self-esteem, however,
are responses to preceding emotional reactions, and, as mentioned earlier,
often obscure or interrupt more primary emotional reactions. For example,
 Emotion Theory  •  25

an individual who feels fear at the possibility of danger may subsequently

experience the secondary emotion of anger at the threatening stimulus or
shame about their fear. These can also be emotions that are secondary to
more cognitive processes (e.g., anxiety in response to catastrophic thinking).
Most secondary emotions are symptomatic feelings, such as panic and
anxiety, or feelings of depletion and hopelessness in depression. For example,
a depressed client with tears running down their face and a complaining
tone to their voice says, “I just can’t take this anymore. Why do I have to
suffer so much?” There is a hopeless quality as well as a tone of protest in
the client’s voice and expression. This is secondary hopelessness or resigna-
tion. In responding to this utterance, the therapist needs to acknowledge
the secondary emotion but then needs to guide the client to the underlying
primary vulnerable emotion—in this case, perhaps a feeling of shame and
worthlessness.
Other-directed blaming or rejecting anger is generally a secondary emotion
that needs to be validated and explored to get at the underlying painful
(probably maladaptive) emotion. In people who have a history of domestic
violence, other-directed secondary rage often covers shame. Rage was needed
in their childhood as self-protection against pain. Frequently, this rage can
become an automatic response to any kind of vulnerability or perceived
threat; so, it appears primary but is generally secondary protection against
underlying vulnerability.
Emotions are generated both by top-down and bottom-up processes.
People have automatic emotions generated bottom up, whereas cognitively
derived emotions generated by top-down deliberative processes are based
on such things as beliefs; an idealized view of the self; and socially derived
expectations, moral standards, and values. Those emotions that are more
influenced by cognition and social factors, are, in my view, generally secondary
emotions, such as when catastrophic thoughts lead to anxiety (McGilchrist,
2009). Catastrophic thoughts are driven by core emotion schemes of fear
and by the resulting frightened or insecure self-organization.
An additional nonprimary emotional response category is instrumental
emotion, which has been termed manipulative emotion, seen as an expression
used to get what one wants or for secondary gain. Typical examples are the
expression of anger to control or to dominate, or crocodile tears to evoke
sympathy. Instrumental emotion can be generated with different degrees of
awareness of conscious intent. Here, therapists need to help people become
aware of the aim of their emotional expression and explore more direct ways
to communicate their emotions.
Although secondary emotions are generally not adaptive responses to
the environment in that they do not help the person get what they need,
26  •  Changing Emotion With Emotion

primary emotions can be either adaptive or maladaptive. Primary adaptive

emotions are those automatic emotions in which the implicit evaluation,
verbal or nonverbal emotional expression, action tendency, and degree of
emotion regulation fit the stimulus situation and are appropriate to it (e.g.,
sadness at loss that reaches out for comfort, fear at threat that prepares
the individual to escape). These automatic emotions prepare the individual
for adaptive action and help them get their needs met. In therapy, to guide
problem solving, the client attends to and expresses these emotions to access
the emotions’ adaptive information and action tendency. Because they are
core and irreducible responses, they therefore are not explored to unpack
their cognitive–affective components. For example, anger at maltreatment is
a primary, irreducible, and core emotional response that needs to be evoked
and symbolized in therapy in order to access the adaptive action tendency to
push the offender away and establish appropriate boundaries.
On the other hand, primary maladaptive emotions are enduring painful
feelings that initially were adaptive responses to bad situations but are
now misplaced. These are feelings such as fear at one’s boss’s raised voice
resulting from having had an aggressive father or fear of one’s partner’s warm
embrace because of past sexual abuse. These feelings produce responses
that are disproportionate or inappropriate to the situation and need to be
accessed to make them available to new experiences.
How does one help access primary feeling? First, therapists need to stay
with whatever feeling the client is experiencing and ask the client to pay
attention to it and explore it. Then, by understanding and empathizing with
their clients, therapists get to more primary feelings by focusing on whatever
else the client may be feeling. The therapist might ask, “What else were you
feeling? Were you feeling anything else at the time? Right now, are there
any feelings underneath the feelings you’re talking about?” It is important
to understand that there is customarily more than is being articulated at
anyone moment.

EMOTION SCHEMATIC PROCESSING

In addition to the aforementioned distinctions about different types of

emotions, an important concept is that of emotions’ schematic memory,
or emotion schemes and the self-organizations they produce. Schemes, or
internal models, are an increasingly common theoretical notion to explain
human functioning. They are networks in the brain that are dynamic orga-
nizations through which the world and interactions with it are coded; they
 Emotion Theory  •  27

operate by forming and influencing people’s current views. Schemes are

internal mental structures that are initially innate but develop through
interactions of lived emotional experiences (J. Pascual-Leone, 1987, 1991;
J. Pascual-Leone & Johnson, 1991, 2011). One can imagine that, initially, there
are affective, motivational, cognitive, and behavioral predispositions; these
biases and preferences are often original inborn schemes that are active and
seek application. For instance, a scheme for faces seeks or searches faces,
and a scheme for being soothed or rocked seeks these experiences and “feels
satisfied” (scheme successfully applied) when they arrive.
The basic psychological units (generating mechanism) of emotional mean-
ing are the emotion schemes, which are action- and experience-producing
structures. As such, they differ from cognitive schemas, which produce beliefs
and inform (inject form into) and assign truth values to experiential, con-
ceptual, and language productions (Greenberg, 2011; J. Pascual-Leone, 1991;
J. Pascual-Leone & Johnson, 1991, 2011). We come into the world with
rudimentary psychoaffective motor programs to aid survival, and from these
programs (in combination with other inborn biases and preferences), we
begin to build our experience of the world. We do not learn how to be angry
or how to be sad—these are hardwired feelings—but what we become angry
at or what we become sad about is a function of learning formed into, and,
later on, activated through, emotion schemes. The presence of emotion in
any given moment indicates than an emotion scheme or, more accurately,
a set of emotion schemes, has been cue activated and is currently guiding
the processing; that is, it is now up and running, and thus is accessible to
change. Activated emotion schemes are synthesized into higher level self-
organizations, such as feeling worthless or feeling insecure, and are a target
of therapy.

Emotion Schemes and Self-Organization

Although emotion schemes generate emotional responses, self-organizations

are higher level patterns of experience and behavior formed by a synthesis
of emotions schemes and other processes, such as complex cognitive and
personal (i.e., affective and cognitive) schemes. Whereas shame is an emo-
tion generated by emotion schemes, a self-organization might be feeling
worthless or feeling insecure. Self-organizations are based on combinations
of a variety of emotions and ways of coping with the emotion, such as fear,
sadness and shame, and constitute one’s way of managing feelings like
withdrawing or clinging. A group of schemes are coactivated by some set
of cueing stimuli, and this synthesis of schemes plus any already activated
28  •  Changing Emotion With Emotion

schemes generate different ways of responding and different conscious states.

These events can trigger responses that lead an individual to shift rapidly
from one state to another, like shifting from rage to sadness, fear to humor,
and so on. In addition, different self-organizations are related to trying to
satisfy different basic needs.
Basic affects or emotions are innate, yet emotion schemes are learned
and arise from our past experiences. They are memory structures that
synthesize affective, cognitive, and behavioral elements in a quick and
automatic way and are related to implicit, unconscious, and idiosyncratic
mechanisms, thus forming the basis for organization of the self. Emotion
schemes are formed over our life history through memory process and
experiences of the whole organism. Thus, emotion schematic memories are
networks of representations built from lived experience, including emotions,
images, sensations, evaluations, meanings, cognitions, learned experiences,
behaviors, and scripts of how to act. Once something happens that is import-
ant to the organism, an emotion scheme with specific meanings is likely to
be constructed. When needs are not met, maladaptive emotion schematic
memories of the painful feelings of unmet need are formed. When present
stimuli, situations, or meanings are close to the ones that happened in the
past, our emotion schemes get activated and generate emotions, producing
an experiential state. Often, when we talk about “accessing emotion,” we mean
activating the output of a complex network of emotion-laden schematic
memories. When we say, “accessing fear, sadness, or anger,” we often mean
accessing an unprocessed complex, a set of feelings or affects intertwined
with cognitions and related to situations (contextualized) that bear on early
attachment and identity-related experiences.
In this view, memories and feelings do not reside, fully formed, in the
unconscious, waiting to be unveiled when the forces of repression are over-
come, as Freud (1915/1955) originally proposed. Rather than seeing the
unconscious as a cauldron of forbidden impulses and wishes, the adaptive
unconscious (Gazzaniga, 1998) is conceptualized as involving an extensive set
of processing (schemes of all sorts) that executes complex evaluations and
computations that interrelate and generate responses without requiring
intention or effort. Much of this processing may be unavailable to conscious
awareness, or, at least, awareness is unnecessary for such processing to
occur. It is important to understand that emotions are a function of implicit
rather than explicit processes. A therapy of emotion will need to work with
implicit processes; emotion schemes are the implicit prime generators of
emotional experience and the tacit or explicit targets of therapeutic change.
Appraisals have become central in the understanding of emotion gener-
ation, which results from appraisal of a situation in relation to need. How
 Emotion Theory  •  29

are appraisals made? Appraisals, in my view, are judgments or evaluations

that result from application and synthesis of a number of activated schemes
(J. Pascual-Leone, personal communication, August 6, 2020). A number
of schemes are tacitly activated, and once synthesized, the schemes result
in the formation of an evaluation, such as danger, loss, or comfort. Highly
activated schemes are dynamically synthesized, thus leading to a judgment
or evaluation. Appraisals can be seen as a higher level construct dependent
on a complex set of processing and scheme activation at a more funda-
mental level.
To demonstrate the functioning of emotion schemes, imagine a situa-
tion in which a person felt fear when meeting a new boss in an apparently
harmless situation. This person has fear schemes that, to differing degrees,
constantly scan the environment for danger, and when stimulated to a
certain level by environmental triggers (cues)—even when there is no real
threat in the situation—activate the appraisal of danger in relation to a need
for safety and produce the emotion of fear. Previous experiences related
to vulnerability or failure, or both, if needs for validation or protection were
not met contribute to creating emotion schemes that are now activated in
this situation. Consequently, the sound of the boss’s voice, a look on their
face, or an environmental aspect of light, sound, or experiences similar to
those of the original situation may raise the fear schemes’ activation level and
cause a fear response.
Emotion schemes are responsible for the great majority of people’s
emotional experience. Essentially, emotion schemes provide an integrated
and automatic response, which includes emotions, cognitions, and action
tendencies, in a kind of package or preprogrammed operation (Greenberg,
2011). Maladaptive emotion schemes are the main reason people look for
psychotherapy. In addition, people’s emotional experience based on their
emotion schemes is highly subjective. The internal emotional state and
experience differ from one person to another, or from one time to another,
in the same person. The feeling, cause, context, degree of regulation, and
intensity all depend on each person’s past experience. For example, when
“Shelley” is sad, her feeling differs from what “Rhonda” feels when she is
sad; however, we understand there is some similarity between these expe-
riences. As different as each person’s sadness may be, when a person is sad,
there is something of the same flavor to sadness across people. It would be
confusing if what one person called “sadness,” another called “joy.” There
is some essence to similarity. Experience is totally personal and contextual,
but something is common to enable us to mutually understand that it is
sadness and not joy or fear.
30  •  Changing Emotion With Emotion

Dynamic Nature of Emotional Response

The emotion process is dynamic. Human beings are dynamic self-organizing

systems that change moment by moment (Greenberg & Pascual-Leone,
1995). You may be walking along, feeling slightly anxious as you anticipate
a business meeting, and you suddenly come across a familiar spot with an
old tree that reminds you of your first kiss under that tree. Immediately,
the sight of the tree brings back a past; you smile as the memory becomes
more vivid, and you may even blush while your heart beats faster. This
same tree may evoke a different emotional reaction from someone else
who fell out of that tree as a child. While savoring your memory of your
first kiss, a person with a vicious-looking dog walks by, and you draw
back in fear because you were once been bitten by a similar type of dog.
As you walk past the dog cautiously and reach a safe distance, you see
another person approaching, and as he gets closer, you recognize him as
a close friend you haven’t seen for a while. You feel surprised and happy,
and greet him in joy. All this took less than a minute. People are dynamic
self-organizing emotion systems always in process with their feelings and
thoughts fluctuating moment by moment and adapting to the environment.
In addition, the different emotional states may be activated by a real-world
stimulus (the tree), a memory (the kiss), or a mixture of both (the dog and
the past attack).
To be human is to continually oscillate between different emotional states,
and such fluctuations are not under our voluntary control. The seat of
emotion is the limbic system, which comprises four main parts: the hypo-
thalamus, amygdala, thalamus, and hippocampus. Several other structures
may be involved in the limbic system, but unanimous consensus on them
has not been reached. The amygdala, which has direct connections with
many other parts of the brain and body in combination with other parts of
the limbic system, is predominantly responsible for the speed and dynamic
nature of our emotional responses. It bypasses the thinking brain (cerebral
cortex) because there is no time to think when we face life-threatening
dangers or threats, and the amygdala has to “sound the alarm.” Even when
it is memories that are evoked and the reaction may be more subtle, feelings
are rapid and automatic. Memories of violation and feelings of anger or
of unrequited love or loss come to mind unbidden. We do not want to feel
them and we do not want to think about a given situation, but our emotion
system persists. Our efforts to stop feelings and thoughts often are in vain.
In a nutshell, emotion schemes are processed automatically and unconsciously,
emerging from the interaction between innate emotional responses and
personal experiences. They consist largely of preverbal and affective elements
 Emotion Theory  •  31

as bodily sensations that produce higher order organizations at the corner-

stone of the self. They become the basic structure for our meaning creation.
The felt experience of who we are comes from the synthesis of these schemes
(Greenberg & Pascual-Leone, 1995; Oatley et al., 2006; J. Pascual-Leone, 1991).
Many complex emotional states exist, and names for emotional states
are unlimited. Terms for emotions that go beyond basic emotion are quite
diverse: words like “astonished,” “ecstatic,” “bashful,” and “wary.” Mixed or
complex emotional states are formed by a synthesis of activated schemes
in the internal world. People rarely feel pure, basic emotions. Children and
adults (at times) may feel pure anger or pure joy, but as people move from
childhood to adulthood, these pure emotions that came so naturally get
intermixed and lose their purity. Adults rarely function with pure emotions
but have complex schematically based emotional experiences that are tinged
with interpretation, idiosyncratic meanings, and syntheses of a variety
of basic emotions. These emotion schemes, however, have their roots in
basic emotions.
The deafening sound of a thunderbolt will frighten any human being
or animal by activating fear just as it would have frightened an ancient
ancestor walking the African plains. This is a species-natural response.
Emotions, however, predominantly do not appear in this kind of universal
response but, rather, in particular and idiosyncratic ones. Most adult experi-
ences involve complex mixed emotions instead of basic ones. For example,
one person’s irritation may be mixed with fear, whereas another’s anger may
be mixed with sadness. In addition, complex emotional states like jealousy
may be a combination of anger, fear, and sadness. Also, different situations
and roles require complex blends of feeling. For example, a parent needs a
certain mixture of emotions to be a good parent. A certain degree of anger
and pride is needed to maintain authority, but softness and warmth are also
needed to provide nurture, and joy and playfulness to provide fun. All these
different emotional states are then synthesized into a being a firm, loving
parent who provides the responses a parent needs to give.

Activation of Emotion Schemes

Basic emotions form the foundation of emotion schemes. But each scheme,
on its own, as it develops over time and when synthesized with a number
of other schemes, produces increasingly complex emotional states. It is
unusual for many clients to feel purely sad or angry; rather, they feel highly
refined and complex emotional states like “being thrown on the dump
heap” when rejected or “adrift at sea in a rudderless boat” when having lost
32  •  Changing Emotion With Emotion

a sense of direction. The following excerpt illustrates the activation of

complex emotion schemes in the context of a client’s current life.

CLIENT:  What happens with Michael is, when I see him enter the room,
I feel emotion towards him . . . [shift to emotional differen-
tiation] just like different emotions, but up until about a week
ago, like friendship.

THERAPIST:  Is that kind of like . . . a feeling of warmth? [empathic conjec-

ture, differentiating emotional experience and symbolizing it]

CLIENT:  Exactly! I was about to say a trust, a warmth . . . just this

complete contentment. [symbolizing the synthesized bodily
felt sense]

THERAPIST:  That feels really good inside.

CLIENT:  Exactly, and, um, it’s followed by this gut-wrenching, sick

feeling of dread [symbolizes, then shifts to reflexive mode and
explains the experience] because the only other person in the
last 4 years that has made me feel that way was Simon, and it
turned out to be exactly opposite to everything that was really
going on . . . like when I thought he most liked me and most
accepted me for who I was. It was a huge act.

Therapy involves working with complex emotional states, such as the

ones in the preceding dialogue, to help people unpack them and get back
to some of the experience of the basic emotions involved. It can be clarify-
ing and liberating for adults to be able to feel their basic anger or sadness
uncontaminated by the guilt, fear, or disgust that usually attend them and to
experience these emotions without the complexity of having to manage them
in socially appropriate ways. The more people are disconnected from their
basic emotions, the more complicated they become, and they lose touch
with an internal emotional compass that tells them if something is good
or bad for them; they also lose touch with what they actually feel in their
bodies and become disoriented.
To anticipate what lies ahead, I briefly describe how to work therapeuti-
cally with these core painful emotion schemes once activated. A therapy to
change emotion follows a two-stage approach of arriving at and then leaving
emotional experience (Greenberg, 2002). In the first stage, the therapist
listens and lets the story and its emotional significance emerge. So, in the
preceding excerpt, the therapist is working with the emotion schemes of
dread and distrust to ensure that the client fully arrives at the experience by
 Emotion Theory  •  33

focusing back on the activated maladaptive emotional experience of dread.

To further attend to, welcome, symbolize, and explore it, the therapist might
say, “Let’s stay with this feeling of sickness and dread that just hits you in the
gut when you are reminded of Michael. Can you stay with it and breathe?”
This draws the client’s attention to the trauma-based emotion memory
schemes and the responses associated with them. The client, articulating a
belief that helps narrate the experience, might now say, “It’s like I can’t open
up. I’ll just be hurt again.”
Having arrived at a core maladaptive feeling and an articulated sense
of its personal meaning, the goal in therapy is to shift to having the client
access a more adaptive emotional resource as an antidote to the maladaptive
feeling. This shift heralds the movement to the second stage of the emotion-
based approach. Focusing on the alternate feeling already present in the
room—the feeling of “trust, a warmth . . . just this complete contentment”—
might do this. If this were not present as the source of an alternate voice,
the therapist could access a more adaptive emotional response by helping
the client articulate a need. The therapist might ask, “What do you need
in this deep feeling of hurt and distrust?” The client might respond with,
“I just need to be held and comforted. I do so want some of the warmth.”
The therapist would then put this more adaptive voice in a dialectical inter-
action with the voice of dread by saying, “So, what are you saying to the
dread and to the voice that says, ‘I can’t open up’?” The client might say,
“I know I need to go slow to protect myself, but I also need to recognize what
is different in this relationship.”

PRINCIPLES OF EMOTIONAL CHANGE

Six principles of how to work with emotions have been gleaned from
the psychology literature. They are (a) emotion awareness: symbolizing core
emotional experience in words; (b) expression: saying or showing what one
feels using words or action; (c) regulation: soothing or reducing emotional
arousal; (d) reflection: making narrative sense of their experience; (e) trans-
formation: undoing a maladaptive emotion with another adaptive emotion;
and (f) corrective emotional experience: a new lived experience with another
person. These principles are seen as best brought about in the context of an
empathic therapeutic relationship that facilitates these processes. The first
three can be thought of as serving emotion utilization in which the client is
helped to use emotion to cope effectively with situations; the next three can
be viewed as serving emotional development. These principles have been
34  •  Changing Emotion With Emotion

described in detail elsewhere (Greenberg, 2011, 2017; Greenberg & Watson,

2006), and the one central and most novel principle—transformation by
changing emotion with emotion—is elaborated on later in this chapter.
I discuss these six principles of emotional change throughout this book
in the context of methods that implement them; this discussion can also be
found in other sources (Greenberg, 2011; Watson & Greenberg, 2017).

TWO PHASES OF WORKING WITH EMOTION

Working with emotion can be conceptualized as having two phases: arriving

and leaving. The first phase, arriving at one’s emotions, involves helping
people become aware of their emotions, accept them, and put their feelings
into words. The second phase is one of leaving the place at which the client
arrived and involves moving on and transforming core painful, maladap-
tive feelings. This transformation involves identifying the negative self or
other views associated with these emotions; identify the need in the core
painful emotion; and then generate new, more agentic emotions and self-
organizations, which will implicitly or explicitly destructure (i.e., destroy
the structure of something) any negative beliefs about self, world, or other.
The person is then helped to access, experience, and rely on alternate, healthy
emotional responses and needs. Change is consolidated in a new narrative.

Feel It to Heal It

As painful as some feelings may be, people need to feel their emotions before
they can change them. You have to feel it to heal it. It is important to help
people understand that they cannot leave a place until they have arrived
there first and that the only way out of painful emotion is to go through it.
In the early phase of therapy, it is helpful to provide clients with a rationale
as to how working with emotion will help. Doing so supports clients’ collab-
oration with the aim to work on emotions expressed within salient personal
stories. For example, the therapist might say, “Your emotions are important;
they are telling you that this is important to you. Let’s work on allowing
them and getting their message.” The therapist also helps the client start
approaching, valuing, and regulating their emotional experience. The focus
of treatment begins to be established in this early stage. Therapists and
clients collaboratively develop an understanding of the person’s core painful
narrative and work toward agreement on the underlying determinants of
presenting symptoms.
 Emotion Theory  •  35

Accordingly, helping clients to disclose, subjectively enter, and situate

their most emotionally vulnerable and painful stories needs to be a central
focus. The therapist works with clients to help them disclose emotionally
salient lived experiences so they can tolerate, accept, and story their most
vulnerable emotions of pain, hurt, anger, and rage for further reflection,
regulation, and new meaning-making. Acceptance of these emotions and
the important meanings they convey about the intentions, goals, and beliefs
of the self and other is the first step in awareness work.
In this first step, gaining awareness involves helping clients pay attention
to, and make contact with, sensations. This is a nonverbal form of knowing
what one is feeling. This type of awareness of feelings is not an intellectual
understanding of feeling. Clients should not feel that they are on the outside
looking in at themselves; rather, they should have a bodily sensed aware-
ness of what is felt from the inside—like the sensing of the throbbing of a
toothache. Clients should be encouraged to welcome their emotions, dwell
on them, breathe, and let them come. They need to accept their feelings as
information. It is helpful for people to become aware of how they interfere
with, or interrupt, their emotions rather than allow themselves to experience
the emotions. Inquiring as to how clients are avoiding their feelings helps
accomplish this.
Various theories of psychotherapy propose that the inhibition—or what
is often called “interruption”—of emotional experience and its expression
is a central phenomenon underlying psychopathology and, as such, is an
important focus in therapy (Fosha, 2000; Greenberg, Rice, & Elliott, 1993;
Linehan, 1993; McCullough, 1999). On a rudimentary level, most approaches
agree that emotions signal to people which situations to avoid and which
to approach, and that we are conditioned to avoid situations in our environ-
ment that are associated with unpleasant experiences. Because of the aver-
sive nature of certain affective experiences, such as shame and fear, these
emotions themselves can become what we avoid. Emotional suppression, the
avoidance of affective responses, has been related to poor psychological
and health outcomes (Gross, 1998, 2002; Gross & John, 2003). What has
come to be called experiential avoidance in cognitive behavior therapy to
describe the chronic avoidance of unwanted internal experiences has been
linked to many different mental health problems and to the dampening of
positive emotions (Gross, 1998, 2002; Gross & John, 2003; Kashdan et al.,
2006; Roemer et al., 2005) Thus, long-term reliance on emotion avoidance
for coping is detrimental to physical and emotional well-being. Although
people can attempt to control the occurrence of emotion by avoiding internal
and external stimuli (e.g., blocking thoughts, engaging in distraction, keeping
36  •  Changing Emotion With Emotion

away from certain environmental cues), the activation of emotion is often

out of their control. The blocking of emotion in therapy becomes an important
target of treatment, as I discuss in Chapters 7 and 8.
Clients also need to be taught that emotions are not reasoned, final
conclusions on which they must act. Emotions provide valuable information
but not reliable conclusions. Clients need to look at their feelings not as truth
but as something to be explored. And no bad feelings are one’s last feeling.
They will change. Emotions do not come into awareness in the form of
factual information; looking at emotions in their context transforms them
into clues that can be interpreted and are amenable to understanding.
People, therefore, can afford to feel emotions without fear of dire conse-
quences. Emotion is neither an action nor a conclusion. People may need
to control their actions, but they should not try to control their primary
internal experience. For people whose emotions are overwhelming, the task,
at first, is not so much one of allowing the emotions and welcoming them
as it is learning how to regulate them. After helping people pay attention to
and welcome their emotions, therapists need to help clients describe their
emotions in words. Describing a feeling in words makes emotional experience
more available for reflection. Naming emotion also is a first step in regulat-
ing emotions.
Once people have arrived at a particular place, they need to decide whether
that place is good for them. If, however, they decide that being in this place
will not enhance them or their intimate bonds with others, then this is not
the place to stay, and clients have to find the means of leaving. Therapists and
clients together need to ask, “Is this feeling adaptive, or is it a maladaptive
feeling possibly based on a wound of some kind?” If the person’s core feel-
ings are healthy, they should use those feelings as guides to action. If those
core feelings are unhealthy, the person needs to process those feelings further
to promote change.

Build a Sense of Agency in the Self

People can only recognize that a feeling is not helpful to them once they have
fully accepted it. The paradox is that if the feeling is judged as unacceptable—
as “not me”—it cannot be changed because the person has not accepted it.
Only when a feeling has been accepted can it be evaluated and changed,
if necessary. People’s core maladaptive feelings are mainly related to three
major, basic emotions: fear–anxiety, shame, and sadness (Greenberg, 2015;
Timulak, 2015). They also related to three basic views of the self: (a) feeling
fragile and insecure, and viewing the self as being unable to hold together
 Emotion Theory  •  37

without support—a “weak me” sense of self; (b) feelings of worthlessness

and a view of the self as a failure—a “bad me” sense of self; or (c) a feeling
of lonely abandonment—a “sad me” sense of self. To change the core vulner­
ability that leads them to so much fear, sadness, and shame, people first
have to access it. Next, they need to identify the wound that resulted in
their basic negative view of themselves. Then, they need to heal the basic
vulnerability and begin to build a stronger sense of self. These maladaptive
feelings are almost always accompanied by negative views of self, others,
or the world. People often experience these feelings as a negative voice in
their heads—a harsh, internal voice that has been learned, often through
previous maltreatment by others, and is destructive to the healthy self. Once
articulated, these core feelings and views of self, world, and others can be
changed by accessing alternate experiences to undo them. Accessing mal-
adaptive feelings and identifying destructive beliefs paradoxically facilitates
change, first by accessing the state that needs to be exposed to new expe-
rience and, second, by stimulating the mobilization of a healthier side of
oneself by a type of opponent process mechanism.
New, more agentic emotions and self-organizations destructure any nega-
tive beliefs about self, world, or other. This step is at the core of the leaving
phase and involves changing emotion with emotion. Helping people focus
on their healthy needs for protection, comfort, and affection in response to
being maltreated as well as on their needs for autonomy and competence
aims to free them from the oppression of their desperate need for approval.
In therapy, I have observed that people’s healthier life-giving emotions are
often activated in response to their own experienced emotional distress.
People are tremendously resilient, especially when they are in a supportive
environment. Everyone has the capacity to bounce back. Ultimately, their
ability to take care of and support themselves allows them to face distress in
a healthy way. When people are suffering or experiencing pain, they generally
know what they need. They know they need comfort when they are hurt.
They know they need to master situations in which they feel out of control.
They know they need safety when they are afraid. Knowing what they need
helps them to get in touch with their resources to cope. Helping people to
stay with their experiences of their distressing feelings thus helps them get
what they need, and this motivates change. The major healthy emotions
appear to be empowering anger, the sadness of grief, and self-compassion
all with approach tendencies that activate the organism to act to get what is
needed. Having accessed adaptive emotions and needs, and having developed
a healthier, internal voice, people create a new narrative using their new
emotion to change their old narratives (Angus & Greenberg, 2011).
38  •  Changing Emotion With Emotion

It is only through the experience of healthy emotion that emotional

distress can truly be cured. Therapists cannot rationally argue clients into
healthier emotional processes or reframe to develop new narratives. They
can, however, assist clients in overcoming their unhealthy feelings by helping
them to identify their painful maladaptive feelings, access their emotional
resources, combat their negative voices with their healthier voices, and
develop a new narrative to consolidate their transformation. The therapist’s
job is to bring people to face their dreaded emotions and find their alternate,
healthy feelings, and then use those alternate feelings to transform their
unhealthy feelings.

CONCLUSION

Emotion is the basic datum of human experience to which we bring cogni-

tion to help us make sense of it and translate its action tendencies into
decisions, behavior, and meaning. This chapter discussed how important it
is clinically to discriminate different types, sequences, and levels of emotions
when working with them in therapy. In addition to discriminating levels of
primary or secondary emotion, it is important to identify degrees of adap-
tiveness. Are the emotions on the surface or are they underlying, and are the
emotions adaptive or maladaptive? All these variations make a difference
in how the emotions are to be dealt with clinically. Emotion schematic pro-
cessing also needs to be discriminated from inborn basic emotion programs
because they are the source of most adult emotional experience.
This chapter also outlined a set of principles for working with emotion
and argued that arriving at, allowing, and accepting emotions—although
important—is not enough for dealing therapeutically with painful emotion.
Therapists need to help clients leave certain painful emotions by activating
new adaptive emotions that help change the old emotions and ultimately
lead to generation of new narratives about the self.
The chapters in Parts II and III illustrate in more detail the clinical phases
of working with emotion that are described briefly in this chapter. First,
however, let’s turn to Chapter 2 for the empirical base for emotion work in
psychotherapy and then on to Chapter 3 for an in-depth clinical example
demonstrating the principle of changing emotion with emotion.
2 RESEARCH ON EMOTIONAL
CHANGE

In this chapter, I review several lines of research that, taken together, help
make the case for a unified transdiagnostic theory of working with emotion
in psychotherapy that is aimed at changing clients’ painful emotions with
adaptive emotions. This discussion of studies demonstrates that similar emo-
tion activation and other emotion change processes occur across different
forms of treatment, different diagnostic groups, and varied clinical presenta-
tions, indicating the transdiagnostic nature of these processes. I also describe
various measures used to quantify depth of emotional experiencing in sessions
and therapeutic gain from emotion work. I also look at how the therapist
process of facilitating emotional processing has been studied so far and relate
this information to the key therapist skills outlined in later chapters.
To support my statements about the effectiveness of emotion-oriented
therapy, I summarize the results of two large meta-analytic studies on
humanistic–experiential therapies (HEP) and, more specifically, emotion-
focused therapy (EFT). These meta-analyses covered studies completed
before 2009 and those from 2009 to 2018 (Elliott et al., 2013, in press). The
studies included data from almost 200 studies before 2009, and 91 studies after
2009, on HEP therapies on a variety of populations. Both studies showed large

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Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

39
40  •  Changing Emotion With Emotion

effect pre–post client gains and controlled effects for the whole group of HEP
treatments. Clients in the studies of EFT specifically had the largest pre–post
effects of the different HEP therapies. In comparative studies, HEP therapies
were statistically and clinically equivalent in effectiveness to other non-HEP
treatments (Goldman et al., 2006; Watson et al., 2003). And, in a comparison
of EFT alone with other non-HEP therapies, these meta-analyses found a
small effect favoring EFT. More specifically, no difference in effect was found
between EFT and cognitive behavior therapy (CBT).
Importantly, the general pattern of effects was found to hold across
different populations studied, including depression, anxiety, interpersonal
problems, substance abuse, eating disorders, and chronic medical conditions.
However, a limitation of all comparative results and the ensuing meta-
analyses is that researcher allegiance bias has a significant effect on results
in comparative trials in psychotherapy (Munder et al., 2013), and most
of the comparative studies reviewed were conducted by advocates of one
of the approaches under study. All in all, though, the evidence supports the
effectiveness of HEP approaches that work phenomenologically with a focus
on emotion.

EMOTION ACTIVATION AND EXPRESSION

Empirical research on the role of emotion in therapeutic change has consis-

tently demonstrated a relationship between in-session emotion activation
and outcome. And this relationship has also been shown in a variety of
different forms of treatment. For example, Jones and Pulos (1993) in the
National Institute of Mental Health collaborative study of depression found
that the strategies of evocation of affect and the bringing of troublesome
feelings into awareness were correlated positively with outcome in both
dynamic and cognitive behavior therapies. In another study by this group,
an examination of the therapist’s stance in interpersonal therapy and CBT of
depression, showed that it was important for therapists to focus on emotion
regardless of orientation. In that study, Coombs et al. (2002) found that
collaborative emotional exploration, which occurred significantly more fre-
quently in interpersonal therapy, was found to relate positively to outcome in
both forms of therapy, whereas educative/directive process—more frequent
in CBT—had no relationship to outcome. Helping people overcome their
avoidance of emotion, focusing collaboratively on emotions, and exploring
them in therapy thus appear to be important in therapeutic change regard-
less of therapeutic orientation.
 Research on Emotional Change  •  41

Research, however, has also shown that venting emotions by expressing

them with high arousal by crying, yelling, or pounding to get emotional
release was unsuccessful in alleviating disorder. Expressing anger, for
example, which was seen as alleviating internal psychic pressure that, if not
released, could lead to explosions, dissociations, or disintegration, did not, by
itself, necessarily result in good outcomes in therapy (Bohart & Greenberg,
2002; Bushman, 2002; Daldrup et al., 1988; Nichols & Efran, 1985; Nichols
& Zax, 1977).
A meta-analytic review found that exposure therapy is a highly effective
treatment for posttraumatic stress disorder (PTSD) and that its effectiveness
is based on emotional processing (Foa et al., 2003). In a series of studies on
behavioral exposure (Foa et al., 1995; Foa & Jaycox, 1999; Foa & Kozak, 1998;
Jaycox et al., 1998), positive outcome for PTSD from rape was predicted
by the arousal of fear and its expression while retelling trauma memories
during the first exposure session and by the attenuation of distress during
exposures over the course of therapy. Evidence also suggests that patients
with anxiety disorders who are best able to experience anxiety during the
therapy session are most likely to benefit from therapy (Borkovec & Sides,
1979). Studies of recovery patterns in sexual and non-sexual assault victims
found that, in general, long-term recovery is impeded if the indispensable
emotional engagement with traumatic material in therapy is delayed (Gilboa-
Schechtman & Foa, 2001). Findings like this indicate that emotional arousal
during imaginal exposure is at least a partial mechanism of change across
different disorders.
Piliero (2004) investigated clients’ experience of the process of affect-
focused psychotherapies on outpatient therapies of mixed populations
and diagnostic groups. The clients had participated in one of three EFTs:
accelerated experiential dynamic therapy (Fosha, 2000), intensive short-
term dynamic therapy (Abbass, 2002), and EFT (Greenberg, 2002). Clients’
self-reports of their experiences in their treatments were assessed retro-
spectively. Their reports of having experienced deep affect in therapy were
clearly related to both being satisfied with therapy and feeling that change
had occurred. A significant relationship existed between clients’ recognition
of their therapist’s affect-eliciting techniques and feelings of satisfaction and
change. Piliero (2004) concluded that emotional experiencing may be the
final common pathway to therapeutic change.
Recent meta-analytic findings attest to the negative effect of suppressing
emotions on therapeutic outcomes (Scherer et al., 2017). They show a signi­
ficant medium-to-large effect size between the client’s emotional expres-
sion and outcomes (d = 0.85). Third-party rating of emotional expression
42  •  Changing Emotion With Emotion

as opposed to self-report emerged as a significant moderator of outcomes.

Pretreatment suppression was found to be the best predictor of nonresponders
to treatment rather than reappraisal or diagnosis of a personality disorder.
This finding suggests that diagnosis is not a good predictor of outcome and,
more specifically, that it is suppression—not reappraisal—that is operative
in disorder and needs to be the target of change.
This finding is, to some degree, in line with other studies that have found
larger relationships between suppression and psychopathology than between
reappraisal and psychopathology (Aldao et al., 2010; Barnow, 2012). It might
also be the case that patients with more suppression at the onset of therapy
are less able to form a therapeutic alliance with their therapist (Ogrodniczuk
et al., 2008). This suggests that training therapists to recognize and facili-
tate client emotional expression is needed Although many diagnoses have
strong affective components (e.g., depression, anxiety, PTSD), researchers
and therapists, over the past few decades, have typically privileged changes in
behavior as the markers of success. More research is needed to systematically
investigate how emotional expression and experiencing relate to therapeutic
progress on the way to lasting change (Luedke et al., 2017; Peluso et al., 2012).

PROCESS-OUTCOME STUDIES

Experiencing and expressing emotion appear to be helpful, but not by a

procedure of cathartic venting. What, then, is helpful about emotion work?
Reviews of process-outcome studies show a strong relationship between
in-session emotional experiencing as measured by the depth of experienc­
ing (EXP) Scale (Klein et al., 1969) and therapeutic gain in dynamic,
cognitive, and experiential therapies (Castonguay et al., 1996; Goldman
et al., 2005; Orlinsky & Howard, 1986; Silberschatz et al., 1986). These
findings suggest that it is the processing of one’s bodily felt experience in
therapy by symbolizing it in awareness that may be a core ingredient of
change in psychotherapy regardless of approach. “Symbolizing,” here, means
making the implicit explicit predominantly by putting inchoate experience
into words, although these feelings could, at times, be symbolized in music,
movement, or art. Symbolizing is making the implicit available to conscious
awareness.
But what is “emotional processing”? Greenberg et al. (2007) defined and
developed a measure of productive emotional processing: client emotional
productivity, which is a person’s being mindfully or contactfully aware of a
presently activated primary emotion. Emotional productivity was operation-
alized in terms of the following seven features: attending, symbolization,
 Research on Emotional Change  •  43

congruence, acceptance, agency, regulation, and differentiation. This measure

discriminated between productive and unproductive arousal in an inten-
sive examination of four poor and four good outcome cases (Greenberg
et al., 2007). No significant relationship was found between high expressed
emotional arousal, measured over the whole course of treatment, and out-
come. Rather, it was the productive processing of the highly aroused emotion
that was an excellent predictor of outcome. In a larger study (Greenberg
& Watson, 1998) on a sample of 74 clients from the randomized clinical trial
of the effects of EFT on depression at York University, Auszra et al. (2013)
found that emotional productivity increased from the beginning to the work-
ing and the termination phases of treatment. In addition, working phase
emotional productivity predicted about 56% of treatment outcome—over
and above variance accounted for by beginning phase emotional productivity,
working alliance, and high expressed emotional arousal in the working phase
of treatment. These results indicated that it is the productive processing of
aroused emotion that is important for therapeutic change.

Productive Emotional Processing

An important feature of working with emotion, as noted in Chapter 1, is

the distinction between primary and secondary emotion on the one hand,
and adaptive and maladaptive emotion on the other. Therapists also need
to assess whether a client’s emotion is being processed productively. To be
productive, primary emotions require a particular manner of processing: being
contactfully or mindfully aware of the emotion. A system for measuring this
productive emotional processing was developed by Auszra et al. (2013) and
found to strongly predict therapeutic outcome.
Referring now to the seven elements of productive emotional processing,
at the most basic level, for emotion to be processed productively, the client has
to attend to an activated primary emotion to be aware of it. Once a physical
or emotional reaction is attended to, it has to be symbolized (generally in
words but perhaps in some other form, e.g., painting, movement) to be able
to fully comprehend its meaning. For example, consider the following state-
ments from a client attending to his feeling:

CLIENT: I don’t know what I feel. It just feels bad.

THERAPIST: Something like, “I feel it was sort of a loss, maybe sad or dis-
appointed.” [empathic exploratory response]

CLIENT: Yeah, really disappointed. In some way, it’s dashed some of

my hopes. [symbolizing]
44  •  Changing Emotion With Emotion

Next, for a feeling to be congruent, what the client says needs to match
how the client feels. Feeling sad is matched with a sad face and voice, not
a smile; feeling anger is expressed with some energy in the voice and an
assertive posture rather than no vocal energy and a downcast look. Another
important aspect of a productive emotional processing is acceptance of
emotional experience. In particular, it is acceptance of unpleasant and pain-
ful emotional experience that is important.
Emotional experiences also have to be sufficiently regulated for the
processing to be productive. The therapist needs to help clients develop and
maintain a working distance from the emotion (Gendlin, 1996) so that the
emotion is not overwhelming. This distancing enables clients to cognitively
orient toward emotion as information, thus allowing for an integration of
cognition and affect. Productive emotional processing also involves clients’
experiencing themselves as “active agents,” rather than as passive victims,
of the emotion. This involves a client’s taking responsibility for their emotional
experience and acknowledges it as a personal experience rather than as
something caused by some external agency. With agency, clients feel that they
are having the emotion (“I feel sad”) rather than the emotion having them
(“It takes me over”).
To be productive and for emotion utilization and transformation to
occur, a client’s primary emotional expression has to be differentiating over
time. Fundamentally, the client must not be stuck in the emotion but, rather,
explores and differentiates new aspects of experience. Their emotional
process is highly fluid.

Emotional Expression: Experiencing and Therapeutic Progress

As important and necessary as arousal, acceptance, and tolerance of emo-

tional experience are, they are insufficient for change. Optimum emotional
processing also involves the integration of cognition and affect (Greenberg,
2002; Greenberg & Pascual-Leone, 1995). Once clients have achieved con-
tact with emotional experience, they also must cognitively orient to that
experience as information and explore, reflect on, and make sense of it. In
addition, they must access other internal emotional resources to help trans-
form the maladaptive state.
A recent meta-analysis found an association between clients’ emotional
expression and treatment outcome (Peluso & Freund, 2018). A significant
medium effect size was found between the therapist’s emotional expression
and outcomes (d = 0.56) and a significant medium-to-large effect size between
the client’s emotional expression and outcomes (d = 0.85). Thus, the client’s
 Research on Emotional Change  •  45

expressions of affect probably prove more important than the therapist’s in

relation to treatment outcomes.
Although many diagnoses have strong affective components (e.g., depres-
sion, anxiety, PTSD), researchers and therapists over the past few decades
have typically privileged changes in behavior as the markers of success. Only
recently have contemporary researchers begun to systematically investigate
how emotional expression and experiencing in therapy can be considered
reliable indicators of therapeutic progress on the way to lasting change
(Luedke et al., 2017; Peluso et al., 2012).
Further supporting the hypothesis that paying attention to and making
sense of emotion are important, process-outcome research on the emotion-
focused treatment of depression in EFT has shown that both higher emotional
arousal at midtreatment coupled with reflection on the aroused emotion
(Warwar & Greenberg, 1999) and deeper emotional processing late in
therapy (Pos et al., 2003, 2009), predicted good treatment outcomes. High
emotional arousal plus high reflection on aroused emotion distinguished good
and poor outcome cases, therefore indicating the importance of combining
arousal and meaning construction (Missirlian et al., 2005; Warwar, 2005).
Watson and Bedard (2006) also found that higher levels of emotional pro-
cessing during sessions predicted better outcome. Emotion-oriented therapy
appears to work by enhancing the type of emotional processing that involves
helping people experience and accept their emotions, and make sense of them.
Core theme-related EXP in the last half of therapy was found to be a
significant predictor of a reduction in symptom distress and increases in
self-esteem (Goldman et al., 2005). EXP on core themes also accounted for
outcome variance over and above that accounted for by early EXP and the
alliance. EXP, therefore, mediated between any client individual capacity
for early experiencing and positive outcome. In another study, Pos et al.
(2003) found that emotional processing—defined here as EXP on emotion
episodes—was found to mediate any client individual capacity for early
experiencing and positive outcome. The EXP variable was contextualized by
being rated only on those in-session episodes that were explicitly on emotion-
ally laden experience.
Early capacity for emotional processing did not guarantee good outcome,
nor did entering therapy without this capacity guarantee poor outcome.
Therefore, although likely an advantage, early emotional processing skill
appeared not as critical as the ability to acquire or increase depth of emo-
tional processing throughout therapy, or both. Late emotional processing was
found to independently add 21% to the outcome variance over and above
early alliance and early emotional processing.
46  •  Changing Emotion With Emotion

Warwar (2005) examined midtherapy emotional arousal as well as

experiencing in the early, middle, and late phases of therapy. Emotional
arousal was measured using the Client Emotional Arousal Scale-III-R (Warwar
& Greenberg, 1999). In the study, clients who had higher emotional arousal
midtherapy were found to have more change at the end of treatment. And
not only did midtherapy arousal predict outcome, but it also predicted a
client’s ability to use internal experience to make meaning and solve problems,
as measured by EXP, particularly in the late phase of treatment. Midtherapy
arousal also added to the outcome variance over and above middle phase
emotional arousal. The study thus showed that a combination of emotional
arousal and experiencing was a better predictor of outcome than either
index alone.
The Warwar (2005) study measured “expressed” as opposed to “expe-
rienced” emotion. In a study examining in-session client reports of experi-
enced emotional intensity, Warwar et al. (2003) found that client reports
of in-session experienced emotion were not related to positive therapeutic
change. A discrepancy was observed between client reports of in-session
experienced emotions and the emotions that were actually expressed based
on arousal ratings of videotaped therapy segments. For example, one client
reported that she had experienced intense, painful emotions in a session.
Her level of expressed emotional arousal, however, was judged to be low
based on observer ratings of emotional arousal from videotaped therapy
segments.
Carryer and Greenberg (2010) found that it was a moderate rather than
high or low frequency of heightened emotional arousal that added signifi-
cantly to the outcome variance predicted by the working alliance. That study,
however, showed that a frequency of 25% of highly aroused emotional
expression was found to best predict outcome. Deviation toward lower
frequencies, which indicated lack of emotional involvement, represented the
generally accepted relationship between low levels of expressed emotional
arousal and poor outcome. Deviation toward higher frequencies, though,
showed that excessive amounts of highly aroused emotion are negatively
related to good therapeutic outcome. These findings suggest that having
the client achieve an intense and full level of emotional expression is
predictive of good outcome as long as the client does not maintain this level
of emotional expression for too long or too often. In addition, the frequency
of reaching only a marginal level of arousal was found to predict poor
outcome. Thus, expression that is on the way to the goal of heightened
expression of emotional arousal but does not attain it, or that reflects an
 Research on Emotional Change  •  47

inability to express full arousal and possibly indicates interruption of possible

arousal, appears undesirable.

Development of a Model of Changing Emotion With Emotion

A model of the in-session process of changing emotion with emotion has

been proposed and tested (Greenberg, 2002; Greenberg & Paivio, 1997;
Herrmann et al., 2016; A. Pascual-Leone & Greenberg, 2007). Clients who
resolve their global distress in sessions move from secondary emotions (e.g.,
“I feel bad”) through primary maladaptive emotions based on fear, sadness,
or shame (e.g., “I’m worthless,” “I can’t survive on my own”) to primary
adaptive emotions (e.g., “I feel resolved,” acceptance; Herrmann et al., 2016;
A. Pascual-Leone & Greenberg, 2007). Transformation of distressed feelings
is thus viewed as occurring by first attending to the aroused presenting
symptomatic feelings followed by exploring the cognitive–affective sequences
that generate the bad feelings (e.g., “I feel hopeless,” “What’s the use of
trying?”). Exploration of these secondary feelings leads to the activation of
some core maladaptive emotion schematic self-organizations.
A. Pascual-Leone and Greenberg (2007) found that clients in states of
global distress resolve their distress by moving in one of two directions: into
a core maladaptive self-organization based on maladaptive emotion schemes
of fear and shame or into the sadness of lonely abandonment. They also
may move into some form of secondary expression, one often of hopeless-
ness or a type of rejecting anger. The path to resolution invariably leads
to the expression of adaptive grief or hurt and to empowering anger or self-
soothing; these expressions facilitate a sense of self-acceptance and agency.
More resourceful clients often move directly from secondary emotions directly
to assertive anger or healthy sadness, but many of the more wounded clients
need to work through their core maladaptive attachment-related fear and
sadness or identity-related shame (Greenberg, 2015; Greenberg & Paivio,
1997; Greenberg & Watson, 2006).
A. Pascual-Leone and Greenberg (2007) also found that transformation
occurs when core maladaptive states are differentiated into adaptive needs,
which act to refute the core negative evaluations about the self that is
embedded in their core maladaptive schemes. The essence of this process is
that, when mobilized and validated, core adaptive attachment and identity
needs (i.e., to be connected and to be validated) embedded in maladaptive
feelings of fear, shame, and sadness act to access more adaptive emotions
and to refute negative self-messages of being unworthy of love, respect, and
48  •  Changing Emotion With Emotion

connection. The inherent opposition of these two experiences (i.e., “I am not

worthy or lovable” and “I deserve to be loved or respected”) supported by
adaptive anger or sadness in response to the same evoking situation over-
comes the maladaptive state. This is done by accessing new self-experience
and creating new meaning, which leads to the emergence of a new, more
positive evaluation of the self.
Within the context of a validating therapeutic relationship, the client then
moves on to grieve, acknowledging the loss or injury suffered (recognizing
“I don’t have what I need, and I miss what I deserved”), and to assert empow-
ering anger or self-soothing. Depending on whether the newly owned need
involves boundary-setting or comfort, clients direct their adaptive emotional
expression outward to protect boundaries (i.e., in anger) or inward toward
the self (as compassion or caring). This expression often transforms into
grieving for what was lost. This grief state is characterized by either sadness
over a loss or recognition of one’s hurt or woundedness (or both) but without
blame, self-pity, or resignation, which characterize the initial states of global
distress. Resolution involves integrating the sense of loss with the sense of
possibility in the newfound ability to assert and self-soothe. Throughout the
process of transformation, moderate-to-high emotional arousal is necessary
but at a level that remains facilitative of the healing process. Therapists
must facilitate optimal emotional arousal that is sufficient enough so that
it is felt and can be oriented to as information but not so much that it is
dysregulating or disorienting. The movement depicted in this process—
from secondary emotions through primary maladaptive emotion to primary
adaptive emotion—represents the core change process by which emotion
changes emotion. The measure Classification of Affective-Meaning States
was developed and shown to predict good outcome (A. Pascual-Leone &
Greenberg, 2007).
A. Pascual-Leone (2018) went on to perform an extensive literature review
of studies that examined the preceding model. He identified 24 studies that
explored the relationship of the processes in the model and therapy outcome.
The studies used a variety of methods and included macro- and micro-
observation on 310 clinical cases and more than a 100 subclinical cases. The
clinical samples represented seven different treatment approaches, includ-
ing experiential, psychodynamic, and dialectical behavior therapy, and were
on a variety of populations ranging from affective disorders through trauma
to personality disorders, thus attesting to the transdiagnostic, transtheoretical
nature of the evidence of changing emotion sequences according to the model.
The evidence supported that experiencing key emotions in therapy predicts
good outcome and that these emotions unfold in a particular sequence. From
 Research on Emotional Change  •  49

this review, A. Pascual-Leone found empirical support for the hypothesis that
an increase in adaptive emotion predicts good outcome regardless of treat-
ment and that the sequence of moving from global distress through primary
maladaptive emotions like shame, fear and sadness, followed by adaptive
emotions like assertive anger and grief as well as compassion, were associated
with good outcome (Kramer et al., 2015).
Herrmann et al. (2016) examined the relationship between in-session
types of emotional experience using a different type of study to test the
validity of the emotion changing emotion hypothesis. They defined and oper-
ationalized the different types of emotion in the Emotion Category Coding
System, which categorized activated in-session emotions as secondary/
instrumental, primary maladaptive, primary adaptive, or mixed/uncodable.
The different emotion categories were related to reduction in depressive
symptoms in a sample of 30 clients who received EFT for depression. Both
fewer secondary and more primary adaptive emotions in the working phases
of therapy were found to significantly predict outcome. Moderate levels
of primary maladaptive emotion in the middle working session were asso­
ciated with outcome, and the frequency with which clients moved from
primary maladaptive to primary adaptive emotions in this session predicted
outcome. Results of the study supported the transformational model of
changing emotion with emotion in which moving from secondary emotion
to primary maladaptive emotion to adaptive emotion is seen to be a key
change process.
In this transformation process, the decrease of secondary emotional expe-
rience and the accessing and deepening of primary maladaptive emotions to
moderate levels of emotional experience played an important role. However,
it was the activation of primary adaptive emotions appearing at the end that
was especially important in transformation. Therapists thus need to help
clients gain access to new primary adaptive emotional resources.
Levels in the different emotion categories in early sessions were not signi­
ficantly related to therapy outcome and did not show significant interactions
with levels later in therapy. Moreover, working phase levels in secondary
and primary adaptive emotions were found to significantly predict outcome
when controlling for early levels. Emotion categories thus seem to measure
ongoing process rather than merely reflect individual dispositions or traits.
A higher percentage of secondary symptomatic emotions in the working
phase significantly predicted poorer outcomes. What is interesting is that
Herrmann et al. (2016) found that the frequency with which clients moved
from primary maladaptive emotions to primary adaptive emotions predicted
outcome over and above the effect of mere emotional activation on outcome.
50  •  Changing Emotion With Emotion

It also predicted outcome independently of the effect of secondary emotions.

Moreover, the authors found the relationship between secondary emotions
in the working phase and treatment outcome to be fully mediated by the
proportion of primary adaptive emotions in that phase.

Importance of Accessing Primary Adaptive Emotions

The Herrmann et al. (2016) study validated that reducing secondary emo-
tions, such as hopelessness, in emotion-focused treatment is important but
only to the extent that the client succeeds in accessing primary adaptive
emotions, such as empowered anger. But primary maladaptive emotions
appear to play a central role in the process of therapy because moderate
levels of primary maladaptive emotions, such as shame or fear in the middle
working session, were associated with outcome. Clients who experienced
and worked through primary maladaptive emotions of, say, shame and then
accessed primary adaptive emotions, say, empowered anger or sadness, in
the middle working session more frequently tended to have better treatment
outcomes than those who did not. “Feeling bad” then neither means that
this is therapeutically bad or good. What seems to matter is for clients to
experience their core painful primary maladaptive emotions at moderate
levels, to work through them, and to access adaptive emotional resources.
The more frequently this is done, the better.
It seems that a mere focus on reducing symptomatic emotional experi-
ence in therapy, such as global depressive hopelessness, symptomatic fear,
or secondary defensive anger, is not enough. Focusing on arriving at core
primary maladaptive experiences that frequently have become part of the
client’s identity—such as shame of not being good enough or fear of being
too weak to survive alone, or the sadness of lonely abandonment—and then
accessing primary adaptive emotional experiences—such as anger against
a degrading inner voice, sadness of having lost a happy childhood, pride
or self-confidence, or self-compassion—seem of central importance (Kramer
& Pascual-Leone, 2016; Kramer et al., 2016).
Of all the variables considered in the Herrmann et al. (2016) study, the
proportion of primary adaptive emotions in the working phase was found
to be the best predictor of outcome. Clients with good treatment outcome
succeeded in accessing more adaptive emotional resources, potentially
counteracting and undoing the effect of automatic primary maladaptive and
secondary emotional responses, and thus leading to better outcome. Results
of the study support the principle of changing emotion with emotion and that
primary adaptive emotions play a role in transforming primary maladaptive
and secondary emotions.
 Research on Emotional Change  •  51

Timing of Emotional Arousal and Processing in Therapy

Good client process early in EFT trauma therapy has been found to be
particularly important because it sets the course for therapy and allows
maximum time to explore and process emotion related to traumatic memories
(Paivio et al., 2001). Emotional arousal during imaginal exposure is at least
a partial mechanism of change (Paivio et al., 2001). One practical impli-
cation of this research is the importance—early in therapy—of facilitating
clients’ emotional engagement with painful memories. Overall, the findings
suggest a chain of influence on the degree to which a client processes emotion
in trauma. First, the severity of trauma symptoms sets a limiting factor in the
facilitation of emotional arousal and processing; next, there is early engage-
ment in imaginal exposure tasks; then, the repetition of exposure tasks over
the course of therapy have a successively cumulative impact on functioning
at outcome (Paivio et al., 2001; Paivio & Nieuwenhuis, 2001).
Emotional processes also have been studied in three controlled studies
(Greenberg et al., 2008; Greenberg & Malcolm, 2002; Paivio & Greenberg,
1995) on resolving emotional injuries and interpersonal difficulties. Emotional
arousal during imagined contact with a significant other was a process
factor that distinguished EFT from a psychoeducational treatment and was
related to outcome (Greenberg et al., 2008; Greenberg & Malcolm, 2002;
Paivio & Greenberg, 1995). Research on couple therapy also supports the
role of emotional awareness and expression in a satisfying relationship and
change in therapy. Couples who showed higher levels of emotional experi-
encing in therapy accompanying the softening in the blaming partner’s stance
were found to interact more affiliatively, and ended therapy more satis-
fied, than couples who showed lower experiencing (Greenberg, Ford, et al.,
1993; Johnson & Greenberg, 1988; Makinen & Johnson, 2006). A similar
effect of the expression of underlying emotion was found in resolving family
conflict (Diamond & Liddle, 1996). Revealing of underlying vulnerable
emotion also has been related to session and final outcome in the context
of EFT for couples.
In another study, couples rated sessions that contained the revealing of
underlying vulnerable emotion significantly more positively than control
sessions on a global measure of session outcome (McKinnon & Greenberg,
2013). In addition, following sessions in which underlying vulnerable emo-
tion was revealed, those who witnessed their partners reveal underlying
vulnerable emotion scored significantly higher on a measure of problem
resolution and a measure of understanding. The revealing of underlying
vulnerable emotion was associated with significantly greater improvement
in relationship satisfaction at termination.
52  •  Changing Emotion With Emotion

Emotion Work With Anxiety

Studies on the treatment of generalized anxiety disorder (GAD) found that

interventions that focus on clients’ affective and bodily experience were
more effective in treating individuals with GAD than treatment as usual
(Levy Berg et al., 2009). Clients themselves noted that supportive, reflec-
tive interventions as well as those that facilitated their emotional expres-
sion were helpful. EFT treatment of GAD has been shown to be effective
in two sets of repeated case studies (Timulak & McElvaney, 2016; Watson
et al., 2017, 2019). The key change process in working with GAD clients
in these studies involved accessing core painful feelings, often of attach-
ment insecurity, and transforming them with more adaptive emotions. The
overall therapeutic process involved, first, the formation of an empathic
relationship. Once a therapeutic relationship was developed, therapists
shifted the focus to how anxiety was generated by using two-chair dia-
logues between a worrier, the anxiety creator, and the experiencing self
who feels the impact of the anxiety and worry. In this process, clients see
that they are the agents rather than the victims of anxiety. This serves to
empower them and give them a sense that they can change (Watson &
Greenberg, 2017).
The overall effectiveness of working with emotion in the treatment of
anxiety is also supported by studies that looked at social anxiety (Elliott,
2013; Elliott & Shahar, 2017; Shahar, 2014; Shahar et al., 2015). In addi-
tion to systematic case studies (MacLeod et al., 2012; Shahar, 2014), two
outcome studies of emotion work with social anxiety showed good effects
(Elliott, 2013; Elliott et al., 2014; Shahar et al., 2017). The effect sizes
obtained for EFT were quite large and superior to effects found in compa-
rable studies of CBT and medication. These two studies provided evidence
supporting that emotion-focused work is promising for social anxiety and
offers large benefits for clients. The key change process in EFT for social
anxiety involved accessing and activating shame so that it could be restruc-
tured within a secure, accepting, validating therapy relationship. Clients were
helped to access their sense that they are defective, worthless, or inferior
and then to deepen it to their core pain (e.g., deep brokenness, isolation)
so that it could be transformed by experiencing and expressing adaptive
emotions, such as self-soothing/compassion, assertive/protective anger, and
connecting sadness (Greenberg, 2011). These adaptive emotions strengthen
socially anxious individuals and help them to connect with important needs
that have been missing in their lives, thus encouraging them to reestablish
relationships and fulfill authentic life goals and values.
 Research on Emotional Change  •  53

Conclusions of Process-Outcome Research

The evidence from psychotherapy research indicates that certain types of

therapeutically facilitated emotional awareness and arousal, when expressed
in supportive relational contexts and in conjunction with access to new
adaptive emotions and some conscious cognitive processing of the emotional
experience, are important for therapeutic change despite, in general, the
type of client or disorder. It appears that the process of change is similar
regardless of diagnostic grouping. It thus seems that (a) arriving at emo-
tion by attending, accepting, and symbolizing, and (b) leaving emotion by
changing emotion with emotion, are transdiagnostic processes. Emotions,
at times, need to be accessed and used as guides; at other times, they need
to be regulated and modified; and yet, at other times, emotions need to be
transformed by other emotions. Cognitive processing of aroused emotion
in therapy has been found to be helpful to make sense of emotions and to
create new narratives.
Arousing emotion or regulating it depends first on factors, such as
whether the client’s emotion is over- or underregulated and whether the
emotion is a sign of distress or of working through the distress (Greenberg,
2002; Kennedy-Moore & Watson, 1999). The role of arousal and the degree
to which it could be useful in therapy also depend on what emotion is
expressed, by whom, about what issue, how it is expressed, to whom,
when and under what conditions, and in what way the emotional expres-
sion is followed by other experiences of emotion and meaning-making
(Greenberg, 2002; Whelton, 2004). Nonetheless, for effective emotional
processing to occur, the distressing affective experience must be activated
and viscerally experienced by the client, and new emotions are needed to
change old emotions.

RESEARCH ON THERAPIST PROCESS

There has been limited research on specific therapist interventions that

facilitate emotional processing. In general, empathic attunement to affect
is the key skill and is discussed throughout this book. Since Rogers (1957)
identified empathy as an important variable in therapy, it has been found
to be a consistent predictor of client change (Bohart et al., 2002; Bohart &
Greenberg, 1997; Elliott et al., 2011). For example, Watson et al. (2014) found
a significant direct relationship between therapists’ empathy and therapy
54  •  Changing Emotion With Emotion

outcome. This finding suggests that clients’ perception of their therapists as

empathic is an important mechanism of change in psychotherapy.
In addition, Adams (2010) tracked moment-by-moment client–therapist
interactions and found that therapist statements that were high in experi-
encing influenced client experiencing and that depth of therapist experien-
tial focus predicted outcome. More specifically, if the client was externally
focused and the therapist made an intervention that was targeted toward
internal experience, the client was more likely to move to a deeper level of
experiencing. Adams’s study highlights the importance of the therapist’s role
in deepening emotional processes. Given that client experiencing predicts
outcome and that therapist depth of experiential focus influences client
experiencing and predicted outcome, a path to outcome is established,
suggesting that therapists’ depth of experiential focus influences clients’
EXP, and this relates to outcome.
Another important development in the articulation of therapist process
has been in the area of therapeutic presence. Specifically, developments
have been made in the conceptualization and provision of therapeutic
presence in EFT. This is seen as a continuation of a tradition that began in
client-centered (Rogers, 1980) and Gestalt therapy (Perls, 1973) and was
further developed within the emotion-focused relationship by Geller and
Greenberg (2012). Geller and Greenberg (2002) developed a measure of
therapist presence and established it as an important condition related to
outcome. Watson and McMullen (2005) studied key aspects of the EFT
therapy process and also compared them with CBT. Watson and McMullen
found that CBT therapists taught more and asked more directive ques-
tions, whereas EFT therapists offered more support. In their examina-
tion of the complex relationship among empathy, affect regulation, and
outcome reporting, Watson and Prosser (2002) found that the effect of
therapist empathy on outcome was mediated by changes in clients’ affect
regulation.

CHANGING EMOTION WITH EMOTION

Empirical evidence has mounted to support the importance of a process of

changing emotion with emotion. Parrott and Sabini (1990) early on found
that mood repair occurs by people recalling events that counteract both sad
and happy moods, and this recollection is done without awareness. In a
further interesting line of investigation, positive emotions have been found
to “undo” lingering negative emotions (Fredrickson, 1998; Fredrickson &
 Research on Emotional Change  •  55

Levenson, 1998). Studies have clearly shown that positive emotions (e.g.,
joy, love) can be used to undo the effects of so-called negative emotions like
anger and sadness (Fredrickson, 2009). For example, Fredrickson (2001)
showed that a positive emotion may loosen the hold that a negative emo-
tion has on a person’s mind by broadening a person’s momentary thought
action repertoire. The experience of joy and contentment were found to
produce faster cardiovascular recovery from negative emotions than a
neutral experience.
Fredrickson et al. (2000) found that resilient individuals cope by recruiting
positive emotions to undo negative emotional experiences. The basic obser-
vation is that key components of positive emotions are incompatible with
negative emotions. In a further study, Tugade and Fredrickson (2004) found
that resilient individuals cope by recruiting positive emotions to regulate
negative emotional experiences. These individuals manifested a physiological
bounce back that helped them to return to cardiovascular baseline more
quickly. Bad feelings appear to be able to be transformed by happy feelings—
not in a deliberate manner by trying to look on the bright side or by replace-
ment, but by the evocation of meaningfully embodied alternate experience
that undoes the physiology and experience of negative feeling. In a therapy
analogue study dealing with self-criticism, Whelton and Greenberg (2000)
found that in two-chair dialogues, people who were more vulnerable to
depression showed less resilience in response to self-contempt than people
who were less vulnerable to depression. The less vulnerable people were
able to recruit positive emotional resources like pride and anger to combat
the depressogenic contempt and negative cognitions. These studies together
indicate that emotion changes emotion.
In a line of research on the effect of motor expressions on experience,
Berkowitz (2000) reported a study on the effect of muscular action on mood.
Subjects who had talked about an angering incident while making a tightly
clenched fist reported having stronger angry feelings, whereas fist-clenching
led to a reduction in sadness when talking about a saddening incident.
This finding indicates both the effects of motor expression on intensifying
congruent emotions and on dampening other emotions. Thus, it appears
that the muscular expressions of one emotion can change another emotion.
In addition and in line with the James–Lange theory of emotions, Flack et al.
(1999) demonstrated that adopting the facial, postural, and vocal expres-
sion of an emotion increases the experience of the emotion whether the
subject is aware of what emotion they are expressing. The experience of
an emotion, to some degree, can be induced or intensified by putting one’s
body into its expression. Interestingly, there are individual differences in
56  •  Changing Emotion With Emotion

this capacity; those who are more body sensitive show this tendency to a
greater degree.
A more general line of research in social psychology on the effects of
role playing on attitude change also supports the idea that performing
actions in a role brings people’s experience and attitudes in line with the
role (Zimbardo et al., 1977). Role playing can transform what is, at first,
not real into something real, just as saying something can lead to believing
it (Myers, 1996). Thus, a possible way to evoke another emotion is to have
people role-play its expression. As they express an emotion, it will change
their experience toward the expression.
In psychotherapy research, it has been found that music is helpful in
evoking alternate emotions and even more helpful than imagery for chang-
ing emotion (Kerr et al., 2001). Right frontal electroencephalogram (EEG)
activation typically associated with sad affect was shifted toward symmetry
by both massage and music (Field, 1998). Shifts to more positive mood or
at least to symmetry between sad and happy affect were accompanied by
shifts from right to left frontal EEG activation in both mothers and children
(Field, 1998).
Results of a number of single-case investigations of therapies of depres-
sion (Watson et al., 2007) combined with larger group studies that compared
therapies of depression (A. Pascual-Leone & Greenberg, 2007), along with
others more generally relating emotional arousal to outcome (Greenberg,
2015; Herrmann et al., 2016), supported the principle that emotional arousal
and the attendant transformation of emotion with emotion occurred signifi-
cantly more in cases with recovery of their depression than in poor outcome
cases with no recovery of their depression. In a number of intensive analyses
of good outcomes, Watson et al. (2007) found reductions in shame and
fear and increases in anger, sadness, contentment, and joy. The patterns
of emotional transformation, however, were idiosyncratic. Which emotions
replaced which were idiosyncratic to each case.

CONCLUSION

In addition to the studies reviewed in this chapter, it is heartening to note an

emerging theoretical approach to a unified treatment: Barlow et al. (2004)
postulated the existence of a negative affect syndrome, which manifests
differentially as depression, anxiety disorders, or even as eating disorders
in different patients. They identified three basic principles that may cause
distress to patients regardless of disorder and that should therefore be targets
 Research on Emotional Change  •  57

of a transdiagnostic approach to therapeutic change: altering antecedent

reappraisals, modifying emotion-related action tendencies, and overcoming
emotional avoidance. In the concluding chapter, “Looking Ahead: A Unified
Approach to Psychotherapy,” I discuss more emerging directions and offer a
fuller vision of what lies ahead for emotion work in psychotherapy. For now,
I summarize by stating that the relationship between therapeutic benefit
and emotional experience, expression, or specific therapy processes is not
a simple one. However, many indicators do suggest the benefits of a trans-
theoretical clinical approach with emotion at its center.
3 CHANGING EMOTION WITH
EMOTION

In this chapter, I discuss changing emotion with emotion—that is, the process
of transformation by the synthesis of opposing emotions. I also look at
the theory of memory reconsolidation, which shows how introducing new
present emotional experience can change old memories through the process
of memory reconstruction. It is new emotional experience that allows auto-
matic connections (unconscious) at a neuronal level (schematic) to sculpt
new ways of feeling and being.
It is important to understand that in discussing changing emotion with
emotion, we clinicians are talking about changing underlying emotions from
the past that influence the present to improve real-world coping. So, for
example, we work to change the painful emotion schemes that have been
developed from past experience that produce emotions, such as fear of
abandonment, shame of unworthiness, or sadness of empty aloneness. These
are the feelings that form the basis of presenting problems, including low
self-worth, interpersonal problems, or global distress. Changing emotion
with emotion is done by accessing underlying maladaptive emotions and
transforming them with new adaptive emotions.

https://doi.org/10.1037/0000248-004
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

59
60  •  Changing Emotion With Emotion

We are not talking about direct modification of presenting symptomatic

behavior—for example, overcoming the anxiety that prevents one from
going to the mall or reducing angry outbursts. We also are not working to
reduce symptomatic emotions by habituation or exposure to reduce arousal.
Rather, the work is to transform underlying painful emotions—often not
initially in awareness or expressed—that are the underlying determinants
of the presenting problematic arousal or symptoms. The necessary first step
in changing emotion with emotion is to increase the dreaded painful under-
lying emotion rather than reduce the presenting symptomatic emotion. The
aim is not the extinction of the activated underlying emotion but, rather,
its transformation with new experience.

MODELS OF CHANGE

Learning theory models of change view change as occurring by extinction,

which involves modifying automatic processing by some form of new con-
ditioning. Change is seen as occurring by inhibition of associations (Craske
et al., 2014). New learning takes place that suppresses the original learning
rather than transforming it, leaving the old learning intact. Cognitive therapy
still embracing learning theory has added the view that people are not only
reactive processors governed by prior conditioning but also are influenced
by goals and expectations. Stimuli are seen not only as leading to behav-
ioral responses but as activating beliefs, which then influence emotions and
behaviors.
Foa and Kozak (1986) developed an emotional processing model that
proposed that the mismatch between what was expected based on prior
knowledge and current learning was one of the necessary conditions for
new learning to occur. This perspective led to exposure as a main form of
treatment; however, it did not take memory change into account. Thus, left
open is the question of whether exposure simply strengthens inhibition of
old memories or leads to change in memories. Are old memories inhibited
or transformed so as to erase the old memory? The fact that people often
relapse after exposure treatments suggest that the memory has not changed,
but is only being inhibited and is ready to be reactivated—if the conditions
are right.
In contrast to learning theory, Greenberg and Safran (1987), adopting a
neo-Piagetian developmental point of view, proposed that change occurs by a
dialectical synthesis of opposing emotion schematic memories of past painful
experience. This view has been supported by the subsequent development of
 Changing Emotion With Emotion  •  61

reconsolidation theory (Lane et al., 2015; Nader et al., 2000), which I elab-
orate later. This theory proposes a different process in which the memory
is actually transformed by new experience. Memory change and extinction,
then, are two different, mutually exclusive, processes. Here, I present the
theory of changing emotion with emotion as a transformational process in
which emotional memories are changed—not inhibited—by the experience
of new emotional responses. Memory reconsolidation involves both activa-
tion of the emotion memory and generation of a new emotional response to
change the old emotional response.
In addition to the debate about transformation versus suppression of
memories and their emotions, a belief commonly held in modern acceptance-
based and other third-wave cognitive behavior therapy approaches (Hayes
et al., 2008) is that change occurs by experiencing and accepting emotion
or by accessing and expressing. The acceptance of the disowned was a view
originally proposed by humanistic–experiential approaches (Perls, 1973;
Rogers, 1959), but, in my view, it is a simplification that can be detrimental
to therapeutic change. This view is based on a notion that mere acceptance
of emotion helps clients to overcome what, in cognitive behavior therapy
language, has come to be called “experiential avoidance” or what human-
istic therapy had originally referred to as “disowned feelings” (Perls, 1969;
Rogers, 1957). In the acceptance or reowning view, problems are seen
essentially as being caused by avoidance or denial of emotion.
In an insight-oriented view of change, emotions or impulses are seen as
being kept out of awareness by habitual defenses, and therapeutic change is
seen as being effected by overcoming defenses and acknowledging feelings.
In their affect phobia approach, McCullough et al. (2003) blended psycho-
analytic and behavioral views, essentially seeing psychological problems
as arising from fear of emotion. Based on this viewpoint, they proposed a
type of exposure and response prevention theory to emotional change. It is
this: Exposure to the client’s fear of and anxiety about their feelings as well
as response prevention (i.e., not avoiding or giving up defenses) help clients
overcome avoidance, put aside defenses, and experience deep emotion long
enough that the anxiety subsides.
Some psychodynamic views also propose that clients also develop enough
of a self-observing capacity and self- understanding that they are able to
see their defenses coming up and, in the course of ordinary life, are able
to make different choices. In these views, therapists thus need to help the
client access unprocessed feelings, experience them deeply enough to break
the conditioned anxiety, and then, through understanding, consciously
choose to overcome the avoidance or defense (see, e.g., Hayes et al., 2008)
and see choice as an important factor in change.
62  •  Changing Emotion With Emotion

As important as acceptance of previously disclaimed emotions and

action tendencies are, the view that I propose here differs. I see clients as
changing by having new emotional experience that is discrepant from old
experience. Changing emotion with emotion is not exposure, is not associa-
tionism or conceptual learning, and is not understanding or insight. Rather,
changing emotion with emotion is new procedural learning by having new
emotional experience in the session that transforms old emotional memo-
ries and responses. This involves implicit psychological processes of change
by the automatic synthesis of old elements of experience (which have been
stored as emotion schematic memories) with new experience in the session.
It works by the brain’s making new implicit linkages as opposed to accepting
or making conscious, previously denied feelings or by counterlearnings as
proposed by learning theorists.

EXPANSION OF THE EMOTIONAL RESPONSE REPERTOIRE

As noted in the Introduction to this volume, Alexander and French (1946)

and Goldfried (1980) proposed that providing clients with new, corrective
experiences is a common therapeutic strategy and a core change principle
regardless of approach. What I am proposing, although in the same spirit,
differs from these proposals by specifying a unique process: that of changing
emotion with emotion as at the core of corrective emotional experience.
This, I am suggesting, is a transtheoretical process that is applicable across
orientations. It necessitates working at an experiential level with visceral
bodily experienced feelings. These feelings change only after a bodily felt
shift occurs that then is symbolized in language and formed into narrative
meaning to consolidate the experiential change. I suggest that the change takes
place neuronally as the brain lays down new pathways to form new emotion
schemes that represent the new lived experience. Furthermore, regardless of
approach—be it experiential, cognitive behavioral, or psychodynamic—when
change takes place, it is because of new emotional experience changing old
emotional experience. In addition, this change process is applicable trans­
diagnostically regardless of disorder because most disorders are disorders of
emotion and emotional processing.
Useful change comes not from what we tell ourselves, what our minds
invent to soothe our anxieties, or even what we are told by others but
by close contact with new experience. This is why this type of process is
called experiential: It involves learning from experience, not from a therapist,
not from reasoning, and not from new understanding. The therapeutic task
 Changing Emotion With Emotion  •  63

becomes to facilitate new experience but not by psychoeducation, skill train-

ing, or interpretation. Working in this way to help clients have new emotional
experiences to change the old emotional experiences involves the ability of
the therapist to handle (i.e., contain) the client’s fear of their dreaded expe-
rience as well as the therapist’s own fear of the client’s emotions.
New experience is what is change producing. In this process, conscious
change in beliefs, narratives, and decisions comes relatively late in the
sequence of change and only after an emotional shift has occurred. The
emphasis is not on just experiencing previously disallowed emotions; rather,
the broad goal of change is arriving at previously disclaimed, dreaded
emotion to make them accessible to transformation by new emotions. People
have to feel emotions to change emotions. They need to feel fear to change
fear, feel shame to change shame. To achieve change, therapists need to pro-
mote experience of new emotions to change old emotions. This goes beyond
the more restricted goal of only making contact with and accepting emotions.
The simple experience and expression of emotions, although important, are
not enough.
As described briefly in Chapter 1, in this book, I focus on two basic aspects
of working with emotion: “arriving at” emotion and “leaving” emotion. To
heal, people have to allow themselves to fully experience what it is that
they are feeling; but, if that’s all they do, then they just end up feeling their
maladaptive fear, shame, or sadness. What is now needed is to leave these
emotions. Transformation of these reowned maladaptive emotional responses
happens when people are able to access new primary adaptive emotional
responses to change the old, now obsolete, responses. So, we have a two-step
process: arriving and leaving. In the first stage, the therapist helps the client
to reown the disowned feelings, reclaim the disclaimed action tendencies,
and articulate and explore their emotional significance.
In the second stage, having arrived at a core maladaptive feeling and
having articulated its personal meaning, the goal is to help the client access
a more adaptive emotional resource as an antidote to the maladaptive feel-
ing. One of the most effective interventions to help access a more adaptive
emotional response is asking clients what their feelings need to feel better.
The therapist might ask, “What does this deep feeling of hurt and distrust
need?” The client might respond, “I just need to be held and to be comforted.
I do so want some of the warmth.” Accessing a feeling of deserving to have a
previously unmet adaptive need met is a central part of the change process
of accessing new feelings to undo old feelings (Greenberg, 2002, 2011).
Once new adaptive feelings are accessed, therapists focus on facilitating
the construction of new narratives.
64  •  Changing Emotion With Emotion

Therapists, for example, can help depressed clients reown their mal­
adaptive feelings of shame of rejection by guiding them to an episodic
memory in which this emotion had been strongly evoked. Clients may, for
instance, be asked to imagine themselves as a frightened child who has been
left alone, and once the emotion is felt, to focus on what is needed.
They need to arrive at the feeling of lonely abandonment before they can
leave this feeling. Transformation occurs when people are able to access new
emotional responses to the old situations. A client first has to reexperience,
for example, their shame and fear as they remembers their abusive father
and scenes related to the abuse. That client then needs to generate new
emotional responses, such as anger at violation, sadness of grief, and com-
passion for the pain their younger self suffered. Transformation results in an
expansion of a person’s emotional response repertoire (Greenberg, 2011)
that enables the expression of more adaptive action tendencies and new story
outcome. Although a feeling has to be felt to be changed, change involves
more than just feeling an emotion; it also requires experiencing a new more
adaptive feeling and developing a new narrative.
Emotion work of this type involves a combination of following and
leading. Following to arrive at the emotion is seen as taking precedence
over leading, which is especially the case with clients having greater internal
locus of control, or those with more oppositional styles who are more reactive
to control, or more fragile clients who need more safety. More distressed
and more avoidant clients, however, often benefit initially from more leading.
Leading takes the form of process guidance and emotion coaching in which
the therapist consistently guides toward emotion. It includes a form of
emotional “re-parenting” in which therapists offer validation, soothing, and
compassion in response to clients’ emotions. Often the clients who need
this type of response had never received it before. Therapists need to fit the
degree of leading and following to each client.
Although there may be something to be said for the more traditional
ways of thinking about changing emotion, such as acceptance, expression
and completion, habituation, extinction or, reflective understanding, I have
found, based on my research of studying actual change events in therapy
(Greenberg, 1984, 2007), that changing emotion with emotion is a more
accurate description of how emotional change actually takes place. Reason is
seldom sufficient to change automatic emergency amygdala-based emotional
responses. Darwin (1897), on having automatically jumped back from the
strike of a glassed-in snake, noted that having approached it with the deter-
mination to not move back, his will and reason were nevertheless powerless
against the imagination of a danger that he had never even experienced.
 Changing Emotion With Emotion  •  65

Maladaptive emotions are impenetrable to reason and are best transformed

by other emotions. An analogy in nature is fighting fire with fire. In King John,
Shakespeare wrote, “Be fire with fire; threaten the threatener and outface
the brow of bragging horror” (V, i, 48–50; Staunton, 1898). In other words,
respond by using a similar method, match kind with kind; so, here: change
emotion with emotion.

Neuronal Change in the Synthesis of New Experience

The repeated or sustained coactivation of a more adaptive emotion along

with a maladaptive emotion to the same stimulus helps to synthesize a
new experience, thereby transforming the maladaptive emotion. There
appear to be a number of aspects of the process of transformation through
the coactivation of different emotional states to synthesize new emotional
responses. At the most fundamental level, the action tendencies in the new
emotion oppose the action tendencies in the old one, leading to a novel
response. A person cannot withdraw in fear if anger with a tendency to thrust
forward is coactivated. This is not a process of one emotion replacing another
emotion; rather, it is that one emotion undoes or transforms another emotion
by a process of a dialectical synthesis to produce a new form of experience.
Just as yellow combines with blue to make green, so do approach tendencies
combine with withdrawal tendencies to make a new response tendency—
possibly of boundary setting or calm.
At the schematic level of processing, different schemes synthesize to form
higher level schemes. As Hebb (1949) stated, the first law of neuroscience is
that neurons that fire together wire together and continue to fire together.
So, new emotion schemes are formed by the synthesis of two or more schemes
coactivated by the same stimulus. With new action tendency, and new scheme
formation, there is new bodily felt experience and changed orientation to
the world. This new feeling is now consolidated by the construction of a
new narrative, which leads to new meanings and new articulated views of
self, world, and other.
In therapy, maladaptive fear, once aroused, can be transformed into
security by the more boundary-establishing emotions of adaptive anger or
disgust or by evoking the softer feelings of the sadness of loss, compassion,
or forgiveness. Similarly, maladaptive anger can be undone by adaptive
sadness and result in letting go and accepting. Maladaptive shame can be
transformed into self-acceptance by accessing anger at violation, pride, and
self-worth or by self-comforting compassion, or all of these. In this manner,
emotions that lead to withdrawal are transformed by approach emotions
66  •  Changing Emotion With Emotion

from another part of the brain. Once emotion changes, cognition and narra-
tives also change. Now, people, neglected as children, who no longer feel
unworthy change their narratives: Where once they were unlovable, now
the narrative specifies that others were incapable of love. Where once people
who were abused blamed themselves and felt ashamed or guilty about the
abuse, now they see themselves as not responsible.

The Undoing, Not Replacement, of Emotion

It is intuitively clear to most people that feeling good can change feeling
bad, but we are not talking primarily about replacing so-called negative
emotions with positive ones. Rather, in therapy, we are talking about undoing
the maladaptive emotion with another emotion that has an opposing action
tendency. For example, anger is frequently used to battle against fear and
helps people overcome fear by changing the experience of situations. In life,
anger changes behavior and enables one to take a greater risk, whereas fear
hinders risky action. In therapy, one way to transform fear from prior abuse
is to experience one’s previously inaccessible anger at violation, which leads
to more assertive experience. If, for example, a client imagines an abusive
father, and doing so evokes his fear from memories of prior abuse, then if
he comes to experience his adaptive anger at violation and expresses it to
the imagined father, he has a corrective emotional experience in which he
now feels stronger and more able to assert himself. Anger influences cogni-
tion; it triggers a more optimistic view of oneself than sadness and biases a
person toward feeling and seeing the self as powerful and capable. By way
of contrast, fear is adept at reducing anger. The action tendency to withdraw
will dampen the forward-thrusting action. In life, angry decision makers
typically process information in ways that fail to consider alternative options
before acting. Introducing the emotion of fear makes them overestimate
danger and holds them back from action. In other words, fear modulates
anger. Clearly, emotions change emotion and change cognition, too.
Probably the most important way of dealing with maladaptive emotion
in therapy involves not only its acceptance, understanding, or regulation but
also its transformation by other emotions. I have found that the primary
maladaptive emotions most in need of change that arise in most therapies
are fear of danger, fear of separation, shame of unworthiness, and the sadness
of lonely abandonment. And the adaptive emotions that help in the transfor-
mation process are empowered anger, the sadness of grief, and compassion
(Greenberg, 2015). An important goal in working with emotions, then,
is first to arrive at the maladaptive emotion—not to accept it for its good
 Changing Emotion With Emotion  •  67

information and motivation—as if it were an adaptive emotion (because it

does not provide such emotions) but to make it accessible to transforma-
tion. In time, the coactivation of the more adaptive emotion along with or
in response to the maladaptive emotion helps transform the maladaptive
emotion. The paradox of this path to emotional change, however, is that
it does not start with trying to change emotion. Rather, it’s the opposite:
to fully accept the painful emotion. Emotions must be fully felt and their
message heard before they are open to change by new emotions. Emotion
acceptance always precedes emotion transformation: You have to feel an
emotion to heal an emotion.
The process of changing emotion with emotion differs from such notions
as catharsis, exposure, extinction, or habituation in that maladaptive feelings
are not purged, nor are they attenuated by people feeling them. Rather, another
feeling is used to transform or undo the old feeling. Although dysregulated
secondary emotions, such as the anxiety in phobias, obsessive–compulsiveness,
and panic, and the fear-laden intrusive images from trauma may be over-
come by exposure, in many situations, primary maladaptive emotions
(e.g., the shame of feeling worthless, the anxiety of basic insecurity, and the
sadness of abandonment) are what underlie symptoms and are best trans-
formed by accessing emotions with opposing action tendencies.
People who suffer from social anxiety, for example, may have core under-
lying primary maladaptive emotions of shame of inadequacy or fear of
abandonment from their developmental history, and it is these that lead to
withdrawal. Change is produced not by exposure to social situations but
by first accessing the underlying painful emotion and then by coactivating
an incompatible, more adaptive approach experience, such as empowering
anger or pride, or compassion for the self. The new emotion undoes the
old response (Fredrickson, 2001) rather than attenuate or replace it. This
involves more than simply facing feelings or accepting feelings of anxiety
to diminish them. Rather than involving efforts to modify the anxiety by, say,
exposure, in-therapy emotion work involves accessing and staying in contact
with the withdrawal tendencies of the underlying primary maladaptive fear
or shame and coactivating the approach tendencies in anger or in comfort-
seeking sadness.

Which Emotions, When, and How?

An important issue in any treatment is what emotion should be activated to

transform the maladaptive emotion. Here, there is no formula. It depends
on the idiosyncratic experience of the client and on what adaptive emotions
68  •  Changing Emotion With Emotion

are available and can be evoked. This accessing of adaptive emotions involves
the therapist’s empathic attunement to what emotions seem to emerge in the
process. This is an exploratory, not a prescriptive, process. Other important
questions are, “When should painful emotions be activated and when
should they be regulated? And exactly which emotions are to be regulated—
and how?”
Underregulated emotions generally are either secondary emotions, such
as despair and hopelessness, or primary maladaptive emotions, such as
the shame of being worthless, the anxiety of basic insecurity, and panic that
are currently not able to be connected to adaptive cognition because they
are so overwhelming. When emotional arousal is too high and outside the
client’s zone of tolerance, emotion no longer informs adaptive thought and
action, so it then needs to be regulated (Greenberg, 2002). In such situations,
clients benefit from interventions that help create a working distance from
the intense emotions to prevent being overwhelmed by them.
In some cases, avoiding or suppressing aroused feelings can produce a
rebound effect or a bottle-up–blow-up syndrome. Disengagement in many
situations is not helpful. In other cases, however, people can effectively dis-
engage from emotion, and this disengagement can facilitate learning and
memory. Too much emotion at too high an intensity can be countertherapeutic
(Carryer & Greenberg, 2010). A crucial clinical judgment is when to distract
and down-regulate, and when to facilitate emotion approach and intensifi-
cation. I deal with this topic in greater depth in Chapter 11.

PATHS TO EMOTIONAL CHANGE AND THERAPY SEQUENCES

In illuminating the process of arriving and leaving, it is helpful to under-

stand that there are two different paths to emotional change. Those paths
depend on whether the previously disclaimed emotion the client is helped
to arrive at in therapy is (a) an adaptive emotion like unacknowledged
grief or assertive anger; or is (b) a maladaptive experience of feeling, say,
fear-based anxious insecurity, the sadness of lonely abandonment, or shame-
based worthlessness. The first path—denying an adaptive emotion, which
provides adaptive information and action tendencies that can be used as
a guide to change one’s behavior—is simpler to work with therapeutically.
This work involves a two-step process of moving from secondary reactive
to primary adaptive emotions—like from secondary anxiety to underlying
adaptive anger. The client is helped to reown the adaptive emotion, accept
it, and experience it in the therapy—not just talk about it or have insight
 Changing Emotion With Emotion  •  69

but have the bodily-felt experience of feeling empowered and asserting

the right to not be violated. Informed and transformed by this emotion,
the client symbolizes it in words, reflects on the emotion to create new
narrative meaning, and decides how to act.
A number of important recognizable two-step sequences occur. The first is
one in which secondary anger often is a reaction to, or sometimes a defense
against, an original or more primary feeling of sadness, hurt, or vulnera-
bility. Another major two-step sequence flows in the opposite direction to
the preceding sequence. This is where secondary sadness masks the more
primary anger. In the first case, when clients have learned that it is unsafe
to experience or share—or both—their sadness–hurt–vulnerability and cover
it with anger, therapists first need to validate the client’s secondary anger
and then focus on the experience of sadness beneath the anger. After the
client has acknowledged the anger, they need to acknowledge and process
the original hurt.
One way to reach the original hurt is to invite clients to pay attention to
what they feel immediately after they have expressed their anger because
a window to the original primary feeling of hurt or sadness often opens
following expression of the secondary feeling. Other ways to approach the
primary feeling are to either empathically inquire into or to conjecture
about the original feeling that might have led to the client’s anger. For
example, the therapist might say, “Something must have hurt very deeply
to leave you feeling so angry. How did you feel when that happened?” or
“Angry but also maybe hurt by what she said?”
When, however, newly accessed primary painful emotions are not a source
of good information or do not provide adaptive orientation to the current
situation, they are maladaptive and need to be changed. When working
on this second, more complex, path, therapists first need to help their
clients arrive at the previously disclaimed painful, maladaptive emotion. This
involves a three-step sequence. This sequence begins with the client in a
symptomatic state and involves moving from secondary reactive to primary
maladaptive emotions to adaptive emotion—for example, from secondary
social anxiety to underlying maladaptive shame and then to a transformative
primary adaptive emotion, say, assertive anger (Greenberg & Paivio, 1997).
When clients are already in their primary maladaptive emotions, there also
is a two-step sequence from primary maladaptive to adaptive—say, from
shame to adaptive anger.
The major three-step sequence involves first acknowledging secondary
distress, hopelessness, or anger. The second step is accessing the primary
maladaptive feelings of shame, fear, or sadness beneath the first state.
70  •  Changing Emotion With Emotion

Once the primary painful emotion has been accepted and symbolized in
awareness, the third step involves accessing more adaptive emotions, usually
healthy anger or sadness that were overregulated or were not readily acces-
sible. This frequently is followed by a sense of compassion for the suffering
of the self. States, such as a shame-filled sense of worthlessness, an anxious
sense of basic insecurity, or a paralyzing state of traumatic fear, often are
found beneath more surface despair, hopelessness, or rage. These avoided
states need to be approached and faced. This two-step sequence from
secondary to primary maladaptive emotion, however, is not yet fully thera­
peutic. The third step of accessing another set of healthy emotions and
motivations is needed to move beyond the maladaptive states. These three
steps embody the basic change process involved in changing emotion with
emotion and have been shown to predict outcome (Herrmann et al., 2016;
A. Pascual-Leone & Greenberg, 2007).
It is important to recognize unproductive sequences, however. A frequent,
unproductive, three-step sequence often occurs when there is a conflict
around feeling a newly accessed primary adaptive emotion. Thus, clients
may present with a sadness or hopelessness, and through exploration, they
may access healthy anger at violation but then feel guilt or anxious about
their anger. Here, the third emotion interrupts and prevents the second
emotion that is the healthy adaptive response.
Maladaptive emotions, such as the anxiety of basic insecurity or the fear
of abandonment, or of annihilation from past childhood maltreatment, are
transformed into security, calm, or even love or happiness by the activation
of more empowering, boundary-establishing emotions of adaptive anger
or grief at what was missed and compassion toward the self. Similarly,
maladaptive fear can be undone by adaptive sadness. Maladaptive shame,
which was internalized from the contempt of others, can be transformed
by accessing anger at violation at the abuse one suffered, which enhances
self-assertion and pride and self-worth, and by accessing self-compassion for
the pain suffered. Anger at being unfairly treated or thwarted helps over-
come hopelessness and helplessness (Sicoli, 2005). The thrusting-forward
tendency in presently accessed anger at violation or the reaching out for
contact and comfort in sadness transforms the tendency to shrink into
the ground in shame or collapse in helplessness. After the new emotion is
accessed, it undoes the original state, and a new state is forged. Introducing
new present experience into currently activated memories of past events
leads to transformation through the assimilation of new emotional material
into past emotion memories during memory reconsolidation (discussed later
in the chapter).
 Changing Emotion With Emotion  •  71

NEW EMOTIONS, NEW SELF-ORGANIZATION

How does the therapist help the client access new emotions to change
old emotions? A number of ways have been outlined (Greenberg, 2002).
Therapists can help the client access new emotions in the present by a variety
of means, including shifting attention to subdominant emotions that are
currently being expressed but are only on the periphery of a client’s aware-
ness. The subdominant emotion is often present in the room nonverbally in
tone of voice or manner of expression.
I have found that focusing on what is needed is a key means of activating
a new emotion (Greenberg, 2002, 2015). Asking clients what they need to
resolve their pain when they are in the pain of their maladaptive state is the
most powerful way of activating a new emotion. Raising a need or a goal
to a dynamic self-organizing system opens a problem space for implicit pro-
cessing to search for a solution. At the affective level, it conjures up a feeling
of what it is like to reach the goal and opens up neural pathways both to
the new feeling and the attainment of the goal. Organisms are motivated to
survive and thrive, and by paying attention to and experiencing their pain.
In so doing, they mobilize to eliminate the pain.
The essence of this process is that when clients’ core maladaptive emotions
of fear, shame, or sadness are accessed, core needs for connection and vali­
dation are mobilized. Emotion is generated by appraising the situation in
relation to a need. When the need is raised in salience, the brain, which
automatically evaluates that the need was not met generally, generates anger
or sadness. Once the need is articulated, clients can be helped to feel deserv-
ing of the previously unmet need by the therapist’s validating the need—
for example: “Yes, as a child, you deserved protection, love, and safety.” Once
clients feel that they deserved to have the need met, a more adaptive emotion
related to their needs not being met is generated automatically. When clients
feel that their need to be loved or protected was valid and that they deserved
to be loved or protected, the emotion system automatically appraises that
needs were not met and generates either anger at having been unfairly
treated or sadness at having missed the opportunity of having one’s needs
met. These new adaptive feelings become a new emotional response to the
old situation, and they act to transform the more maladaptive feelings.
The result is an implicit refutation of the sense that the person does not
deserve love, respect, and connection. The opposition of the two experi-
ences “I am not worthy or lovable” and “I deserve to be loved or respected,”
supported by adaptive anger or sadness in response to the same evoking
situation, produces a reorganization that undoes the maladaptive state and
72  •  Changing Emotion With Emotion

leads to a new self-organization. These new feelings were either felt in the
original situation but not expressed, or are felt now as an adaptive response to
the old situation. For example, accessing implicit adaptive anger at violation
by a perpetrator can help change maladaptive fear in a trauma survivor.
When the tendency to run away in fear is transformed by both anger’s
tendency to thrust forward and by sadness’s tendency to reach out for comfort
and care, the abuser is able to be held accountable for wrongs done. There-
after, there is a grieving for the loss of what was missed, and self or other
comfort is more likely to be experienced. Accessing one’s adaptive needs
acts automatically as disconfirmation of maladaptive feelings and beliefs.
In this way, new experience changes old experience. The newly accessed,
alternate feelings are resources in the personality that help change the
maladaptive state.
Often a period of validating and making sense of the painful emotion
is needed before the activation of an opposing transforming emotion. It is
essential to symbolize, explore, and differentiate the primary maladaptive
emotion, especially in the case of fear, and to regulate it by breathing and
calming before accessing the new, more adaptive emotion—often, anger.

Expressive Enactments

Other methods of accessing new emotion involve using enactment and

imagery to evoke new emotions, remembering a time an emotion was felt,
changing how the client views things, or even the therapist’s expressing
an emotion for the client (Greenberg, 2002). Expressive enactment entails
asking people to adopt certain emotional stances and helping them deliber-
ately assume the expressive posture of that feeling, and then intensifying
it to help evoke the experience of the emotion. Therapists might use psycho­
dramatic enactments and instruct clients, for example, “Try telling him
I’m angry. Say it again. Yes, louder. Can you put your feet on the floor and
sit up straight?” The therapist coaches the client to express until the client
experiences the emotion.
A number of experimental social psychology studies lend support to the
notion that expression activates emotion. Berkowitz (2000) found that
people who made a tightly clenched fist while talking about an angering
incident reported stronger feelings of anger. However, clenching a fist while
talking about a sad incident led to a reduction in sadness. These findings
showed that motor expression intensified congruent emotions and dampened
other emotions. The bodily expressions of one emotion can change another
emotion.
 Changing Emotion With Emotion  •  73

Similarly, Flack et al. (1999), in line with the James–Lange theory of

emotions (i.e., that action leads to emotion), showed that adopting the facial,
postural, and vocal expression of an emotion increases the experience of
the emotion being expressed regardless of the person’s awareness of the
emotion they are expressing. Thus, the experience of an emotion can, to
some degree, be activated or intensified by body expression. Interestingly,
people who were more body sensitive showed this tendency to a greater
degree. Research on the effects of role playing on attitude change also
supports the idea that performing actions brings people’s experience in line
with the role (Zimbardo et al., 1977). Playing a role can evoke emotion.

New Emotions Provided by the Therapist and Therapy Relationship

Remembering a situation in which an emotion occurred can bring the

memory alive in the present. The therapist can ask the client, “Remember
a time when you felt happy or sad? What was it like?” Cognitively creating
a new meaning by changing how one views a situation or talking about the
meaning of an emotional episode often helps people experience new feelings.
Therapists also can express the new emotion for the client, such as outrage,
pain, or sadness that the client is unable to express, and this helps the client
experience their own emotion.
The therapy relationship can generate new emotion. A new emotion can
be evoked in response to new interactions with the therapist that disconfirm
pathogenic expectations. The client can undergo a corrective emotional
experience with the therapist that repairs the traumatic influence of previous
relational experiences. Corrective emotional experiences with the therapist
are happening constantly whenever clients experience their therapists as
attuning to and validating their internal experience. Therapy repeatedly
offers opportunities for the regulation of distressing emotion via the soothing
effect of an empathic therapist who helps break the client’s feeling of isolation
because the client is in contact with the therapist and is mirrored. Overall,
the genuine relationship between the patient and the therapist, and its
constancy, is a corrective emotional experience. In addition, therapy provides
new self-experience through more intrapsychic experiences in which new,
alternate adaptive emotion schemes that can potentiate new emergent self-
organizations are activated.
Specific new emotional experiences with the therapist that supply an
undoing of specific patterns of interpersonal experience provide the other
form of corrective experience. People’s core emotion schemes change by
positive interpersonal experience, disconfirming pathogenic ways of being
74  •  Changing Emotion With Emotion

like not trusting or feeling controlled or diminished. Clients often disconfirm

pathogenic ways of being by testing them directly in the therapeutic relation-
ship (Weiss et al., 1986). Thus, clients who fear abandonment may test to
see if the therapist will not abandon them; clients who fear being controlled
test limits. If the therapist provides, in the first case, a new experience by
caring and, in the second case, by giving freedom, these become corrective
emotional experiences that help alter past experience.

Mastery Over Emotions

The goal is for clients, with the help of safety in therapy, to experience
mastery in reexperiencing emotions they could not handle in the past. Clients
in therapy thus can reexperience events differently than they did originally.
Now, the client can express vulnerability or anger with the therapist without
being punished, and can assert without being put down. This new experi-
ence allows clients to feel that they are no longer powerless children facing
powerful adults.
Furthermore, the therapist can be seen as a transitional conductor pro-
moting an experience of transitioning from one emotional state to another
just as a caretaker does with an infant in distress. With a distressed infant,
the caretaker first soothes the feeling, thus validating the presence of the
feeling. Then, when the infant has calmed down, the caretaker introduces
some novel stimulus like a rattle or teddy bear to evoke a new emotion. The
infant learns implicitly two things: that emotional distress can be soothed
and, maybe even more importantly, that it is possible to transition from a
negative to a more positive state. A great number of fragile clients have never
experienced this type of soothing and transitioning. Their experience has
taught them that if you enter a negative state, it is a vortex that sucks you in.
When the therapist validates the painful feeling and responds empathically,
the client has a new experience and begins to internalize not only the sooth-
ing but also the possibility of transitioning. Therapy thus provides two new
experiences: It is possible for emotional pain to be soothed, and it is possible
to transition to more salutary states and escape the painful emotion.

MEMORY RECONSOLIDATION

Memory and the impact of the past on our current lives play a central role in
working with emotion. Previous theories of memory stability, grouped under
the traditional name “memory consolidation,” argued that once short-term
memory was consolidated into long-term memory, it would become stable.
 Changing Emotion With Emotion  •  75

In the past 20 years, a new memory process referred to as “memory reconsol-

idation” has been proposed and studied. Introducing new present experience
into currently activated memories of past events has been shown to lead to
the assimilation of new material in the present into memories of the past
(Nadel & Bohbot, 2001; Nadel et al., 2012; Nader & Hardt, 2009).
The standard view of memory suggested that immediately after learning,
there was a window of time during which the memory was labile, and, after
sufficient time had passed, the memory became more or less permanent.
During what was called the “consolidation period,” it was possible to influence
memory formation; once this time window had passed, however, the memory
could not be changed or eliminated. Developments in memory research,
however, have shown that every time a memory is activated, the underlying
memory seems to be labile once again and requires another consolidation
period (Nadel & Moscovitch, 1997). This reconsolidation period allows for
another opportunity to disrupt the memory. Nader et al. (2000) demonstrated
that conditioned fear can be eliminated in rats by blocking reconsolidation,
but it also appears that the new experience needs to occur not immediately
but only about 10 minutes after the activation of the memory. Also, it has been
shown (Hupbach et al., 2008) that when memories in humans are reactivated
through reminders, they are open to modification through the presenta-
tion of similar material that then becomes incorporated into the original
event memory.
Because memory reconsolidation only occurs once a memory is activated,
it follows that emotional memories have to be activated in therapy to be able
to change them. Thus, emotional memories can be changed by activating
the experience of the memory in a session, and, if, after about 10 minutes of
working on the painful experience related to this memory, a new emotion is
experienced, it will in some way be incorporated into the memory and can
change the experience of the original memory (Greenberg, 2019). By being
activated in the present, the old memories are updated by the new current
experience.
The new experience comes both from the safety of the therapy relation-
ship and through the activation of more adaptive emotional responses in
an in-session enactment of reacting to the old situation in a new way using
new adult resources. Incorporating these new elements, the memories are
reconsolidated. This process of memory reconsolidation offers a possible
view of a general therapeutic change process for transforming experience of
past emotional injuries. Introducing new present experience into currently
activated memories of past events can lead to transformation via the assimi-
lation of new material into past memories during memory reconsolidation
(Lane et al., 2015).
76  •  Changing Emotion With Emotion

It is important to distinguish “memory reconsolidation” from “behavioral

extinction,” though. Reconsolidation is assumed to change components of
the reactivated memory, whereas extinction is assumed to merely create a
new memory that overrides the previously trained response. Thus, an “extin-
guished” response is not really gone because it can spontaneously recover
over time or be reinstated if the organism is exposed to a relevant cue in a
new context. Recent work has shown that cellular and molecular differences
exist between the two processes. Whether reconsolidation or extinction occurs
depends on the temporal dynamics of the test procedure and how recently
the memory in question was formed, reactivated, or both (de la Fuente et al.,
2011; Inda et al., 2011; Maren, 2011). At this time, it is clear that reconsoli­
dation and extinction represent distinct reactions to reactivating a memory
(Lane et al., 2015).
To exemplify the change process in a nutshell, consider the following
synopsis of a course of therapy. Doug, a 52-year-old man suffering from
panic, reported a life marked by abusive relationships with his father. With
support from the therapist, Doug revisited difficult moments in his childhood.
When he did so, memories were activated, and he made contact with his core
fear and with his unmet needs for support and protection. After a number
of sessions, Doug also accessed empowering anger toward his father in
conjunction with his fear. Assertive anger, with its function of protecting
an individual’s boundaries and its behavioral tendency toward facing and
fighting, allowed him to experience himself as an agent able to survive—
something he had never felt before. Instead of fleeing or freezing with fear,
he synthesized new emotions into his memory, adding anger to the previous
fear, strengthening the self, and feeling more confident. He also experienced
compassion toward himself and his remembered self, a frightened child.
This important emotion was reconsolidated in Doug’s memory. Coupled
with the experience of empathy and compassion from the therapist, Doug
built new emotional memories.

SESSION TRANSCRIPT

This section includes a session transcript that demonstrates changing emotion

with emotion with a client suffering from anxiety. Underlying this 60-year-
old woman’s anxiety (she was diagnosed with generalized anxiety disorder),
with which she had grappled all her life, was her fear-based basic insecurity
and the painful sadness of lonely abandonment from having a mother who
had died of cancer. Her mother had languished slowly over many years of
the client’s childhood. In therapy, these painful maladaptive feelings were
transformed by accessing a different type of sadness: the sadness of grief
 Changing Emotion With Emotion  •  77

and accompanying feelings of assertive anger. The anger came from a sense
of having deserved to not have the burden of an incapable mother and to
have deserved a more normal childhood.
Near the end of the transcript, note that the client finally feels compassion
for herself. Her feelings of being alone and afraid at the base of her weak
self-organization are thereby transformed to a more secure sense of self.
New feelings strengthen her sense of self, and new emotions undo her
insecure sense of self. Her compassion toward her wounded-child sense of
self undoes her anxiety, leaving her feeling calmer and more comforted and
safe. By the end of treatment, she grieves for what she missed and assimilates
her loss into a new narrative. In addition, as her self-organization changes,
new and more positive memories become accessible; these new memories
counterbalance her old, negative ones.
The transcript that follows is from Session 16. Early sessions focused on
her symptomatic anxiety, provided empathic attunement to her feelings of
vulnerability, and helped her to unfold her narrative, which fairly quickly
zeroed in on her childhood growing up with a mother who was bedridden
and dying of cancer. To help the client regulate her anxiety, the therapist had
her focus on her breathing when she was anxious. From Session 3 onward,
the therapist began a process of guiding the client to pay attention to her
feelings and connect them to her anxiety. A good alliance was developed,
and the client commented that she felt safe and liked coming to the sessions,
but it was difficult helping the client face her underlying feelings.
The segment that follows starts close to the beginning of Session 16; it is
provided so the reader can see how the session theme was established. The
segment then skips to minute 17, when the therapist guides the client to talk
about her relationship with her mother.

Arriving at the Ache

CLIENT:  I get tired. Well, that always happens. Remember: (Therapist:
Yeah.) I told you the (Therapist: Yeah.)—when the sun comes
down (Therapist: Mm-hmm.) and it starts getting darker,
I always feel this, ah, you know the feeling of (Therapist:
Mm-hmm.) emptiness (Therapist: Yes.), and—and, like, it—it’s
not really a pain but like an emptiness in my stomach.

THERAPIST: Yeah, an empty, ah, an ache. That happens inside.

CLIENT:  Yeah, some kind of an ache. Yeah (Therapist: Yeah.) and, um,
and—and it seems like, ah, in my mind, um, things come—
come in like, I worry (Therapist: Mm-hmm.) about my son, my
daughter, my husband, all the problems, you know?
78  •  Changing Emotion With Emotion

In the next 12 minutes or so, the client talks about feeling down and
depressed as well as not really appreciated by her children. When she
returns to talking about her feelings of lonely abandonment, the therapist
guides her toward the therapeutic focus based on the coconstructed case
formulation: that her anxiety is based on underlying feelings of isolation
and abandonment by her mother. Up until now, in previous sessions, they
worked on her paying more attention to her bodily felt feelings in general
and more specifically when her anxiety is triggered. In addition, they have,
to some degree, talked about her feelings toward her mother, but the client
has never experienced those feelings in the session. The first part of the ses-
sion involves arriving at the emotion.

THERAPIST:  Yeah (Client: Yeah.), in terms of, ah, last week, something that,
um, we were talking about that seems like—I mean, let me tell
you what I’m thinking about in terms of where (Client: Yeah,
yeah, yeah.) I think we need to go in the next few sessions
and see what you think. So, there’s this feeling that you keep
trying to get rid of, right? And this really seems like the—the
place that, ah, a lot of—of the sadness comes from, right, and
the anxiety? And this—this place is kind of—if there is—if
there would be something that would be good for us to work on,
it might be kind of around that (Client: That feeling.)—that ache
you know (Client: Yes, yeah.), and that ache, as we have said,
certainly goes back to the childhood (Client: Yeah, yeah, yeah.)
time. And I wonder about your mother in terms of revisiting
your mother. Like I understand it’s hard, but I kind of get the
sense that it’s hard to say anything bad about your mother.
It’s like you feel, “I don’t blame her for being sick,” and you
know. [guiding to a focus]

CLIENT:  How can I say it (Therapist: Yeah.), sure it was not her fault
(Therapist: Yeah.), what happened to her. [cancer]

THERAPIST:  But what I wonder at the same time: It’s not whether it’s
someone’s fault or not. I wonder at the same time if it’s that
those needs you had still weren’t met.

CLIENT:  Mm-hmm. I—I never—never—never thought (Therapist:

Mm-hmm.) this was her fault. Never. (Therapist: Mm-hmm.)
I might have been sometimes upset because, you know (Thera-
pist: Mm-hmm.), I didn’t—I didn’t have her the way I wanted,
but, ah (Therapist: Mm-hmm.), you know, I just had to deal
with it.
 Changing Emotion With Emotion  •  79

THERAPIST:  What about what it was like for you. I mean, I think this
might be . . .

CLIENT:  I never talked to her or anybody about these things (Therapist:

Yeah, yeah.). No, no.

THERAPIST:  And I don’t mean in a blaming way, but I mean, would it feel
okay to try that—to talk to her about what it was like for you?

CLIENT:  You mean, now, ah (Therapist: Yeah.), how?

THERAPIST:  Imagining her. (Client: Yeah, yeah.) Like it—it—would that

feel okay? Or . . .

CLIENT:  Yeah, I mean it (Therapist: Yeah.) should. Yeah, okay.

THERAPIST:  We’ll try it and see. So, just close your eyes if you like and
imagine your mom (Client: And . . .), if you could just—just
take a minute and just (Client: Yeah.) slow it down, and just
take a minute and take in some breaths. And just sit with it for a
second, and just try to get a picture of her. (Client: Yeah, yeah.)
And just—just see what—what comes up when you f—when
you start feeling something and try to put words to it.

CLIENT:  Ah, yeah, I’m trying to remember when I was young and, ah . . .

THERAPIST:  Mm-hmm. Try to picture her. How old were you?

CLIENT:  6 to 8 to 9, yeah, yeah.

THERAPIST:  So, you can kind of—so, you can kind of picture—how about
picturing the mother that she was?

CLIENT:  Yeah, but, yeah, I can see when I was 6 years old (Thera-
pist: Yeah.), and she was a lot younger, and, ah (Therapist:
Mm-hmm.), and, um, and I couldn’t—she couldn’t take—make
to the movies. I had to go with somebody else if (Therapist:
Okay.) I could.

THERAPIST:  So, what does (Client: You know [sighs].) it feel like inside?
When you see this. [focusing internally]

CLIENT:  It felt like, ah, I was alone.

THERAPIST:  What’s it feel like (Client: Ah.) when you say this?

CLIENT:  Ah, I feel that, um—um something is missing.

THERAPIST:  Something is missing.

80  •  Changing Emotion With Emotion

CLIENT:  I want her to be there, you know.

THERAPIST:  What do you miss?

CLIENT:  I miss like that she was there with me. (Therapist: Mm-hmm.)
You know, taking care of me, and (Therapist: Yeah.), ah, and
I didn’t have her next to me (Therapist: Mm-hmm.) when I was
going to the movies with my friends and her mother. (Thera-
pist: Mm-hmm.) And I felt like I was, yeah, I was a tagalong
with other people.

CLIENT:  The—the, I don’t know, I felt like I went along with them like
but didn’t belong.

THERAPIST:  A third wheel.

CLIENT:  Third wheel. Yeah, exactly.

THERAPIST:  Tell her, “I’m 6 years old, and I (Client: Ah.)—I tag along.”

CLIENT:  Yeah, yeah, I had to tag along with other people (Therapist:
Yeah.), yeah, yeah, and, um (Therapist: Yeah.), and, of course,
my father couldn’t do much. (Therapist: Yeah.) He did a few,
you know, things for me, but, ah (Therapist: Mm-hmm.), he had
other things to do (Therapist: Mm-hmm.) because he had to be
father and mother. [accessing emotion schematic memories of
loneliness]

THERAPIST:  Mm-hmm. (Client: Right.) Try to stay with this feeling of being
alone. [focusing internally]

CLIENT:  With her.

THERAPIST:  Yeah (Client: Um.), try to stay with this feeling. So, what did it
feel like to be—to miss not having her there? I mean, in physical
being she was there, but to really not have her, (Client: Yeah,
yeah.) she was really not really there. (Client: Yeah.) What did
that feel like? [focusing internally]

CLIENT:  Well, it was—it was—it was lone—it was lonely! (Therapist:

Mm-hmm.) It was the—the sadness.

THERAPIST:  If you could tell your mom, “I feel lonely because (Client: Yeah.),
as your 6-year-old . . .”

CLIENT:  I felt so—I feel so lonely because you’re not there for me.
(Therapist: Yeah.), ah, and sometimes I wish you were because
 Changing Emotion With Emotion  •  81

I (Therapist: Yeah.)—some people say things that I didn’t like,

or (Therapist: Yeah.)—and maybe you would have been there
just to defend me but, ah (Therapist: Mm-hmm.), you couldn’t
because you couldn’t (cries), and I felt so alone. I felt afraid,
unsafe. [accessing emotions, schematic feelings of sadness and
fear; arriving]

THERAPIST:  “And it left me feeling so scared and alone.”

CLIENT:  I felt like I didn’t know what to do. Maybe I wouldn’t have these
inadequacies now if those—if those things never happened.
Maybe if I, ah—ah—ah—I would have felt loved, felt a lot, ah,
more secure (Therapist: More secure, yeah.), more self-assured,
ah (Therapist: Yeah.), but, um, I don’t blame her. I don’t blame
her because she’s sick. It’s not her doing. I mean, she’s sick
(Therapist: Mm-hmm.) like that, and I can’t help her.

THERAPIST:  Yeah, so I don’t blame her, and at the same time, it doesn’t take
away that I missed something. (Client: Yeah.) Is that it? Yeah.
(Client: Yes, yeah.) What would you want to say to her?

CLIENT:  You know, I—I don’t blame you because you’re like that—
you’re (Therapist: Mm-hmm.)—you have a physical problem,
um (Therapist: But . . .), a mental (Therapist: There’s still a but,
yeah.) problem. I don’t want to say that, but (Therapist: Right.)
it’s that what it was, and I never want to tell her that, but
I would say, “You have a mental problem.”

THERAPIST:  So, you weren’t there. I don’t blame (Client sighs.) you because
you didn’t have control over it but, I needed you and you
weren’t there emotionally, mentally. (Client: Yeah.) That’s what
it comes down to.

CLIENT:  Ah, I need, yeah, I needed you, and you weren’t there. (Ther-
apist: Yeah.) And many times, I felt alone (Therapist: Yeah.)
and, um, and—and—and alone and—and insecure and afraid.
(Therapist: Yeah, afraid.) Afraid—yes. [need]

THERAPIST:  Can you tell her about that fear? (Client: Yes, yes.) Tell her about
that fear. [focusing on core maladaptive fear]

CLIENT:  Ah, I felt afraid, like in my stomach, a kind of queasy feeling

because, ah, I was always surrounded by people that weren’t,
ah, my family (Therapist: Mm-hmm.), and I needed you to be
82  •  Changing Emotion With Emotion

with me! (Therapist: Mm-hmm.) I—in—in—in school, you

know, when they had, ah, you know, the plays or whatever
(Therapist: Mm-hmm.). You know, they—I needed you (Ther-
apist: Yeah.), and—and, ah, you didn’t help me because some-
times you didn’t sew my—my—my dresses for me and for—for
(Therapist: Mm-hmm.) me and for the stage and everything,
but, ah (Therapist: Yeah.), you should have been there. So,
the—the teachers—the teachers had to do, yeah, the teachers
had to fix it for me. Um . . . [arriving at fear plus need]

THERAPIST:  Get a sense of her and tell her again, “I needed you to be there
for me.”

CLIENT:  Yeah, I needed you to be there for me.

THERAPIST:  How does that feel when you say that to her.

CLIENT:  Yeah, I feel guilty. (Therapist: Yeah.) [secondary emotion]

THERAPIST:  So, it feels bad to say this to her because . . .

CLIENT:  Yeah, it’s still that’s—that’s what happened for me, that’s what
happened. (Therapist: Yeah, yes.) And, um, ah, whenever I pray,
I was always praying that, ah, please, you know, bring her back
to me (Therapist: Mm-hmm.) the way she was. I never knew
how she was before (Therapist: Mm-hmm.), but, ah, bring her
to me normal.

THERAPIST:  Yeah, like I wanted you to be something different. (Client:

That’s right.) I needed you to be something different.

CLIENT:  Something like a friend, you know, who, like, you could talk
to and . . . [need]

THERAPIST:  Yeah, tell her what you needed from her. What did you need
from her? [focusing on need]

CLIENT:  And, ah—eh—eh—you know, I need you to—to take walks

with me, take me for ice cream (Therapist: Yeah.) like, you
know, um (Therapist: Mm-hmm.), and maybe we could just
fix the garden together. (Therapist: Mm-hmm.) Ah, you know
those things that the mothers and daughters do (Therapist:
Mm-hmm.), but, ah (Therapist: Mm-hmm.), we never did even
though you were home. (Therapist: Yeah.) And, yeah, you did
show me how to sew, but . . . [need]
 Changing Emotion With Emotion  •  83

THERAPIST:  That’s the most painful part (Client: Yeah.), right? The most
painful part is that, as you said last week, “You know I had a
mother, but I really didn’t.”

CLIENT:  No, no, I really didn’t. (Therapist: Yeah.) No, no. (Therapist:
Yeah, and she . . .) She was there, she helped me for, ah—eh—
you know, she helped me, she showed me, she sometimes tried
to teach me.

THERAPIST:  Yeah, so I (Client: Um.) appreciate that you did (Client: Yeah.),
um—um, yeah, it’s not that it wasn’t all bad, but when it came
down to the important things . . .

CLIENT:  Yeah, when it came to the important things, you weren’t there
(Therapist: Mm-hmm.), like, ah, more like personal (Therapist:
Mm-hmm.) things (cries). [arriving]

THERAPIST:  Yeah, tell her (Client: This.) more about that. What other
things you would have liked to have had from her? What else
would have been nice?

CLIENT:  You stopped cooking, um (Therapist: Mm-hmm.), so my dad

had to cook. (Therapist: Mm-hmm.) So, he cooked whatever
he could, mostly—ha ha—barbecues because he (Therapist:
Mm-hmm.), you know, he—he wasn’t, ah, really a cook. (Ther-
apist: Mm-hmm.) But, ah, when you—when you—I remember
when you used to cook, and I used to love the things that
you used to make. (Therapist: Mm.) Ah, you used to make a
preserves and things that (Therapist: Mm-hmm.) I loved, you
know. (Therapist: Mm.) Ah, but then (Therapist: This child
missing these things.)—yeah, yeah, I—I remember that, but
(Therapist: Yeah.) you stopped doing them.

THERAPIST:  That important part of my childhood, it was gone, so try to get a

sense for here, I know, it’s kind of hard, so try to picture her there
and tell her what it was like when she stopped doing things.

CLIENT:  Yeah, ah—ah, I don’t remember exactly (Therapist: Mm-hmm.)

when you stopped. . . . Maybe I was 7 or 8. I was, busier.
I had to do a lot more homework (Therapist: Mm-hmm.), and
I didn’t have time, and . . .

THERAPIST:  But I knew there was something missing. You were gone.
(Client: Yeah.) You vanished. (Client: Yeah.) Is that what
I’m feeling? (Client: Yeah, yeah.) Tell her what that felt like.
84  •  Changing Emotion With Emotion

CLIENT:  Yeah, it felt like, ah, you abandoned me, you know. You know,
you just want to choose to be in bed, that’s all. (Therapist:
Yeah.), and I felt so abandoned.

THERAPIST:  And still sits inside (Client: Yes.). I feel it now when I (Client:
Yes.)—when the sun goes down (Client: Yeah [weeps].), and
I have to come in from playing. (Client sighs deeply.) I feel that
in—it’s the—it’s here (points to stomach).

CLIENT:  Yeah, it’s in my stomach, yeah (Therapist: Yeah.), yeah.

[arriving]

THERAPIST:  And can you (Client: This.) speak from that like that’s almost
where the abandonment sits? Can you speak from that place
and tell her?

Naming the Need, Leaving, and Changing the Narrative

With the emergence of the need, the session now enters the leaving phase.

CLIENT:  I needed you to come to me? Mm (Therapist: Yeah.), why don’t

you come and talk to me and (Therapist: Yeah.) be a mother.
(Therapist: Mm-hmm.) Ah, be my friend. (Therapist: Mm-hmm.)
Um, when I had problems with my other girlfriends that they—
they used to fight and I’d come home, and I would never have
anybody to talk to, or (Therapist: Mm-hmm.) nobody would just
give me any sympathy because nobody was there to do that.
(Therapist: Yeah.) My dad didn’t want to hear about all these
things (Therapist: Mm-hmm.), but, ah, you—you know, you
won’t—you won’t hear it. Yeah, you won’t hear it. Ah.

THERAPIST:  So, what do you feel as you say this?

CLIENT:  I feel angry. [new transforming emotion; leaving]

THERAPIST:  Tell her what you resent.

CLIENT:  I resented you chose your bed over me. I needed you. I resented
you preferred your bed to me, you never spoke to me, let me
come into your room. It was like I didn’t exist. I resented you
didn’t care. I felt like you didn’t care.

THERAPIST:  I felt so uncared for. You were the one who I needed to be,
yeah, yeah, and I felt abandoned. I (Client: Yeah.)—and it was
almost—you vanished, and because of that, I felt?
 Changing Emotion With Emotion  •  85

CLIENT:  I feel alone—alone—very, very, very lonely. I was scared and

alone.

THERAPIST:  Very alone (Client: Mm-hmm.). I felt alone and—and, scared

I wouldn’t have felt that way if you had been there.

CLIENT:  If you were, yeah, if you had been there, yeah (Therapist: Yeah.),
I would have been, ah, you know, with my mother. (Therapist:
Mm-hmm. Mm-hmm.) And that’s, ah, that’s an important—
I missed so much. (Eyes fill with tears. Gets a tissue.) I needed
a mom.

THERAPIST:  What do you feel as you say this?

CLIENT:  So sad, and it was so unfair to be robbed of my mother. I feel

mad I resented not having a mom when all the others had moms
who picked them up after school, took them to movies. I was
robbed of a normal childhood. [leaving, transforming anger;
leaving]

THERAPIST:  So, sort of angry at how unfair it was. Yeah, life dealt you a
hard blow, losing your mom emotionally like that.

CLIENT:  Yeah, I feel sad that I missed out on having a mother to take care
of me. I needed her to be there for me, too (eyes fill with tears),
and I deserved to have a mom, and I missed having a child-
hood free of those fears. [emerging sadness of grief; leaving]

A few minutes later in the session, the dialogue shifts to what the mother
would have said to the 6-year-old. The therapist says to the client, who is
now in the mother’s role:

THERAPIST:  Okay, so let’s put—let’s try to put this into words when you see
that 6-year-old, what do you want to say to that lonely girl?

CLIENT:  Well, you know, yes, I’m sorry—I’m . . .

THERAPIST:  I’m sorry, yeah, yeah.

CLIENT:  But I’m here anyways, and, ah, if you and I do my best . . .

THERAPIST:  So, it’s like doing the best I can. (Client: Yeah.) Is that what
she’s saying?

CLIENT:  Oh, I feel very, very sorry.

THERAPIST:  Your mother (Client sniffles) feels very, very–feels very sorry.
86  •  Changing Emotion With Emotion

CLIENT:  I feel myself very, ah, looking at (Therapist: Mm-hmm.) myself,

I’m now 60 years old. You know, I feel (Therapist: Yeah.) that
I missed that a lot. [sadness of grief ]

CLIENT: (Speaks as mother) I’m sorry that you had to miss so much
because, um, ah, I wasn’t there for you. (Therapist: Uh-huh.)
I wish—I was okay, ah (Therapist: Yeah.), I wish I could, you
know, be more with you, and I could have been more, you
know (Therapist: Mm-hmm.), of a mother, but, unfortunately
I (Therapist: Mm-hmm.)—it was something that I couldn’t do.

THERAPIST:  So I wish I could have been there. What do you—what—what

do you wish you could have done?

CLIENT:  Mm, well, be more of a mother. Be more (Therapist: Mm-hmm.),

yeah, take you for ice cream in the summertime when you
were on holidays and, ah (Therapist: Mm-hmm.), play more
with you. You know (Therapist: Yeah.), I remember you used
to bring a couple of friends that they were really nice, and
(Therapist: Mm-hmm.) they didn’t mind me, and, um (Thera-
pist: Yeah.), and you used to play with the hose and, you know
(Therapist: Mm-hmm.), and . . . [compassion for self ]

THERAPIST:  I remember those moments. (Client: Yeah, yeah.) I remember

when we were (Client: I remember, yeah, yeah.) together. And
it (Client: Yeah.) felt good. (Client: Yeah.) Is that what she’s
saying to her?

CLIENT:  Those—those—those—those moments were good, yeah.

THERAPIST:  So, I missed (Client: Yeah.) those moments, too.

CLIENT:  And she even baked—she even baked a couple of times

(Therapist: Yeah.). You know, I remember, a couple of times she
baked cookies (Therapist: Mm-hmm.), and she baked a couple
cakes, whatever. (Therapist: Mm-hmm.) And, um, and we had
a good time, yeah. [accessing positive memories]

THERAPIST:  What about this when you were 6, though. I mean, when you
were 6, that’s when it really . . .

CLIENT:  Well, she did buy me things to (Therapist: Yeah.)—and I was,

you know, some days, she was okay, yes, but some days, she
would (Therapist: Mm-hmm.), just like I said, talk to herself
 Changing Emotion With Emotion  •  87

and, ah (Therapist: Mm-hmm.), the poor woman, she never

talked to anybody, so she had to talk to herself. (Therapist:
Mm-hmm. Yeah.)

THERAPIST:  So, you really feel for her. Yeah.

CLIENT:  And she would just stay in bed as much as she could (Therapist:
Yeah, yeah.) because she probably . . .

THERAPIST:  How does the 6-year-old feel when she hears that?

CLIENT:  Yeah, I would feel that, um, yeah, it’s true. She should have
done more me. (Therapist: Mm-hmm.) Uh, you—you did do
that (Therapist: Mm-hmm.). I mean, she could have done it.
(Therapist: Mm-hmm.) But in some ways, you—you—you—
you were in a cocoon, I don’t know (Therapist: Mm-hmm.), for
some reason.

THERAPIST:  Untouchable to me. I see . . .

CLIENT:  Yeah, she was hidden somewhere. She just (Therapist: Mm.)—
she hid herself from everybody. (Therapist: Mm-hmm.) Ah, it
seems like, well, yeah, it must have been, ah—ah—a problem
that she had. (Therapist: Mm-hmm.) You know, like a condition,
but, um, maybe if she tried a little harder, she would, you know,
I know . . .

THERAPIST:  Mm-hmm. (Client: Um.) But you could have tried.

CLIENT:  (Speaks to remembered mother) You could have tried.

THERAPIST:  You could have done something different, maybe. Yeah.

THERAPIST:  Tell her what—that you would have liked.

CLIENT:  It would have been great. (Therapist: Yeah.) I would have

more memories of my childhood. (Therapist: Yeah. Mm-hmm.)
Better memories. [deserving]

THERAPIST:  Better memories.

CLIENT:  Yeah, because I really, I think I erased a lot of memories, you

know, because (Therapist: Mm-hmm.) they weren’t nice, so
(Therapist: Mm-hmm.), um.

THERAPIST:  So, I remember the bad. I mean there’s bleeding (Client: Yeah.),
but I really remember the alone abandoned, lying in bed.
88  •  Changing Emotion With Emotion

CLIENT:  I remember that, but, ah, I don’t dwell on that. I’ve always
tried to remember the—the good things, you know. (Thera-
pist: Mm-hmm.) But, ah, those things, of course, come up to
(Therapist: Mm-hmm.), but, um, I think I was always an . . .

THERAPIST:  Can you tell her about this place?

CLIENT:  I—I have this feeling because—because of you, actually.

(Therapist: Yeah.) Yeah, yeah, because . . .

THERAPIST:  I have this feeling. Tell her (Client: Yeah.) again. Can you say
that again?

CLIENT:  Yeah, you, because of the way she was (Therapist: Yeah.)
and because the things that—that I were missing in my life.
(Therapist: Mm-hmm.) I had always this feeling of emptiness
(Therapist: Mm-hmm.) and, eh, that aches inside me. (Therapist:
Mm-hmm.) And that, eh, always applies to everything in my
life. (Therapist: Mm-hmm.) It applies to my—my husband, my
family, my way of life. (Therapist: Yeah.) My everything.

THERAPIST:  Everything. It touch—it taints it, colors it everything.

CLIENT:  It’s—it’s exactly. So, it seems like I’m never going to be able
to be happy. (Therapist: Yeah.), and I was never really happy.
I deserved to have a mom who took care of me, not one I had
to care of.

THERAPIST:  Yes. It wasn’t my responsibility. I was just a kid.

CLIENT:  Yeah, I was just a child. [changing the narrative]

THERAPIST:  Let’s try something. Come over here. Remember—remember

about a bunch of sessions ago, I don’t remember the number,
you were imagining as if you could be an older sister (Client:
Mm-hmm.), and you could see that 6-year-old, and you could
almost, like I remember you—you (Client: Yeah, I remember.)
just wanted to hold her. (Client: Yeah.) Can you, I mean, if you
picture that 6-year-old girl who is just sitting there with that
ache, what comes up for you? I mean, is this—this, I mean, if
you could be that big sister, then . . . [self-soothing]

CLIENT:  No, well, I would just grab her and, you know, and hug her and
just kiss her and say, you know, don’t worry about anything.
(Therapist: Mm-hmm.) Everything is going to be all right.
(Therapist: Mm-hmm.) Ah, you’re always going to be looked
 Changing Emotion With Emotion  •  89

after. You’re always going to have (Therapist: Mm-hmm.), you

know, whatever you need. Um . . . [self soothing]

THERAPIST:  You say that ache is here (points to stomach). That’s where—
that’s where it sits. A lot of people are walking around (Client:
Yeah.) with big holes in their stomachs. You can’t see them.

CLIENT:  Is that right? (Therapist: Oh, yeah.) I’m not the only one. And
that—and that is where—and that’s where—where it stings.
That’s why I feel that thing.

THERAPIST:  Right in the gut.

CLIENT:  A sickness or something. Like a physical problem that I—like

when I had ulcers, and I said, Well maybe when my ulcers go
away (Therapist: Yeah.), this will go away as well, but no, ha ha.

THERAPIST:  Yeah. (Client sniffles.) Like people describe it in different ways:

It’s like a hole. It’s like a wound. (Client: Yeah, yeah.) That
yours is an ache (Client: Yeah.), a painful ache sometimes.

CLIENT:  Yeah, yeah, and a hole to, like, you know, like an emptiness
there (Therapist: Yeah, yeah.) that aches. Yeah. You know what
I realize too? (Therapist: Mm-hmm.) That this gave me a great—
great inferiority complex. (Therapist: Yeah.) I feel—you know
(Therapist: Yeah [sniffles].), yeah, so part of you was, like, I feel
so—I just—like I’m not good enough and—no—yes—and, on
the other hand, it’s like I’m angry.

THERAPIST:  Right, okay. So, there’s this inadequacy (Client: Yeah, yeah.)
like here, and then if you went underneath, that inadequacy,
it’s like the pain and hurt (Client: Yes.) because if she had been
there, would this even exist? You know, would you even have
the ache? [narrative reconstruction]

The session ends with self-soothing in the form of an imagined older

sister and restorying her experience and realizing how the ache affected
her sense of self. Crucial was accessing her core maladaptive feelings of
fear associated with being abandoned and the attendant sadness of loneli-
ness (emotion schematic processing), and through accessing her need, she
begins to feel sad about what she missed and anger at not having a mother.
Her sadness is a central aspect of grieving her loss and is a healthy adap-
tive emotion that helps her assimilate the loss. It differs from the sadness
of lonely abandonment, which is a more passive, helpless state. Her anger
90  •  Changing Emotion With Emotion

strengthens her sense of self and helps her to feel deserving of what she
missed that she had not felt before.
The new experiences of grieving what she missed and feeling more
deserving undo her “weak me” feelings of fear and loneliness. She cannot
believe she is unlovable or inadequate while she feels deserving of love. She
ends up validating her needs and feels compassionate to herself. A process
of change has begun. After having arrived at her core lonely abandonment
and fear, she is able to change these emotions with the adaptive sadness of
grief, with assertive anger, and with self-compassion. The different emotion
schemes synthesize at an implicit level to help her leave these painful states
by producing a new state: one of confidence and calm, a truly novel experi-
ence for her from all her years of anxiety.

CONCLUSION

I hope to have shown how changing emotion with emotion is a key change
process. It helps people who present with symptoms based on underlying
maladaptive emotions, first arrive at their core painful feelings, accept
them, tolerate them, and symbolize them in awareness. Then, it helps them
access new adaptive emotions to transform the old maladaptive feelings
they arrived at. It is not just accepting emotion or overcoming avoidance of
emotion that is change producing. Rather, it is experiencing new emotion to
oppose old emotion that is central in changing maladaptive emotion. This
change, achieved by a synthesis of the old and the new, is consolidated into
a new narrative and gives a people a more salutary view of self, world, and
other. This process of new emotional experience changing old experience
is a transtheoretical process in line with Goldfried’s (1980, 2012) proposal
that providing corrective experiences is a midlevel strategy of change shared
by all approaches.
In addition, changing emotion with emotion is best viewed not only as
a transtheoretical process but also as a transdiagnostic process applicable
regardless of the disorder. Whether one arrives at core shame in depression
or social anxiety, or attachment-related anxiety in generalized anxiety dis-
order, or destructive anger in addictions, it is the access to adaptive feelings
that help bring about a transformation to a new emotional state regardless
of diagnostic category. All disorders are based on emotional disorder, and all
require emotional change by the process of changing emotion with emotion.
 ESSENTIAL THERAPIST

4
SKILLS FOR PRACTICING
EMOTION-BASED
APPROACHES

Before unpacking the clinical processes of helping clients arrive at and leave
painful emotions, regulate emotions, and construct new narratives, I want to
first describe the mind-set, background knowledge, and basic skills I have
found to be most facilitative in practicing emotion-based approaches. I have
most often had success when adopting a mindset that is open to the oppor-
tunities and limitations that my own in-session emotional disclosures present
to therapy. When working with emotion, therapists frequently must discern
whether, when, and how it may be appropriate to disclose their own emotions
with clients in a session. Part of this discernment process involves thinking
through how the content and manner of the disclosure might be received,
which depends, among other factors, on the therapist’s and client’s inter-
secting cultural identities (e.g., nationality, ethnicity, race, religion, gender
identity, sexual orientation). I expand on this theme in the first part of
this chapter.
Regarding background knowledge for working with emotion, I have
found it helpful to focus on information that helps increase my comfort in
“sitting with” an ever-increasing variety of emotions. Not only do therapists
need to sit nonjudgmentally with their own and their clients’ emotions, they

https://doi.org/10.1037/0000248-005
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

91
92  •  Changing Emotion With Emotion

also need to apply a transcultural frame to evaluate which emotions are most
distressing to the client or in what terms the client will feel most comfort-
able expressing emotion. I go into more depth on these topics in the second
part of this chapter.
Despite my view that, at core, people are all pretty much alike emotion-
ally, therapists cannot simply assume the universal applicability of our models
unless the issues of culture, race, and gender that permeate every aspect of
life are embedded in our treatment framework. We thus need to always
consider who we are working with, where we are conducting our therapy,
and to whom our research applies. Accordingly, the last section of the
chapter focuses on recognizing how institutionalized racism is baked into so
many of our social structures, including scientific research, and indeed into
the very psychotherapy models we practice. I conclude by advocating that
therapists confront systemic racism by adopting the role of social change
agent in their work.
Having worked now in many world cultures, I am convinced that although
cultural upbringings and the rules of emotional expression vary, what people
feel inside and the prototypic, existential situations are all experienced in
similar ways across cultures (Capps et al., 2015). All people, regardless of
culture, react internally, emotionally, and in a similar fashion to death, loss,
loneliness, meaninglessness, and to issues of freedom as well as issues of
abuse, intimacy, attachment, and dominance and submission. What leads to
these difficulties and how people express their emotions may be different
because of culture, but what is felt is similar. In addition, I have found that
emotional problems, such as unfinished business, destructive self-criticism,
and interruption of emotion, manifest and can be framed and resolved in
therapy in similar fashion regardless of culture.
Around 2007, when I began doing training in China, I subscribed to the
stereotype that Chinese people were inscrutable and would not express
much emotion. I was wrong! Working among groups of trainees on personal
issues in the emotion-friendly environment of experiential training, where
permission was given for emotional expression, it was more a case of how to
dampen down expression rather than how to activate it. When I first went to
Norway to train, some of the Norwegians said that “this soft empathy stuff
won’t wash with Norwegians because they are tough and won’t respond to
this caring stuff.” How wrong that was, too. In Turkey, people had difficulty
opening up in the self-experience component of the training until we talked
about it. They said that, in Turkey, they were used to getting criticism and
advice, so they had learned to close up as a means of self-protection. Once
my team and I set the ground rules of listening and empathy rather than
 Essential Therapist Skills  •  93

advice and criticism, our Turkish trainees and clients, delighted with the
opportunity to speak their truths, went to great emotional depths. All people
respond to being listened to and understood, and when they feel safe enough,
all people regardless of culture have painful feelings that benefit from airing
and attention.

KNOWING WHETHER TO DISCLOSE EMOTIONS DURING

SESSIONS

As noted in Chapter 2, the past several years have seen a growing interest in
the study of therapist emotions. In part, this interest stems from a broader
attention to studying therapists’ effects on outcome in general. In a recent
meta-analysis of the effect of therapists’ emotional expression on outcome
(Scherer et al., 2017), a significant medium effect size was found between
the therapist’s emotional expression and outcomes (d = 0.56). This finding
validates that therapists’ emotional expression in therapy has value and needs
further understanding, and that training therapists on emotional expression
is warranted.
Nearly every therapist has probably experienced an intense emotion
during a client’s session and possibly even cried (Blume-Marcovici et al.,
2013). Perhaps it was grief as a client described the death of her 5-year-old
son. Maybe it was anger triggered by the client who consistently showed
up late or sadness at the termination of a therapy. Imagine the following
scenarios: Your panic client takes her first ride in an elevator. How do you
feel? A patient tells you that his therapy with you is going nowhere, and
he wants a referral. How do you feel? You have a new client who reminds
you strongly of your estranged, hostile mother. How do you feel? Your client
makes a fortune on his annual bonus while you are struggling economically.
How do you feel?
How should therapists best deal with such emotions and with the myriad
of other emotions they experience in sessions? Should they or shouldn’t
they express them? Deciding whether to disclose emotions, such as anger
or sadness, with clients depends on many factors, including the client’s
emotional state, the amount of time left in the session, and the therapist’s
clinical assessment as to how the patient will handle the emotion.

Ensure Disclosed Feelings Are Relevant to What’s Happening in the Session

I disclose quite a bit of my personal feelings about things that pertain to me—
if they come up in the session and seem relevant. I, for example, expressed
94  •  Changing Emotion With Emotion

anger toward an insurance company’s handling of a flood in my office

when a client asked me how the flood had been managed. And when a client
arrived and saw me standing in the street watching an ambulance take away
a neighbor, I expressed how my own anxiety about having a heart attack
was activated as I observed what was happening. This type of expression
usually would take place at the beginning of a session as part of the meet-
and-greet phase of a session or maybe at the end if it was about something
that came up in the session. The client and I might get into a brief discus-
sion about some of what was happening in the world, like the effects of the
COVID-19 pandemic, but soon I would redirect the conversation back to the
client’s experience. I believe that it helps clients feel more trusting and safer
talking to me when they see me reacting to things in a human way.
If a client asks me how I felt or would feel in certain situations that they
encountered, I may share more personal feelings or thoughts; however, I am
careful to say it in a way so that I do not imply that this is what the client
did, or should, feel. Usually, my expression involves a type of validation of
the universality of what most people may feel in that type of situation. I also
might show my feelings in response to a highly emotional or self-relevant
topic the client is talking about. For example, a new client came for therapy
because her 12-year-old son had recently been killed when, as a pedestrian,
he was hit by a car. This woman’s grief was so raw—she talked to me for
an hour about the last time she saw her son, from getting the call from the
coroner’s office, going to identify his body, and describing how he looked
when she saw him at the morgue. It was absolutely heart wrenching to listen
to her story and to witness her grief. I had lost my wife a number of years
earlier in a similar fashion, and I found myself close to tears several times
until, at some point, she said something that was particularly impactful,
and I showed some tear drops. To not respond with sadness, to not share
that I had suffered a similar, although different, tragedy would have been
inhuman. We have to allow ourselves to be human, but we also have to stay
focused on our clients’ emotions.

Consider Whether the Feelings Might Build or Disrupt the Therapy Relationship

Therapists have all kinds of feelings. So-called negative feelings, such as

anger or fear, may signal an alliance rupture, which therapists then need
to identify, explore, and work through (Safran & Muran, 2000). Feelings
like shame or guilt also may occur when the therapist makes a mistake or
is criticized. If therapists avoid contact with such feelings or discard them,
they unwittingly ignore clues that may indicate that something important is
 Essential Therapist Skills  •  95

going wrong in the relationship. Therapists’ emotional reactions to clients’

behaviors also often are a consequence of client behavior. Asking oneself
questions like, “How does what I feel now relate to what the client is doing
with me?” will help the therapist understand aspects of the interaction that
they have not yet identified. Therapists who know more about their feelings
and are good at exploring the origins of those feelings as well as their effects
on the relationship will be able to use the information in treatment. Thus,
the therapist’s emotional reactions can provide valuable clues for identifying
clinically relevant client behavior.
The therapist’s own emotional history could also be the source of their
reactions; they need to take into account the possibility of so-called counter-
transference reactions (i.e., emotional reactions to one’s client). Attraction
to, admiration for, or boredom and irritation with a client may be related
to the therapist’s personal experiences, sensitivities, or preferences that are
not relevant to the client’s problems. Or a therapist may feel that ethical or
religious commitments are threatened by the direction therapy is taking. It is
important that therapists be alert to such confounding factors because they
affect their ability to help the client.
Therapists are often trained to limit self-disclosure about their personal
thoughts and feelings as well as to manage their countertransference. At the
same time, they are trained to be authentic, genuine, warm, and trustworthy.
To hold these opposing views in mind can be tricky, and different therapists
choose to practice in different ways. The best approach, in my view, is to be
genuinely present and focused on the client in an empathic way. Showing
feelings about what the client is saying can be a sincere and helpful response.
Simultaneously, therapists must learn how to avoid expressing their reactive
secondary emotions—for instance, getting angry at someone who has led
one to feel diminished.
Some clinicians believe that a therapist should never express anger or
grief in front of a client. But therapists who express emotion with a client
model integrity, and doing so encourages more open communication and
often reinforces a client’s instincts. Therapists need to show emotions that
they believe will be most helpful for progressing in therapy. That would
mean, then, that the therapist would be genuinely excited if a client made
progress with things that were worked on in therapy, but the therapist would
not necessarily share the frustration they were feeling if the client had not
followed through on an action they had committed to in a previous session.
Feelings disclosed by the therapist should be, at any given moment, the best
response for the client in the situation so that, from that experience, the client
learns that sharing one’s inner feelings and thoughts can be worthwhile.
96  •  Changing Emotion With Emotion

Practice Self-Awareness of Emotion

To facilitate the emotional work of clients, therapists have to be engaged

in their own emotion awareness and development process. Probably the
best training in this process of being aware of one’s emotions is to be in
emotion-oriented personal therapy or some form of self-experience process
that focuses on emotion. It is only through working with one’s own emotions
that one can help others to do that work. It is only by allowing and accepting
our own emotions that we can see that emotions do inform and organize us.
It is only by learning to discriminate between our own adaptive and mal­
adaptive emotions, as well as by learning to tolerate our own unpleasant emo-
tions, that we can experience that they do come and go. It is only by suffering
our own pain and finding that we survive and are resurrected that we
truly know that this is possible for our clients. Thus, we might rephrase the
saying “Physician, heal thyself” as “Therapist, deal with thine own emotions.”
Therapists have to train themselves, or receive training, in identifying and
staying with their own emotions. They have to learn by experiencing their
own emotions, symbolizing their own feelings in words, and identifying
their own painful maladaptive emotions. And they need to experience
accessing adaptive emotional resources to transform and soothe their mal-
adaptive emotions.
Psychotherapists should undergo psychotherapy themselves and reclaim
their own unresolved feelings and psychological needs. This work will
help them better understand their clients’ emotional dynamics and ensure
that their own psychological dynamics do not interfere with accessing
clients’ emotions or impede their ability to be truly helpful to their clients.
Therapists who find themselves becoming overly personally upset, defen-
sively insecure, embarrassed, or fatigued by their work with clients should
explore how the contact with their clients may be triggering these emotions.
They need to examine doubts about their own sense of identity, negative
self-evaluations, unpleasant memories, painful feelings, and other uncomfort-
able experiential states that may not necessarily be pertinent to understand-
ing and healing the client’s own psychological issues.
When therapists openly explore and resolve their own psychological issues,
they can then view clients in a more compassionate, empathically under-
standing manner and thereby respond to clients in a more appropriate, truly
therapeutic way. Although reactivity by the therapist can be an impediment
to effective psychotherapy, taking a cold, detached, uncaring, “professional”
stance toward clients also can detract from the effectiveness of psychotherapy
work. Clients who pick up that kind of coldly detached attitude may likely
feel uncomfortable baring their intense feelings, needs, and experiential
 Essential Therapist Skills  •  97

dynamics. A lack of caring, empathic communion between client and ther-

apist also can prevent awareness of blocked feelings that the client does
not feel comfortable sharing with a therapist perceived as coldly detached
and uncaring. However, when the client experiences genuine warmhearted,
caring, compassion, empathic understanding, and deeply invested “good
listening” from the therapist, that warm caring can function like a melting
process. It helps the client become unfrozen and blocked emotions to become
more fluidly available and to flow more freely so that the client can move
toward core painful feelings.

Use Facilitative, Congruent Responses

Emotional awareness and emotional authenticity in therapists promote

the same in their clients. Therapists need to be aware of their own internal
experience, and they need to be transparent and able to communicate to their
clients what is going on within when it is therapeutic to do so (Rogers, 1957).
If, however, therapists find themselves often feeling anger toward particular
clients, it is important for them to explore if their reactions toward their
client are coming from their own unresolved issues or concerns and to seek
supervision or therapy. Congruence involves being aware of what one is
feeling and disclosing it in an effective manner.
There are two central components of congruence (Greenberg & Geller,
2001). The internal-awareness component is the easiest aspect of the
concept to endorse as universally therapeutic. If therapists are not aware
of their own feelings in their interaction with their clients, that is likely
to impede therapeutic progress because they will be ignoring important
information generated by their emotion system about what was happening
between them and their clients. It would be akin to a surgeon’s operating
in the dark.
The second aspect of transparency, the communication of what one is
feeling, is much more complicated than the self-awareness component.
Being able to be facilitatively transparent involves a variety of interpersonal
skills, such as the ability to express not only what one is truly feeling but
also to express it in a nonthreatening way. Genuineness is a higher order
concept for a complex set of interpersonal skills embedded within a set of
thera­peutic attitudes. This ability to be genuine in a facilitative way seems to
depend on three factors: (a) the therapist’s attitudes, (b) certain processes,
and (c) the therapist’s interpersonal stance (Greenberg & Geller, 2001). To be
facilitative, congruent responses need to be communicated nonjudgmentally.
It helpful to use the word “facilitative” to qualify the word “congruent.” The
98  •  Changing Emotion With Emotion

therapist’s expression of themselves needs to be done for the client’s benefit,

not for the therapist’s.
Therapists need to communicate their primary feelings genuinely and
in a disciplined manner rather than impulsively blurting out whatever they
feel in the moment. First, they need to be aware of their primary experience,
which may take exploration and reflection as well as time. They also need
to be very clear on their intention for communicating what they are feeling:
that this sharing is not for themselves but to help clients or to improve the
relationship. In addition, therapists need to be sensitive to the timing of the
disclosure and not disclose if they sense the client is closed or too vulner-
able to receive it. Disciplined genuineness thus involves the therapist’s not
simply saying whatever they are feeling in the moment and communicating
core primary feelings rather than secondary ones.
Another important aspect of congruence that makes it helpful is compre-
hensiveness, which means “saying all of it.” The therapist needs to express
the central or focal aspect that is being experienced. But, they also must
express the experience of what they are feeling about what the client may
be experiencing in response to what the therapist said as well as what they,
the therapist, is feeling about what they said. Thus, saying that one feels
irritated or bored—even if done to take full responsibility for it as their own
feeling, as in “I find myself reacting with some irritation” or “I’m finding it
hard to stay connected and involved”—does not compose comprehensive
communication. Therapists also need to communicate their concern about
such revelations being potentially hurtful. For example, one may say, “I am
anxious that this not be hurtful [or “I am concerned about this being hurtful”],
but I want you to know I’m saying this to help me deal with this feeling,
so we cannot let it get in the way of our relationship.” Therapists communi-
cate that they are revealing their emotions out of a desire to improve their
connection, not damage it. This is the meaning of “saying all of it.” Being
therapeutically congruent, in addition to the skill of being aware of one’s
feelings, involves the interpersonal skills of knowing one’s primary feelings,
being nonjudgmental, disclosing for the good of the client, and being dis-
ciplined and comprehensive in one’s communication.
The therapist’s interpersonal stance is important in helping understand
how to be facilitatively transparent. The key aspect that makes transparency
facilitative is that the communication comes from an affirming and disclosing
position. Responses in supportive therapies are generally affirming, but a
transparently genuine response of what one is feeling, to be facilitative, needs
to be expressed as a disclosure. It is not the content of the disclosure that
makes a response facilitative; rather, it is the interpersonal stance of dis-
closure that is important.
 Essential Therapist Skills  •  99

Disclosure implicitly or explicitly communicates a willingness to, or an

interest in, exploring with the other person what one is disclosing. For
example, attacking when one is angry is different to disclosing that one
is feeling angry. Therapists take responsibility for their feelings by using
“I” language that helps disclose what they are feeling, not “you” language,
which is blaming. The key aspect of openly disclosing vulnerable feelings,
be they fear, or hurt, or even anger, is that the communication does not
involve going into a one-up, power position. When a therapist is experiencing
nonaffiliative, difficult feelings, such as anger or a loss of interest, it is being
able to disclose those feelings in a stance that is affiliative—and that is
helped by communicating that the therapist does not wish to feel this way.
Therapists thus might reveal these feelings as problematic feelings that are
getting in the way of their being able to be as present as they would like.
They also might explain that they are attempting to repair the distance
so they will be able to feel more understanding and feel closer to the client.
The key to communicating what could be perceived as negative feelings in a
congruently facilitative way is generally occupying an interactional position
that involves disclosing in an affiliative and nondominant manner.

SITTING WITH ALL TYPES OF EMOTION

Therapists conducting emotion-focused therapy need to be able to sit

within their clients’ feelings, be able to dwell in them, and accept them
whatever they are. For many helping professionals, especially younger ones
in Western “fix-it” cultures, this can be difficult. In current psychotherapy,
doing something to modify the problem quickly is favored over acceptance,
which is a longer process. Evidence of this quick modification, at least in the
United States, can be seen in the confusing array of insurance policies that
cover only “medically necessary” behavioral or mental health care and often
only a few sessions at that. Although many mental health practitioners do
not work with insurance companies, it would be hard to deny that public
policy has some influence on training programs and individual therapists’
service offerings.
In addition to policies that are inhospitable to emotions, the human
impulse to self-preserve—even when it plays out as a well-meaning desire
to help—can impede emotional work. After all, it is difficult to sit in the
poignant moment when the client is experiencing painful feelings, such as
the shame of being a “failure,” or is feeling powerless or hopeless. The ability
to be with painful emotion is a skill that therapists must learn to be most
100  •  Changing Emotion With Emotion

helpful and to deepen the therapeutic process. Having helped the client
arrive at the painful place, therapists can then help them not by giving
advice or correcting errors but by helping them explore, pay attention to
internal alternatives that arise on the edge of their awareness, and create
new meaning from their new experience. As Chapter 5 reveals, therapists
can be most helpful by being sensitively attuned to clients’ feelings and
assisting them to stay focused on their internal tracks so they can face what
causes them pain. This work cannot be done if therapists fear emotion—
an attitude that, in my opinion, has become too prevalent with the advent of
providing coping skills. Helping clients simply regulate emotion or remove
symptoms works against deepening emotion to get to core painful feelings
so they can be made amenable to new input.

Learn to Be Vulnerable

In general, society has seen emotion as being weak and has not seen vulner-
ability as a healthy possibility. Vulnerability essentially is about showing up
and being seen. It is tough to do that when people are terrified about what
others might see or think of them. Learning to be vulnerable in one’s own
life is important if one is going to carry this message to clients.
This denial of vulnerability is undergoing a change with the growth of
emotion-oriented treatments, especially in couple therapy in which dis-
closing vulnerability is seen as a key change process (Greenberg & Goldman,
2008; Wile, 1992). The work of Brené Brown (2012), who is a proponent
of the benefit of vulnerability, has popularized the idea that the courage to
be vulnerable will transform the way we live. Men now cry publicly, and
needing support and getting it from others are viewed as important.
I, however, still supervise therapists who are trying with the best of
intentions to help people by using self-soothing or emphasizing the positive
when clients clearly are in pain. For example, when clients are feeling
worthless and like failure, the therapist might try to help the client stand
up to their negative voice by saying, “The reason you are still trying and
haven’t given up totally means you are standing up for yourself.” Although
the therapist thinks this is therapeutic, their positive framing goes counter
to the aim of deepening into the core feeling of shame to access it so that it
can be made amenable to new input. Essentially, therapists are often afraid
to go into the hopelessness to get to the shame; instead, they try to save
clients from the pain produced by their punitive voices. But, in working with
emotion in most cases, the only way out is through. Therapists have to help
clients face, rather than run away from, their dragons.
 Essential Therapist Skills  •  101

Learn How Culturally Informed Views of Self Influence Emotion

A frequent limitation noted in research publications on therapy is the homo-

geneity of the population examined: predominantly White, educated, and
middle class and above. Clinicians need to recognize that people of different
cultures may differ in their emotional responses. White therapists, in partic-
ular, cannot necessarily accurately read the emotions of a client of color if
trying to understand from the White experience. Likewise, the emotions of
gender nonbinary people cannot necessarily be fully understood from the
heteronormative experience.
The predominant model of the self in the Western world, which is implicit
in most if not all psychotherapy, is one of an independent self (Markus &
Kitayama, 1991). From this perspective, personhood involves being sepa-
rate and distinct from others, and behaving as such, and groups are viewed
as existing to promote an individual’s well-being. Western culture is, there-
fore, viewed as an individualist culture in which each person’s uniqueness
is important. People are encouraged to express their feelings, wishes, and
thoughts, and effectiveness is seen as being able to influence others. All affect
how therapy is conducted to promote assertiveness and self-esteem.
In East Asian contexts, the main model of the self, however, is one based on
interdependence. From this perspective, being connected to others is funda-
mental to what it means to be a person as well as be responsive to situational
demands. The central unit of society is the group, and for social harmony to
be maintained, individuals must adjust themselves to the group. Thus, Eastern
culture is viewed as a collectivist culture in which individuals attempt to modify
themselves to fit into the group rather than try to influence others. Western
psychotherapy has more recently been strongly influenced by Eastern tradi-
tions and now promotes acceptance and awareness (mindfulness).
There appears to be a real difference in the way people view themselves
and their place in society as a function of cultural upbringing. In a classic
study comparing American and Japanese students (Cousins, 1989), U.S.
subjects were significantly more likely than Japanese subjects to describe
themselves by means of individualistic psychological attributes (e.g., friendly,
cheerful). Japanese participants were more likely to describe themselves with
references to social roles and responsibilities (e.g., a daughter, a student).
Cultures that ascribe to an independent model of self encourage people to
express themselves and influence others by, for example, trying to change
their environments to attain their own goals and to fit their own beliefs and
desires. In contrast, people brought up in a culture that has an interdependent
model of self are taught to suppress their own, goals, beliefs, and desires,
and to adjust to others.
102  •  Changing Emotion With Emotion

Markus and Kitayama (1991) argued that these different cultural models
of self influence how people in Western and East Asian contexts feel. For
example, Western culture has been found to value high arousal emotions,
which are ideal and effective for influencing others and, therefore, are
valued, promoted, and experienced more often in the West. Eastern cultures,
on the other hand, value low arousal emotions and consider adjusting and
conforming to other people as desirable. To meet this goal, low arousal
emotions work better than high arousal emotions and are, therefore, valued,
experienced, and preferred more than high arousal emotions. These differ-
ences influence how readily people of different cultures will be to experience
and express high and low arousal emotional states.
Other studies have revealed some of the cultural aspects of emotion
experience and expression. In a study of somatization comparing Korean and
American subjects, Choi et al. (2016) found that Koreans somatize emotions
more than Westerners do, and, more importantly, somatizing emotions
compared with verbally naming emotions elicits more empathy from the
other. Similarly, the Ghanian language has a preponderance of somatic refer-
ences in the communication of emotion, which suggests that embodiment
features prominently in Ghanaian cultural scripts of emotions (Dzokoto
et al., 2013). Thus, cultural differences in use of somatization may reflect
differences in ways of communicating and responding to distress in different
cultures (see Ye, 2002).
Culture also regulates emotion at the individual level by making emo-
tional responses that are in line with cultural models of emotion more
readily accessible (Mesquita & Albert, 2007). In this way, culture increases
the likelihood of an emotional response when it is consistent with the model
and decreases its likelihood when it is inconsistent with the model. There
are also culture-specific emotion syndromes. In Korea, Hwa-Byung, with
the literal meaning of “anger disease” or “fire disease,” is a culture-related
syndrome related to suppressed anger that is characterized by unique symp-
toms of a fire in the chest or heart (Lin, 1983; Min et al., 2009). Another
example of cultural differences includes higher levels of alexithymia among
Chinese Canadian versus Euro Canadian outpatients. This finding has been
explained by group differences in one component of alexithymia—externally
oriented thinking (EOT)—possibly because Chinese cultural contexts may
encourage EOT given a greater emphasis on social relationships and inter-
personal harmony rather than on inner emotional experience. In a study of
alexithymia, Chinese Canadians showed higher levels of EOT than did Euro
Canadians. Those results suggest that cultural differences in alexithymia
may be explained by culturally based variations in the importance placed on
emotions rather than on deficits in emotional processing (Dere et al., 2012).
 Essential Therapist Skills  •  103

Given that emotion is not only biologically determined but also is influ-
enced by the environment, cultural differences do need to be understood.
Culture clearly does constrain how emotions are expressed. It influences
how people should feel in different situations and the ways people should
express their emotions. And because emotion is not only biologically deter-
mined, culture, to some degree, influences emotional experience and even
more strongly influences emotional expression. Therapists, therefore, need
to be culturally sensitive.
Being a culturally sensitive therapist involves first recognizing and under-
standing that their own culture influences them, and then, that it influences
their relationships with clients. Subsequently, they need to understand and
respond respectfully to the culture that is different from their own. Given
that a main principle of an emotion-oriented therapy is to understand and
be empathically attuned to the client’s feelings, this baseline stance provides
a general safeguard against imposing one’s culturally biased views on others.
Still, it is important to be on guard against enacting our cultural biases
because they often may be more implicit than explicit.

Learn How Culture Influences Which Emotions Are Appropriate

One major issue in which different cultural assumptions can cause confusion
in therapy is the role of assertion and boundary setting. Because preserving
social harmony is a major concern in Asian culture, interpersonal conflict,
for example, in marital relationships, is not a common presenting problem.
It has been found that American partners are more apt to express anger
and argue than Japanese partners (Kitayama et al., 2000). For example,
in Japan, an individual does not say “no” in direct response to the other’s
opinion or suggestions. To do so would be viewed as hostile. Instead, to avoid
conflict, a response is phrased as a positive sentence or a polite “yes,” or by
silence. The listener is then expected to determine if the answer is a definite
agreement or simply a polite no. In East Asia, indirect communication that
is possibly ambiguous is, therefore, deemed more appropriate and seen as
maintaining group cohesiveness and harmony.
As a result of an interdependent perspective on self, the expression of
emotions is significantly shaped and influenced by a consideration for how
it will affect others (Hwang, 2006; Markus & Kitayama, 1991). For example,
expressing anger to defend the self, which is independent of the other, is not
uncommon in Western cultures. This emotion is less prevalent for those with
interdependent selves for which there is not much of a sense of being sepa-
rate from the other. In this cultural context, self-serving motives are usually
104  •  Changing Emotion With Emotion

replaced by what appears as other-serving motives (Markus & Kitayama,

2001). In addition, because Japanese people place high value on emotions
that are low on the arousal spectrum, calmness, serenity, and tranquility are
encouraged (Ruby et al., 2012), and similarly “powerful” emotions, such as
anger, contempt, and disgust, are discouraged (Safdar et al., 2009). Japanese
individuals thus may often minimize negative self-expressions in an effort
to preserve social harmony. This presents a challenge for therapists working
within a Western individualist model that views authentic self-expression
(i.e., want and needs) as an essential step toward change in therapy and
toward creating a strong connection between people.

UNDERSTANDING THE RULES OF EMOTIONAL EXPRESSION

My experience in conducting individual therapy in a variety of cultures

is that although different cultures have different rules of expression, when
therapists get to core issues, the emotions and the processes of change are
the same. I mention “individual therapy” because modality does affect how
much attention needs to be given to culturally informed rules of emotional
expression. Doing individual therapy, therapists predominantly are not deal-
ing with communication between partners and resolving current relational
conflict for which rules of expression would be more important. Rather, we
are dealing with the effect of clients’ own painful emotion histories on their
lives. Couple therapy needs to deal much more with rules of expression and
the meaning of communication, which are more culturally laden than dealing,
in individual therapy, with people’s experience of their own emotions.
Emotions are a given of human existence and are experienced by all
people regardless of culture. However, the expression of emotion as opposed
to the experience of emotion is highly influenced by culture, including
influencing whether an emotion is perceived as healthy or problematic.
Western approaches to psychology need to be careful to not pathologize the
way different cultures experience and express emotion. Different ways of
perceiving, experiencing, and expressing emotion can be healthy within
one cultural context but often be oppressive and problematic in another.
Cultural knowledge, therefore, can be instructive in helping therapists
develop the necessary skills to work with client emotions in a culturally
sensitive manner. For example, consider my observation about emotional
arousal: When Turkish clients in Germany present their problem, they show
more intense emotion than German clients in similar situations. Both Turks
and Germans feel anger and sadness, yet it appears that in the Turkish
 Essential Therapist Skills  •  105

context, one needs to show a lot of emotion to indicate the seriousness of the
problem. If a person does not weep or express their anger, they might not
be taken seriously. So, cultural rules of expression influence what people do.

Be Open to Positive and Negative Interpretations of Anger and Shame

Anger is probably the emotion with the strongest differences in cultural
prohibitions. How therapists talk to clients about anger may need to be
adjusted in more collectivist cultures by saying, for instance, “I don’t like” or
“I feel it’s not fair” rather than directly encouraging clients to say, “I’m angry.”
It is almost forbidden to express anger at one’s parents in collectivist cultures,
and this prohibition is even stronger in cultures like Thailand and Vietnam,
where there is ancestor worship.
People in different cultures do acquire different views of emotions and
do carry those views into therapy with them, so it is useful for therapists to
be aware of them. In Eastern cultures, shame is generally considered a good
emotion; it can be seen as modesty or embarrassment, and it shows pro-
priety, humility, and that one knows one’s place in the world. Experiencing
and showing shame when one has violated cultural norms are seen as ways
of repairing norm violation. In Western cultures, shame, however, is often
more associated with failure and frequently results in behaviors that are
destructive for self and relationships. Westerners withdraw in shame and do
not want to be seen. It is not just that the same emotion is valued differently;
the view of emotion is different. How one experiences shame, whether one
reaches out or withdraws, and how shame impacts one’s reputation and
relationships are all culturally specific.
I had the experience of lecturing on self-criticism in Japan, and it was
from a question in the audience that I realized when I said “self-criticism,”
it implied something good to many audience members, when, in my Western
context, it automatically meant something bad. I had to qualify and talk about
destructive versus constructive self-criticism. In the same way, therapists can
broaden their view to see that there can be both adaptive and maladaptive
shame. Although the feeling of shame is universal, therapists need to be
sensitive to what it means in the client’s cultural context.
Shame is so unbearable in individualist cultures that it is often turned
into anger. When people who want to be seen as independent feel ashamed,
they feel bad about themselves. And they do not think to question, “How
important is it that I feel good about myself?” If people took some distance
from the culturally set goal of feeling high self-esteem and independence,
then they could live with shame. Understanding how one’s emotions are
culturally influenced does provide the possibility of options to feel different.
106  •  Changing Emotion With Emotion

Help Clients Find Their Own Solutions

While working in Hong Kong, which has mixed Asian and British influences,
I encountered the influence of culture in interesting ways in dealing with the
perennial problem of the “mother-in-law.” In an Asian context, I observed,
the mother-in-law may come into the married couple’s kitchen and cook. The
daughter in-law may feel this as an intrusion or may accept it as normative.
How should she handle this? The harmonious Asian way is to value harmony
above assertion, which will lead to acceptance with goodwill. The Western
way would be to prioritize assertion and boundary setting and would involve
directness and possible conflict.
When working on their own intrapersonal conflict about how to manage
these situations, those daughters-in-law who held harmony as an integrated,
intrinsic, cherished value resolved the conflict in favor of harmony. Those
who were more Westernized and valued individual rights favored asser-
tive solutions. The problems arose for those who had adopted harmony as
a “should” rather than as an intrinsic value. They became depressed and
unhappy. In helping clients work on their internal conflict between harmony
and assertion, it was important for the therapists to not be biased in one
direction or another but, rather, to help the client find her own solution. It
would have been countertherapeutic to assert a more individualistic, Western
view that one should stand up to one’s mother-in-law with a client who had
harmony as a core value.

Develop Safety and Trust

The way in which cultural difference can affect relationship formation in

therapy is meaningful because alliance formation and how to create trust
do differ across cultures. In therapy in an Asian context like Japan, where
saving face is important and concern about not shaming the other is a
priority, it is crucial in creating an alliance to work on emotion and to be
direct about the importance of self-disclosure (Greenberg & Iwakabe, 2013).
At the start of therapy, the therapist can lay out that in the therapy session,
it is counterproductive to save face, so the client needs to disclose their
underlying feelings whenever possible. Also, it can be helpful to note that
the purpose of therapy is not for the therapist to give advice (which often is
the client’s expectation) but, rather, to help the client with their emotions—
and that therapy is a place to experience and resolve painful emotions.
Some psychoeducation on emotion often is needed to encourage clients
to express emotion. Given the difference in view on arousal and given the
importance of saving face, in general, as well as harmony and filial loyalty
 Essential Therapist Skills  •  107

in Asia, it frequently takes longer to develop safety, trust, and an alliance to

work on these emotions.
As another example of how emotions involved in forming the therapy
relationship need cultural sensitivity, I learned from my work with Indigenous
cultures in North America that empathy and questions can be experienced as
intrusive and lead to withdrawal. To survive, small, close-knit communities
needed to avoid conflict. Because they lived in close proximity while main-
taining privacy, it was important not to interfere with one another. Asking
questions, giving advice, or being too familiar could be experienced as inter-
fering. Thus, an aboriginal client could experience empathy as unwanted;
the more therapists would try to engage clients in this way, the more the
clients would close up.
Working with any person from any culture to develop an alliance to work
on emotion involves dealing with the same universal fear of emotion: It is
dangerous because it is not fully in one’s control, and it comes unbidden and
can take control of behavior, and be seen by others. Different cultures teach
different ways of dealing with the uncontrollability and exposure to others
of emotion: the West, with rational control; the East, with observational
distancing. But one thing is clear: All cultures have the same feelings that
humans have been grappling with for thousands of years.

Recognize How Societal Oppression Influences Emotional Expression

Gender, race, culture, and class all combine to encourage and suppress the
expression of certain emotions as do societal oppression and institutional
power structures. The socialization process of emotion and its expression
are also known to be different for both men and women, and for people of
different races and ethnicities. It is important to recognize how these inter-
sections affect working with emotion in therapy.
It is known that women express emotion more freely than men, both
more positive feelings and more internalized negative feelings, and they
cry in front of others more than do men (Gard & Kring, 2007). Men, on the
other hand, express more anger and aggression than do women. However,
when their physiology, such as blood pressure and cortisol level, is mea-
sured, it is higher than women’s, which suggests that men feel but do not
express; they tend to keep their emotions bottled up inside (Gard & Kring,
2007). Although, undoubtedly, people regardless of gender feel all emotions,
the degree of emotional expression and which emotions are expressed in
therapy will be somewhat different according to gender (Brody & Hall, 2008;
Fischer & Manstead, 2000).
108  •  Changing Emotion With Emotion

Race also exerts a strong influence on emotional expression, especially

in the context of racism. Members of marginalized racial or ethnic groups
have reported fears that expressing emotion is dangerous and evokes nega­
tive stereotyping (Richman & Leary, 2009; Wingfield, 2010). Because of
these fears, African American children, for example, are socialized to not
express anger so they will not be judged as violent. It is generally more
dangerous, especially for African American men, to be assertive in public,
and it is potentially lethal to be so with police. The terrible paradox is that
anger, which is a healthy response to injustice and violation, is denied to
African Americans, and, yet, they have the most cause to feel angry about
social injustice. Therapists, in working with anger with African American
clients, need to understand that it is dangerous for them to express anger
because of racial stereotyping. People of color are in much greater danger
of the use of force against them if they express anger, whereas White people
have the privilege of being able to express anger without prejudice or fear
of being penalized for being angry.
We therapists who have been trained to work with emotion have had to
learn to get comfortable with difficult feelings. It is imperative, then, that
we deal with our own difficult feelings related to racism so we can serve
and improve our clients’ lives—and not perpetuate their problems. It has
become clear that, in the dominant, White culture, people in general and
specifically therapists find talking about race uncomfortable. This discomfort
is a fear-based feeling that needs to be faced. As therapists who promote
digging into uncomfortable feelings for transformation, we need to engage
in the antiracist work of self-transformation.
Dominant culture therapists need to recognize that racism has been—
and is—a major problem and be able to sit with their own discomfort as well
as explore questions about racism that make them uncomfortable, ques-
tions such as their own privilege. They need to address their own guilt and
complicity in perpetuating systems that have worked to their advantage but
have oppressed others and have made people of color feel negatively about
themselves and their place in the world (Kendi, 2019; see also Morin, 2020).

TAKING THE ROLE OF SOCIAL CHANGE AGENT

White, heterosexual, educated, and middle-class therapists need to be better

at acknowledging the impact of their own and others’ silence when it comes
to the experiences of people of color. Therapists need to understand their
own privilege in ignoring racism and their own unearned power by virtue
 Essential Therapist Skills  •  109

of being White. In sessions with their clients, they also need to speak out
against racism. Healing from internalized whiteness is needed. To do this,
therapists need to be aware of the prevalence of systemic racism and listen
to clients of different races, cultures, and genders to understand their expe-
rience of disempowerment. However, these are only the first steps.
The next step for therapists is to adopt the position of educators, raising
the awareness of both their White and African American clients of how they
have been affected by systemic racism if they are not already aware of it. It is
important for therapists to be able to discuss the effect of race when their
clients are ready and open to it but also not to impose this conversation on
clients who do not wish for it.
At this time in history, with the visibility of recent horrifying examples
of systemic racism in police murders of people of color and accompanying
protests, the world is being called again to confront this injustice, which has
existed for centuries in most European countries. This form of prejudice and
institutionalized racism were made explicit for many years in the modern era
by the South Africa apartheid system but was kept more hidden in European
countries. Now, systemic racism is being named and needs to be included
in therapeutic dialogues, including unequivocally stating how racism has
damaged one’s clients. Racism in its systemic structural, institutional, and
interpersonal forms is a threat to mental and public health.
Therapy needs to address the emotional issues of racism that people of
color have had to suffer. Therapists need to do more than be supportive;
they need to take the role of a social change agent by teaching and raising
awareness of the effects of systemic racism. This means engaging in a more
directive stance around these issues—a stance that is somewhat different to
following responsively and being empathic. Every good therapist, in some
ways, needs to be a revolutionary, questioning the lies widely accepted within
any cultural context and helping people extricate themselves from social
constraints and oppression.
This more proactive stance involves helping people face issues created by
society. What needs to be discussed are problems that people of color may
have experienced that relate to the pressure they experienced to identify
and conform to White culture rather than learn about and identify with
their own racial heritage. Their experience of questioning White culture and
showing an interest in their own racial group needs to be encouraged as
does their experience of possibly wanting to withdraw from White culture
to delve into their own racial history in the effort to define a new identity.
Therapists also may help clients who wish to integrate with the dominant
culture without compromising aspects of their own racial or ethnic identity
work on balancing all aspects of their heritage.
110  •  Changing Emotion With Emotion

Clarify Who the Self-Critic Is

Clients who are members of racial and ethnic minority groups possess a
unique set of lived experiences that may drastically differ from that of the
dominant culture. Failure to recognize these differences can cause ruptures
to the therapeutic alliance and hinder the effectiveness of therapists’ inter-
ventions. An example of one major issue that needs attention in an awareness-
raising context is the chronic stress related to stigmatization from negative
societal attitudes toward minority individuals in a racist/White/heterosexist
privileged society. Many feel shame induced by the internalization of hostile
criticism, discrimination, and violence to which others have subjected them.
This influences their sense of self.
For a person of color growing up in a dominant, White culture, there is
not only an internalized personal self-critic but also an internalized external
societal oppressor. Here, the behavior of others has diminished, disempowered,
or destroyed the person’s self-confidence and invalidated the person’s iden-
tity by communicating messages of core unworthiness (Wong et al., 2014).
It is essential in therapeutic work that individual self-criticism and social
oppression not be confused with each other. The internalization of a critical
voice of a parent, for example, that produces shame differs from the inter-
nalization of systemic racial oppression and marginalization of the self by
the society one lives in. The latter aspect develops through living with one
or more marginalized identities in the dominant culture.
Therapists thus need to work with clients to clarify who the self-critic
appears to represent. Is it a personal, psychological, criticism, or is it the
internalization of societal invalidation? If it is an internalized personal
self-critic, work needs to proceed to resolve the self-criticism and shame
induced by it and work toward self-compassion and negotiation or inte-
gration between different internal voices. If, however, it is the introjection
of external, dominant culture or criticism, assertion of self through adaptive
anger needs to be supported and encouraged followed, possibly, by self-
soothing to strengthen the self.

Attend to Chronic Stress and Trauma

Another important topic for therapist to attend to is unresolved racial trauma

or race-based stress. Many people of color experience danger from real
or perceived experience of racial discrimination, such as threats of harm,
humiliation, and the witnessing of harm to other people of color from racist
attacks. Although similar to posttraumatic stress disorder, racial trauma is
unique in that it involves ongoing individual and collective injuries resulting
 Essential Therapist Skills  •  111

from exposure and repeated exposure to race-based stress (Comas-Díaz

et al., 2019). Historical trauma, the cumulative psychological wounds that
result from historical traumatic experiences, such as colonization, genocide,
slavery, dislocation, and other related trauma, has intergenerational effects
such that racial trauma may accompany people of color throughout their
whole life.
Although African Americans are more exposed to racial discrimination
than are other ethnoracial groups (Chou et al., 2012), many Indigenous
people, Latinx, and Asian Americans also suffer from race-based stress.
Therapy needs to help clients work through the emotional wounds caused
by racial trauma to find relief, gain awareness, and cope with systemic
oppression while encouraging resistance and protection from the external
forces that cause ethnoracial trauma.

CONCLUSION

Does emotional experience and expression come first because of in-wired

programs, or is emotion determined by culture? In the dialectical construc-
tivist view of emotion that I have sketched out in this and previous chapters,
the answer is that both views are valid. Although there are basic emotional
expressions before culture, there are not many adult expressed emotions
that are separate from a person’s culture and learning. Emotional experience
is a synthesis of inborn, basic, psychoaffective motor emotion programs in
interaction with previous lived experiences, learned expectations, and social
knowledge plus what is happening in the moment.
When, for example, shame is discussed, many elements are similar regard-
less of culture. For instance, shame includes a wanting to disappear and an
idea that “I am not good enough.” Clearly, elements in the experience of
emotions are universal and recognized across cultures—both types of situ-
ations and types of meanings that are similar in different cultural contexts.
But emotions also are not totally independent of social context or culture,
and feelings do not always feel exactly the same across different situations
or different cultures. Therapists need to be empathically attuned to what
this person in this culture is saying about their feelings. They also need to
ensure that any self-disclosure of their own emotion respects these differ-
ences and does not invalidate the client’s concerns or reinforce oppressive
power structures.
There are different differences between different cultures. Latinx cultures
are more expressive than more Anglo Saxon, British, and Swedish cultures,
112  •  Changing Emotion With Emotion

which are more restrained (Hareli et al., 2015). Also, certain cultures have
more masculine-derived philosophies of being strong, with notions of
“don’t whine or be a baby.” These cultures, or possibly subcultures in many
cultures, put down vulnerability in favor of being tough or value the virtues
of a stiff upper lip. But all these differences are more at the level of rules of
expression and not at the level of more basic emotional experience. I have
not found a lot of difficulty in applying my work with emotion across different
cultures provided I am aware of what my own Western biases are and know
a bit about the culture I am working in.
In North America, when a White therapist meets with an African American
client, race is in the room and needs to be dealt with. White people typically
avoid Black spaces, but Black people are required to enter White spaces.
Both the therapy room and training room are White spaces where Black
people are constantly required to navigate as a condition of their existence
(Anderson, 2015). The experience of otherness by virtue of being a member
of a non-White group living in a predominantly White society is impossible
for people of color to avoid. Thus, therapists need to negotiate the rapids
of how to acknowledge their clients’ collective experience of unfairness and
oppression while not denying the person’s individuality and personal expe-
rience. Therapists need to bear witness to the person’s experience of injus-
tice without thereby exacerbating feelings of otherness. In developing this
skill, therapists seek not only to be better helping professionals but also to
become agents of social change.
PART 

II ARRIVING AT
EMOTION
 
5 EMPATHIC ATTUNEMENT
TO AFFECT

As we introduced in Part I, therapy to change emotion follows a two-stage

approach of arriving at and then leaving emotional experience (Greenberg,
2002). In the first stage, the therapist listens to the client’s narrative and
lets the story and its emotional significance emerge. In this first stage, the
therapist works to activate core emotion schemes to access painful mal-
adaptive feelings. They do so in various steps, the first of which—empathic
attunement to affect—is the subject of this chapter.
Empathic attunement to affect involves a kinesthetic and emotional sensing
of another’s inner world, knowing their rhythm, feeling, and experiencing
by metaphorically being in their skin. Empathically following affect is more
a right brain process than a left brain, analytic one. It functions at levels
beneath conscious awareness and involves being with the client rather than
doing to the client. It is helpful to distinguish between “empathic under-
standing” and “empathic attunement to affect.” Both are therapeutically
important, but empathic attunement to affect goes beyond empathic under-
standing to create a two-person experience of reciprocal affective resonance,
a responsiveness that creates a feeling of unbroken connectedness in which
the focus is clearly on affect, not meaning. This type of connection allows
for the coregulation of affect.

https://doi.org/10.1037/0000248-006
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

115
116  •  Changing Emotion With Emotion

Rogers (1957) famously introduced the idea of empathy as reflection of

feeling, but what he called “reflections” were more predominantly reflec-
tions of meaning. Before his death, he said he wished he had used the term
“checking his understanding” instead. Empathic understanding involves imagi­
native entry into the world of the other plus the ability to turn this under-
standing of the other’s inner world into words. It is a crucial therapeutic
skill (Watson, 2016). Empathic attunement to affect, however, goes beyond
empathic understanding because the focus is not only on conveying under-
standing but also on focusing on and mirroring affect. “Feeling felt” by another
creates a resonance of minds that is essential to survival, is pleasurable, and
helps in regulating one’s affect.
Another way of describing the process of empathic attunement to affect is
by an analogy with the experience of musical attunement in which a singer
matches their pitch with that of another singer or musical instrument. Using
this metaphor, listening to the client in an affectively attuned manner would
mean to attune with the client’s affective experiences in the here and now
or, extending the metaphor a little, attune with the melody (or tune) of the
client’s internal affective experience. That is, through empathic attunement
to affect, the therapist vibrates to or resonates with the client’s melody that
is emanating from their being in the immediacy of the therapeutic encounter.
The pitch and rise, energy, rhythm, and tone of the therapist’s voice, and the
expression of the face and eyes, and their contours over time, all mirror
the client’s affective experience of tiredness, excitement, anger, or sadness.
This does not occur by deliberate means but automatically out of being
fully present, interested, and attuned. Unpacking the meaning of the word
“interest” is helpful because its use in the previous sentence conveys the
special sense of the kind of presence needed. The word, broken into its
components in Latin is: est, “to be” and inter, “among.” Thus, one is “among”
the other. One needs to be fully absorbed and curious.
The addition of the words “attunement to affect” to “empathic” emphasizes
being spontaneously tuned into, interested in, and harmonizing, with the
rhythm and contour of the client’s emotional experience (Stern, 1985). Given
that the goal of working with emotion in therapy is to facilitate people’s
ability to deal with their emotional pain, it is important that therapists
focus on their clients’ moment-by-moment emotional states. The ability to
be attuned really comes down to how present therapists are to their clients’
affective states in the moment and how successfully they mirror those states so
that a connection that goes beyond words is felt. The client will then feel felt.
As well as conveying understanding of clients’ meanings and feelings, thera-
pists also need to mirror their clients’ bodily based physiological experience.
 Empathic Attunement to Affect  •  117

Therapists need to respond to their clients’ facial expressions, the way they
sit and hold their bodies, their micromovements, their breathing, and their
vocal tone. Therapists can achieve synchrony with their clients by being
attuned to their clients’ physiological processes. The therapist’s pacing and
the tempo of the interaction needs to match the client’s state; their bio-
rhythms become coordinated. This is expressed in a matching of language
use, vocal tone, skin conductance, pauses, and other nonverbal behaviors
(Watson, 2019). And all of this is occurring automatically.
Affect attunement is an embodied phenomenon. Neuroscience research
demonstrates that this type of attunement is a whole-body experience (Gallese,
2009). The discovery of mirror neurons suggests that human and primates’
brains run a type of embodied simulation that allows people to understand
the experience of others’ feelings, sensations, emotions, and intentions with-
out words and at a sensory-motoric level (Watson, 2019). This simulation is
not a deliberate or conscious process; rather, it is nonconscious and prereflec-
tive. It is through the simulation of others’ intentions, which are conveyed
mainly by bodily actions and facial expressions, but also by understanding
the context that the emotions of others are sensed and recognized. In other
words, the brain runs a type of simulation of what it’s like to do what the other
is doing in the situation described.
In therapy, the more vivid the description the other provides, the more
the therapist can imagine the experience and the more their brains will be
able, automatically, to run a simulation, thus giving the therapist a sense of
what it was like for the client. Therapists need to actively imagine clients’
stories and actively imagine what clients experience. Therapists’ empathy is
enhanced when they can deliberately imagine and sense clients’ experience
(Greenberg & Ruchanski-Rosenberg, 2002; Watson & Greenberg, 2017).
It is important that in both empathic attunement and empathic under-
standing, therapists do not feel what the other feels. Rather, we experience,
bodily, a type of metaexperience, feeling what it feels like to feel a feeling
but not actually feel the feeling. Thus, if my client feels shame, I do not feel
a taste of shame with its action tendency to withdraw. Rather, I feel what
it feels like to feel this, always keeping distinct that this is what it feels like
for the other rather than feeling it myself. What I might feel as my own
emotional reaction might be something quite different. For example, when
my client feels shame, I do not feel shame. Rather, I may feel compassion or
even a sense of anger or sadness at what the client has suffered. A study of
what therapists felt when they were being highly found that only 11% of the
time did therapists report feeling the same feeling as the clients empathic
(Greenberg & Ruchanski-Rosenberg, 2002). The majority response about
118  •  Changing Emotion With Emotion

40% of the time was that therapists had a vivid image of what the client was
saying, and they read the feeling of what was depicted in the image.
Affect attunement is a profound process. The question becomes: How
do we learn it, how do we do it in therapy, and how do we train people to
improve their capacity to be empathically attuned to affect? We probably
learn empathic attunement to affect by a combining some innate ability to
recognize emotion with having had our own affective experience empathically
mirrored and, over time, internalizing this capacity at a procedural level.
One could say that a caregiver’s attunement to their infant’s affect provides
the building blocks to how children learn to be connected to others, build
relationships, and be attuned to affect. A caregiver’s ability to be attuned
is important to children’s ability to learn to regulate their nervous systems
and deal with distress. The consistent failure of caregivers to be attuned to
infants’ ever-changing affective states results in poor affect regulation and
poor abilities to deal with affect in others. In addition, then, to our personal
experience of attunement throughout our life that has given us some capacity
for attunement now as helping professionals, training in being present is a
way to enhance attunement.

THERAPEUTIC PRESENCE

Therapeutic presence involves the ability to be fully in the moment with the
client in the fullness of their experience (Geller & Greenberg, 2012). Thera­
peutic presence is not a technique; rather, it is a way of being with the
client. It involves therapists’ being open and sensitive to their own, and to
their clients’, moment-by-moment changing, awareness, and experience, and
responding from this state of inner receptivity. What the therapist does is
almost not as important as when the therapist does it; being present to the
moment enhances attuned responsiveness. Therapeutic presence entails being
fully immersed in the moment with the intention of being in service of the
client’s healing process while maintaining a sense of groundedness in one’s
own personal existence and a connection with the other. This state is enhanced
when therapists suspend or defocus from their own needs, hopes, concerns,
beliefs, or assumptions, and instead focus with their full attention on the
client’s process and what is occurring between them in the moment.
This quality of being in the moment provides a foundation for attunement
to affect. All emotion occurs in the present, so therapists need to be in the
present to be aware of their client’s emotions. Primarily, presence is a way of
 Empathic Attunement to Affect  •  119

meeting the client that is free of the therapist’s preconceptions, judgments,

and agendas. I like to describe my experience of presence this way: When
I am sitting in front of a client, if a sunbeam is shining through the window,
I see the sunbeam, and if a speck of dust drops between us, I see the speck
of dust. Likewise, if the client’s eyes film over before tears appear, I see the
change in the reflected light in the eyes. Therapeutic presence is a way of
being fully open to clients in the depth and complexity of their internal
emotional, cognitive, and spiritual world.
Geller and I (Geller & Greenberg, 2012) defined therapeutic presence as
bringing one’s whole self into the encounter with a client by being completely
in the moment on a multiplicity of levels: physically, emotionally, cognitively,
and spiritually. Presence involves (a) being in contact with one’s integrated
and healthy self while (b) being open and receptive to what is poignant in
the moment, and immersed in it, with (c) a larger sense of spaciousness and
expansion of awareness and perception, and with (d) the intention of being
with and for the client in service of their healing process. The inner receptive
state involves a complete openness to the client’s multidimensional internal
world, including their bodily and verbal expression, and openness to the
therapist’s own bodily experience of the moment to access the knowledge,
professional skill, and wisdom embodied within. Being fully present, then,
allows for an attuned responsiveness based on a kinesthetic and emotional
sensing of the other’s affect and experience as well as one’s own intuition
and skill, and the relationship between.
Therapists can train to become more present by engaging in different exer-
cises of present-centered awareness. In the 1950s, Gestalt therapy, drawing
on Zen Buddhist practice, introduced exercises in present-centered aware-
ness. These exercises essentially involved practicing being in the moment
by saying, “Now I am aware of . . .” and shuttling between awareness of
outer sensation, involving perceptions beyond the skin, inner sensation and
perception within the boundary of the skin, and what was called “middle zone
awareness”—thought, expectation, memories, and so forth—that involved
conceptual processing. This conceptual processing was meta to or beyond
the experience of present sensory-motor awareness. Mindfulness meditation—
which has gained popularity since the 1990s—is another form of practice in
being present to what is occurring; it also trains attention to focus on present
internal experience within. These and other forms of Eastern practice, such
as tai chi and yoga, aid the development of the capacity to be in the moment
without memory, thought, or desire—what Bion (1967) suggested as the ideal
state for therapists to be in during therapy.
120  •  Changing Emotion With Emotion

THE EXPERIENCE OF ATTUNEMENT

Attunement implies a type of communication that occurs between two

people who each have a body gifted with a sense of direction. I use my
bodily felt sense of direction to guide each of my clients to become what
they are but what they may never have been able to become by themselves
alone. In this process, I am not reducing the other’s experiences to mine,
but, rather, I am simultaneously making explicit my experience and also my
client’s experience as it is conveyed to me. I try to understand the other’s
experience through my own (see, e.g., Merleau-Ponty, 1945/1962). It is
something like the two of us—my client and I—are one—like my body and
the other person’s body are one whole, two sides of a coin, and my body
inhabits both bodies simultaneously. My client’s emotions like anger, fear,
shame, hate, and love are not hidden at the bottom of their awareness.
Rather, they exist as possibilities in the specifics, in this person’s description,
on this face or in these gestures, not hidden behind them. The client’s feelings
and meanings are embodied, and my empathic attunement to affect is a lived
bodily experience in which I develop a “felt sense” of the other’s “interior.”
I sense something by resonating with my client’s sense of intention.
This sense is given to me spontaneously in a passive construction of felt
meaning. As I listen, my client’s private world shows through, permeating
the fabric of my own experience, and, for a moment, I sense what it feels
like. As Merleau-Ponty (1968) described it in his book The Visible and the
Invisible, “My private world has ceased to be mine only; it is now the instru-
ment which another plays” (p. 11). It is precisely my body that perceives the
body of another and discovers in that other body a miraculous continuity
of my own intentions, a familiar way of dealing with the world. I reach into
this shared bodily experience and sense what it feels or felt like. Doing this,
I pronounce, “You must have felt so lonely, or afraid, or even humiliated,”
even though the client has not said any of this explicitly.
Transposing myself into the other’s experience does not mean actually
putting myself in the place of the other person and thereby displacing the
other’s experience with my own. Rather, it consists of being myself and,
only in this way, bringing about the possibility of being able to go along
with my client while still remaining other with respect to them (Heidegger,
1953/2000). I go along with the other through imaginative identification,
transposing myself into the other’s way of being. This going-along-with
means directly learning how it is with this experience for my client and
discovering what it is like to be this person with whom I am going along
in this way.
 Empathic Attunement to Affect  •  121

When I am talking with my client, attunement involves relying on the

resonance I find within my own body. I pay attention to what I feel called to
do by the other. I try to say what would capture all that the other feels, wants,
and intends. Feelings and emotions always refer to something; therefore,
to fathom my client’s emotional or mental states, I also try to understand
their mental representations or the contents of their narrative to capture
what their mind is directed at. There is an “aboutness” or “directedness”
to emotional mental states, and it is this that I am trying to understand.
Attunement to affect is not just naming a feeling but capturing the whole
state, its felt meaning, and its sense of direction. It is not just “You are sad”
but “You are sad about missing or losing this, and you want or need this.”
In this way, I try to capture the whole feeling, what it is about, and what it
implies as well as its sense of direction. I ultimately try to put into words the
need or want that is embedded in the emotion.

THE EFFECTS OF ATTUNEMENT

Attunement to affect in therapy has similar effects as it does in human

growth and development. There is a right-brain to right-brain form of
communication between people that is constantly helping to regulate affect
through both verbal and nonverbal aspects of communication. The client’s
brain is constantly reading and responding physiologically to patterns and,
most importantly, to moment-by-moment changes in patterns of vocal
and facial features. The voice is soothing; the face, reassuring; the eyes,
concerned. It’s not just the look, or the face, or the tone of the voice but the
way it is changing moment by moment. The brain reads change over time,
not just static features. It is not the smile alone that affects us, it the speed
with which it emerges and how rapidly it decays that is being read, and it is
this that provides information as to its authenticity.
Porges (2007) demonstrated that affect is regulated interpersonally by
a direct face-to-heart connection. The brain is constantly processing inter­
actions to determine safety, and the reading of the facial and vocal patterns
of the person with whom we are interacting bypasses the cerebral cortex
and goes directly to regulate our sympathetic and parasympathetic nervous
systems. People relax automatically in the presence of the right nonverbal
patterns of the other.
In his book The Polyvagal Theory, Porges (2011) showed how the vagus
nerve, which connects the heart and brain, serves as a type of brake that can
be switched on or off to either calm or activate a person’s protective action.
122  •  Changing Emotion With Emotion

As people’s brains neuroperceive safety and danger, their body reacts.

Neuroception describes how neural circuits discern safety and danger based
on information outside awareness. When there is a neuroperception of safety,
individuals feel calm and soothed, and protective action is inhibited. This
state of safety and calm is communicated by means of posture, gaze, atten-
tion, vocal quality, care, warmth, and attunement to the client’s experience.
As a result, the client’s heart rate may slow down. To add to Porges’s (2011)
findings, from a philosophical perspective, Levinas (1969, 2000), the French
post-Martin Buber philosopher, emphasized how compelling the face is
in human relationships. He insisted that the face of the other demands a
response from us and pulls for a reaction automatically at the nonverbal and
neuronal levels. We know that gazing into the eyes of another automatically
activates specific areas in the brain.
Therapists, therefore, need to keep their fingers on the client’s emotional
pulse, moment by moment; respond to the client’s momentary shifting states;
and recognize when the attunement and the safety it produces are lost. This
means that the therapist may sense through a client’s body posture, pitch
rise in their voice, disconnected eye gaze, or tight facial expression that they
are not feeling safe. The sensing helps therapists understand that they may
have said something that has led the client to not feel heard, and they adjust
accordingly. Therapists, thus, are reading both the client’s and their own
bodily felt sense and action tendencies moment by moment, and then they
are intervening to try to correct any misattunement. They watch to see if
their next response causes the client’s facial expressions to soften and leads
to deeper breathing, and if the client again feels safe in the relationship and
that a tear in the alliance has been repaired.
To work with affect, one has to learn that less is more and that attune-
ment to affect is profoundly helpful and central to transformative experience.
This lesson can be difficult to accept for beginning therapists, especially in
the current era in which fix-it therapies fit into in a fix-it culture. It is easy
to feel the pressure to do something to help their clients in distress. And it
is reassuring to have techniques to modify and to psychoeducate—all more
deliberate efforts to change what a person does to relieve their suffering.
However, what therapists most need to learn is the power of communicat-
ing to their clients that their experience matters. When clients see that the
therapist is attuned to and interested in their affective experience, this helps
them deal with their emotional pain. One of the core beliefs that develops
for many clients as a result of early childhood betrayal and trauma is that they
and their experience do not matter, that others are not interested in their
experience, and that having feelings gets in the way of surviving. In the face
 Empathic Attunement to Affect  •  123

of that reality, having someone who is affectively attuned, interested, and

accepting is the beginning of the development of trust, which may in itself
be a profound fundamental change.

THE SKILLS OF EMPATHY AND EMPATHIC ATTUNEMENT TO

AFFECT

Therapists can learn a number of skills in addition to practicing being

present to help them become more empathic and more attuned to affect.
These skills include the creation of an alliance to work on emotion, internal
tracking, perceptual skills, fluency in different types of empathic responses,
and compassion.

An Alliance to Work on Affect

Working on affect assumes that an alliance has been created to do so. The
collaborative aspect of the alliance requires both an agreement on goals and
on tasks. The goal is to transform emotion, and the task, in this instance, is
to accept empathy and empathic attunement. However, given that emotion
work involves approaching painful, dreaded emotions, clients often have
adopted a self-protective strategy of not feeling. Thus, forming an alliance
to work on emotions can be a major task. Clients might believe that it is
better to put their feelings in a box and shut the lid tightly, and also that
to talk about feelings just feels bad and is a waste of time. To clients with
those beliefs, vulnerability implies weakness, and being strong has been
their main mode of survival. This means that, initially, certain clients will not
respond well to an empathic style and to a focus on emotion because they see
both as counter to their method of coping: to “be strong” and to steer away
from emotion. So, how does one kindle an alliance to work on emotion in
these circumstances?
First, therapists need to understand and validate clients’ concerns about
going into their emotions. Clients need to feel neither pushed nor confronted.
Rather, the therapist’s presence, and the provision of enough safety, leads
clients to feel able to access their emotional experience. Providing safety can
mean spending time providing a detailed rationale for approaching emotion
in therapy. Two of the main objections that clients often raise are: “How can
feeling bad lead to feeling good?” and “It’s all in the past. You can’t change
the past, so what’s the use of going into it?” Therapists need first to provide
a rationale for how “feeling bad can lead to feeling good” and then how
124  •  Changing Emotion With Emotion

“going into the past” can be helpful. These rationales help motivate clients
to overcome their avoidance of emotion.
All the material on the theory of how emotion works and on memory
reconsolidation forms the basis of these rationales. Therapists can say,
“Emotion gives you information about what is good and bad for you, and
about what needs are being met or not.” Metaphors like the following are
often more communicative:
Emotion is like the warning light on the dashboard of a car. When it goes on,
it tells you something is wrong in the engine or another important system like
the brakes, and you best pay attention to what it is saying.

Another is to liken emotion to how a GPS helps you navigate on a journey:

Emotions are like an emotional positioning system, or EPS: They provide
us with information on whether where we are is meeting our needs. Yet
another rationale, developed initially in Hawaii, where, of course, surfing is
king, is to liken emotion to a wave coming at you. As all experienced surfers
know, it is best to dive into and under the wave rather than try to swim away
from it. If you try to escape, the wave upends you, but if you go through it,
you come out the other side into calm. This image illustrates the idea that
the only way out is through.
Regarding past memories, therapists can tell clients that the past influ-
ences the present, emotion memories are formed at a young age when they
could not be adequately processed, and those past memories pop up to
affect the present. Therapists also can say evidence shows that by going
into the memory and working on it, how one experiences the past can be
changed (memory reconsolidation). Events in the past will not change, but
the way we think and feel about them, the way we see ourselves in relation
to the events, and the way our bodies react can all change.
This process of developing an alliance to work on emotion is the sine qua
non of emotion work. Clients have to be helped to see the relevance of talking
about their feelings. This is achieved partly by developing a safe, trusting
bond and partly by providing a rationale to those clients who are closed or
openly opposed to going into their emotions. Another way to help clients feel
safe is to have a mutually agreed on formulation of the underlying painful
emotions. That is, therapist and client coconstruct a way to describe the pre-
senting difficulties that puts emotion at the center.
One client, a 30-year-old man in therapy for social anxiety, said he was
“allergic to emotion.” He declared that his emotions were dangerous and
overwhelming, so he did not want to talk about them. Instead, what he
wanted to do was stop being so anxious: “So, please don’t talk to me about
my emotions.” Despite any of the rationales given by the therapist, he
 Empathic Attunement to Affect  •  125

remained opposed to talking about how he felt. In such situations, therapists

have their work cut out for them to help clients see that focusing on emotion
can be helpful and the way to heal. Eventually, after about eight sessions,
this client came to see the usefulness of emotions.
It happened by a strange route. He first began to understand something
about his wife’s emotions. He noticed how her feelings led her to behave,
and this opened him up to see that his own emotions led him to behave
in certain ways. Then, a few sessions later, he came in and reported that,
one day, as he was sitting in his car and was feeling anxious, he suddenly
remembered having this feeling when he was kid and his parents were fight-
ing. This feeling memory just came to him out of the blue, so to speak. The
therapist gently explained that, although the memory had come on suddenly,
it actually was the result of the slow increase in the man’s attention to
emotion that had been taking place over the 12 weeks of therapy up to that
point. Now, the therapist and client were able to truly collaborate. They
agreed on the goal of therapy as greater facility with emotion, on the task
of paying attention to what he felt in the moment, and on evoking his
childhood emotion of anxious insecurity that was at the root of his current
social anxiety.

Internal Tracking

First and foremost in learning the skills of attunement to affect is to make

the distinction between “internal” and “external” tracking. In terms of a
psychotherapy process coding system called the narrative coding system
(Angus et al., 1999), one can categorize client narratives as being in one
of three landscapes: (a) the landscape of action “what happened”; (b) the
reflexive landscape “what it meant”; or, most important, (c) the “landscape
of feeling “what it felt like.” Clients, in general, talk initially in the land-
scape of action of what happened, and therapists often respond by following
this external track; conveying their understanding of what happened; or, in
some cases, responding in the landscape of meaning by offering a response
focused on what this meant. The first important skill in being attuned to
affect, however, is to not respond by reflecting an understanding of the
content of what occurred or its meaning. Rather, it is to respond to the
client’s experience—to the internal track in the landscape of feeling.
Say a client says, “My husband’s never there for me. He doesn’t pay
attention to what I say. At dinner, he looks at his phone repeatedly and
barely looks at me, and I just handle this now by having another glass of
wine.” The therapist has options in how to respond. If the therapist were to
126  •  Changing Emotion With Emotion

respond by focusing on what happened rather than what was felt by saying,
“So, you husband is just so inattentive, looking at his phone, barely looking
at you, and all you can do to manage this is turn to drinking,” the client is
likely to continue with more of a description of what happens; for example:
“Sometimes I ask him to put his phone away, but then he does it reluctantly
and just gets morose, and we still don’t talk.” Although allowing the client
to elaborate on a sequence of events is not wrong in and of itself, it belabors
the therapeutic process.
To start getting to the work at hand, therapists need to respond to the
client’s internal track and say, “It must leave you feeling so unimportant,
so lonely and terribly hurt, and maybe kind of angry, too.” This response
focuses the client on her internal track, and she might respond, “Yes, hurt
and angry. I’m basically feeling hopeless,” and the narrative now unfolds in
the landscape of feeling. In a study of therapist responses, my colleagues
and I (Adams, 2010; Adams & Greenberg, 1996) showed that clients are
8 times more likely to deepen their experience in their next talk turns when
responding to a therapist’s statement that focuses on the client’s internal
track than when responding to a therapist’s empathic reflection on the client’s
external track. The internal track gets to a deeper level of experience; the
external track is at a shallow depth of experience (EXP).
The key skill is applying a gentle, persistent focus on the client’s internal
track—on the client’s bodily sense of experience. A helpful technique is
for the therapist to adopt the position of seeing the client as providing a
movie of what happened: a description of events and behaviors. The ther-
apist runs in parallel a movie of the client’s internal track, extracting from
what happened, what it must have been like for the client, and what must
possibly have been experienced. The therapist does this not by focusing
on the actions of the actors but, rather, by listening to the music—the
client’s voice and nonverbal manner of expression—accompanying the
narrative. It is the voice and nonverbal manner of expression that carry
the affect accompanying the contents and actions. In a movie, we see the
actor peering around the door, but it is the music, slow and scary or light
and happy, that conveys the affective tone. It is the music, not the content,
that needs to be responded to and put into language. This is following the
internal track.
In conjunction with a focus on the client’s internal track is the important
tenet that clients are experts of their own experience. Their internal stream
of experience has a direction. The client knows what hurts the client and is
an active agent who tries internally to make sense of their experience. For
this reason, the therapist follows their internal track rather than imposes a
 Empathic Attunement to Affect  •  127

sense of direction from outside that may distort this process of client-guided
internal search. How, then, can therapists be process guiding if following
is so crucial? By guiding toward the client’s internal experiential track,
the therapist helps the client get closer to their own experience. Whatever
the therapist does by being attuned and by guiding is based on the under-
standing that the client has an internal track of experience, and this is the
path therapists want to guide them along.
This focus on the client’s internal track is achieved by both the therapist
and the client’s engaging in the detailed unfolding and exploration of sen-
sations and emotions, which emerge in the retelling of an event. Working
in the landscape of feeling and focusing on the internal track, there is an
elaboration of subjective feelings, reactions, and emotions connected with
an event. This addresses the question of “What do I feel?” during the event.
In the following example, a client talks about a visit from her mother, and
the therapist’s focus on the internal track guides the client to pay attention
to her bodily felt sense.

THERAPIST:  Mm-hmm. So, how does it make you feel when she [the
client’s mother] acts like this?

CLIENT:  I feel like she’s intruding. I mean, she’s the guest. I don’t know,
I just want to scream, I get so frustrated. She treats me like a
little kid. There is no point telling my husband. He just sides
with her. I just get really upset—just feel like one of the kids
when she’s around. [external track, moderately low EXP; giving
limited emotional reactions]

THERAPIST:  Leaves you feeling, I guess, kind of criticized but so hopeless

and powerless. [focusing on internal track at a deeper level of
experience]

CLIENT:  Yeah. Like when she cleans or says that I’m not dressing my
kids right. It’s so aggravating. No matter how hard I try, I can’t
please her. [semi-internal; still just emotional reactions]

THERAPIST:  I just can’t please her. A kind of helpless, hopeless feeling.

A sinking inside?

CLIENT:  More of a jittery, shaky feeling. Like I think I’m starting to

experience panic attacks when I know she’s coming for a visit.
I do feel helpless.

THERAPIST:  Jittery. Feeling panicky anticipating not being able to please

her. Just so helpless.
128  •  Changing Emotion With Emotion

CLIENT:  Like before she arrived, I had a headache for a week. My

stomach was in a knot, and I could hardly eat. I just felt really
tense and nervous. I just know that she will find something
to criticize me about, and I will feel like I’ve failed again. Yes,
that’s what I feel—failed again and can’t do anything about it.

Here, we see the therapist running the internal track movie and responding
in the landscape of feeling. The client is struggling with making sense of
her experience, and the therapist is helping her arrive at this internal sense
of feeling helpless and failing again. She has now arrived at what she feels,
always a first step in problem solving. Now that the client experiences and
knows what she feels, she can begin to work on what she needs and wants
to do to move on and solve this problem.

Perceptual Skills

It is the therapist’s perceptual skills that are so important in enabling

moment-by-moment attunement to affect. First, as a client tells the therapist
their story, the therapist must listen both explicitly and implicitly for what is
the client’s most poignant and painful emotional experience. The therapist
focuses on those stories that are emotionally tinged and, in some way, touch
or move the therapist; these stories are deepened and further explored to
identify core painful emotions. As clients talk, therapists hear from among
all the things clients are saying those things that stand out because the way
they are expressed has more force or concern behind them. Something cap-
tures the therapist’s interest and attention, compelling them to focus on that
point. What makes it stand out might be a sigh, a look on the face, the voice,
a change in breathing, or a stronger emotional intensity in the body—
all indications of poignancy. The therapist may feel a twinge in their chest
or an anticipatory holding of their breath that indicates internally that some-
thing is important or meaningful in what the client is describing. Therapists
can recognize when an emotion is adaptive because there tends to be a
natural body rhythm, and the person’s whole system appears coordinated
and congruent. Therapists also need to use their knowledge about universal
emotional responses as well as knowledge of their own emotional responses
to understand their clients’ emotions.
Therapists also need to attend to clients’ emotional processing styles.
These styles indicate client’s emotional accessibility and how currently
amenable they are to an emotion-focused treatment, or whether more
specific work is needed to increase their emotional accessibility. Various
features and dimensions of manner of processing are to be considered in
 Empathic Attunement to Affect  •  129

this process. First, when there is an activated client emotional expression, the
therapist and the client together need to determine whether the emotional
expression is primary, secondary, or instrumental (Greenberg, 2011). For
emotional processing to be productive, primary emotions need to be accessed.
Thus, the therapist must know how to determine what type of emotion is
being expressed in the differences between primary adaptive, maladaptive,
secondary, and instrumental emotions (see Chapter 1 for a more detailed
discussion of emotion types).
In observing how clients are processing emotion, client vocal quality,
degree of emotional arousal, levels of experiencing, and degree of productive
processing of emotion are all important. Client vocal quality, a crucial guide
to the type of processing the client is engaged in, has been divided into
four mutually exclusive categories describing a pattern of vocal features that
reflect the momentary deployment of attention and energy of the speaker
(Rice & Kerr, 1986; Rice & Wagstaff, 1967). Each of the four categories—
focused, external, limited, and emotional—describes a particular type of
processing of experience. Focused voice indicates that clients are tracking
their internal experience, their eyeballs are turned inward, and they are
attempting to symbolize their experience in words. External voice has a
prerehearsed, speechlike quality with a “talking at,” lecturing quality; this
voice lacks spontaneity. It has an even, rhythmic tone and a quality of energy
turned outward. It is unlikely that content is being freshly experienced.
Limited voice is low energy and often comes out high pitched. Anxiety leads
to tightening in the throat, indicating that affect is being strangulated and
that it is difficult for these clients to trust. The clinical picture, thus, is one of
wariness. Emotional voice is indicated by emotion breaking through in the
voice as the client talks. Focused and emotional voices have been found to
predict good outcome in experiential therapy (Rice & Kerr, 1986; Watson &
Greenberg, 1996).
Aspects of speech patterns identified by Rice (Rice & Kerr, 1986;
Rice et al., 1979) that characterize the different voices just described are
(a) accentuation pattern, (b) regularity of pace, (c) terminal contours, and
(d) whether there has been a disruption of speech patterns. Accentuation
pattern refers to emphasis patterns in sentences. In the English language,
accentuation of words tends to occur in particular ways in sentences. This
can either give the effect of a regular beat that can be more pronounced than
usual for the English language, analogous to a sermon (e.g., “We are gath-
ered here today to . . .”). Conversely, accentuation patterns also can be more
irregular than usual. Regularity of pace refers to the variation of pace within
a particular utterance. For example, a person may begin speaking quickly
130  •  Changing Emotion With Emotion

and continue the last half of their phrase in a slower manner. Terminal con-
tours involve aspects of pitchlike evenness: rises or drops in pitch. Contours
can be used in an accentuating speechmaking way, or they can give the total
intonation pattern a more ragged, unexpected sound. Disruption of speech
pattern refers to the extent to which the regular speech pattern is disrupted
or distorted by emotional overflow.
Moving from vocal features, another important aspect of client process
that predicts outcome is expressed emotional arousal. As defined in the
Client Emotional Arousal Scale-III-R (Warwar & Greenberg, 1999), emo-
tional arousal depends on the degree of intensity in the voice and body, and
the degree of restriction of expression. Research has shown that moderate
levels of emotional arousal in combination with deeper experiencing to make
sense of the arousal, rather than pure high emotional arousal, predict positive
outcome in experiential therapies (Carryer & Greenberg, 2010; Missirlian
et al., 2005; Warwar & Greenberg, 1999).
Client EXP (Klein et al., 1969) has been studied extensively (Klein et al.,
1986) and has been related to positive outcome in therapy. EXP differs from
arousal by describing clients’ ways of talking about their inner experience
to make sense of it as well as to achieve self-understanding and problem
resolution. In this seven-level scale, at early levels (1 and 2), the speaker’s
content and manner of expression is impersonal, and feelings are avoided.
This moves to description of events in external or behavioral terms with
emotional reactions. At Level 4, the quality of involvement in speech content
clearly shifts the speaker’s attention to the subjective felt flow of internal
experience rather than to events or abstractions. At the higher level (6), the
client synthesizes newly discovered feelings and meanings to resolve emo-
tional problems related to the self.
Findings by Warwar and me (Warwar & Greenberg, 1999) indicated
that higher emotional arousal at midtreatment predicted outcome, but, as
clinicians, we knew that some emotional arousal was productive and some
was not productive, and the correlation between arousal and outcome was
around .33. This left a lot of the outcome variance unaccounted for. We
knew that the therapists in the study discriminated between good and poor
arousal, so unproductive process was curtailed because the therapists worked
to facilitate more productive forms of emotion processing. We, therefore,
set out to develop a measure to discriminate productive from unproductive
emotional processing.
As mentioned earlier, the main elements of productive emotional process-
ing are attending, symbolization, congruence, acceptance, agency, regulation,
 Empathic Attunement to Affect  •  131

and differentiation. See the section Productive Emotional Processing in

Chapter 2 for a detailed description of these elements.

Fluency in Different Types of Empathic Responses

This approach to working with emotion grew out of Rogers’s (1957) non­
directive approach combined with Perl’s (1973) more active Gestalt approach.
I blended the two interactional styles into one in which following and leading
are combined synergistically into a sense of flow. Elliott and I (Greenberg &
Elliott, 1997) delineated different types of empathic responses, and thera-
pists can use these types to focus predominantly on affect by helping clients
focus on their affective experience. These types range from purely empathic
understanding responses, to validating and evocative responses, to explor-
atory ones, and to conjectural and refocusing responses (Greenberg & Elliott,
1997). These types are described in this section. Remember that “affect
attunement” means that added to the words is the therapist’s bodily felt
resonance that is communicated in the rhythm and tone of the response as
well as the content.
The empathic responses to be described shortly increase in the proportion
of leading over following as one goes down the list. One of the fundamental
skills of working with emotion is being able to effectively combine following
and leading in a seamless manner. In working with emotion, I recommend
that therapists take a not-knowing position. See clients as being experts on
their own experience. They know what hurts, and we, as therapists, need
to follow their pain because it will point the process in the right direction.
Clients, however, also protect themselves from experiencing their dreaded
emotions. They can benefit from suggestions by a guide who points them
toward that place where they feel their feelings and also helps evoke painful
emotions, in the safety of the therapeutic situation, which makes clients
amenable to change. Later in therapy, as the bond develops, more process-
directive interventions are added using guided imagery and psychodramatic
enactments.

Empathic Understanding
This involves a type of interchangeable understanding by reflecting on the
main point of the client’s message (Elliott et al., 2004). Here, the therapist is
most strongly following the client. Empathic reflection seeks to demonstrate
understanding to help build and maintain a safe, therapeutic relationship.
It provides an underlining of the important meaning of what the client is
132  •  Changing Emotion With Emotion

saying. The empathic understanding response carries the flavor of, “Is this
what you mean? Do I understand? Do I get it?” The therapist is trying to
understanding the main thing the client is saying.

Empathic Affirmation
Here, the therapist’s response goes beyond understanding to validation,
support, and confirmation of the client’s experience. This is especially
helpful when the client is taking about a painful emotion related to self. Buber
and Rogers disagreed on this point (Merrill, 2008). Rogers (1957) said he
just wanted to convey understanding and the client would then be able to
eventually grow. This was a more an intrapsychic, as opposed to an inter-
personal, process. Buber, on the hand, emphasized the interpersonal aspect
in which it is the therapist’s confirmation of the other that helps the other
come into being, as captured in the Swahili greeting, “I see you,” to which
the response is, “I am here.” We exist in the eyes of the other, which adds
validation to understanding. A good example of this type of response is
the no-wonder response. A generic example is: “No wonder you felt this
way given what happened.” Here, the therapist validates that the client’s
experience makes sense. This helps the client bear their painful experience
because they feel the therapist’s support and validation. The end result is
feeling stronger. A further example might be: “Yeah, it’s really hard to stay
with the sadness because it rips you apart inside. How else could it be?
It was such a devastating loss.”

Empathic Evocation
Evocative empathy involves communicating understanding via metaphors,
connotative language, and expressive speech to help activate experience.
It brings experience alive emotionally and helps clients reenter past scenes
and reexperience what was felt. Evocative reflections capture clients’ expe-
rience in such a way that it becomes more vivid. There is some degree of
going beyond following to help evoke an experience.
Using evocative language, metaphor, and imagery promotes reexperienc-
ing via accessing episodic memory. Standard metaphors like “feeling like a
motherless child” or spontaneously produced metaphors like “feeling stuck
in the mud” to evoke a sense of being trapped can be used. Connotative and
onomatopoetic words, like “squished,” “slimy,” “gritty,” “velvety buzzing,”
and “splash,” that convey the feeling and capture the sound of experience
are helpful.

Empathic Exploration
Empathic exploration involves making explicit what is implicit, and under-
standing what is at the edge of the client’s awareness. Here, in addition to
 Empathic Attunement to Affect  •  133

following, the therapist is guiding attention to the client’s internal track.

This is based on a view of the mind as working by figure and background
formation, or by a space with a center and boundaries where experience/
meaning can be at the edge of the mind. What is at the edge of awareness
is brought to the center of awareness. By paying attention to something in
the background, the mind begins to form a figure in the foreground. This is
as opposed to a psychodynamic depth view of the mind in which material
is buried in the unconscious—beneath a barrier that needs to be accessed
by and interpreted by an observer because it is not available to awareness.
Instead, empathic exploration helps clients become focally aware of the
not-yet-aware feelings and to experience them.

Empathic Conjectures
These are tentative guesses of clients’ immediate, implicit experience. Now,
the proportion of leading increases. These responses come from the therapist’s
frame of reference and are more inferential than exploration. In exploration,
the feelings come from the client’s frame of reference and make explicit
what the client may be feeling or thinking but has not yet said explicitly out
loud. Here, the therapist adds a guess to something the client is not saying
implicitly or explicitly. The guess comes from the therapist’s understanding
of the client and also the narrative and case formulation. It helps the client
deepen or intensify their experiencing. An example is: “When you think of
that, you feel a great sense of sadness and a real sense of loss. My hunch is
that you still feel that, and it’s still very much alive. Does that fit?”

Empathic Refocusing
Here, the therapist responds to something the client has said earlier that
was poignant or seemed important even though the client has veered off
in another direction. The therapist empathizes with what the client may
be having difficulty facing to invite continued exploration of what seemed
most salient. In this case, the therapist is leading by guiding the client to
something that seemed poignant or important. When a client goes on a side
narrative that takes the focus away from something that seemed meaning-
ful or emotionally laden, the therapist may refocus the dialogue back to
the earlier topic or experience. For example, the therapist might say, “So,
it seems that what was most important is that feeling of being overlooked
that you mentioned a while back.”
In terms of the prevalence of the different types of responses in a general
outpatient context, empathic exploration is seen as the fundamental mode
of intervention. Exploratory empathy, however, is always balanced with
empathic understanding to provide a framework of safety, acceptance, and
134  •  Changing Emotion With Emotion

validation. The therapist, thus, mixes roughly 50% understanding responses

with at least 50% exploratory responses that focus more on articulating
what is on the edge of a client’s experience to get at what has not yet been
said explicitly. When a therapist’s exploratory response ends with a focus on
what appears to be most alive in a client’s statement, the client’s attention is
focused on this aspect of their experience. The client then is encouraged to
focus on and differentiate the leading edges of their experience.
Exploratory empathy is exemplified in the following segment in which a
depressed client explores her experience at the end of a romantic relationship:

CLIENT:  I keep wondering if he will call.

THERAPIST:  The image I have is of you is sitting there, waiting for the
phone to ring, and even though there is only silence and
emptiness, it is just so hard to get up and walk away [evocative
empathy] . . . somehow feeling hopeful, hoping he will call.
[exploratory empathic attunement]

CLIENT:  I keep hoping he will come back (weeps softly).

THERAPIST:  So, somehow hoping keeps the door open? [exploratory

empathy]

CLIENT:  Yes. I guess I have been reluctant to move on. . . . It makes me

feel so sad, but I am beginning to realize there is no point in
hanging around.

When the therapist’s responses are structured in such a way that they
end with a focus on what is felt, the client’s attention is, in turn, focused
on their feelings, and they are more likely to differentiate the feeling. This
helps the client symbolize previously implicit experience consciously in
awareness. In the next excerpt, the therapist consistently focuses on the
client’s emotional experience with exploratory responses and questions as
well as with empathic conjectures. The client initially focuses externally,
but the therapist’s consistent focus internally guides the client inward:

CLIENT:  My parents just expected me to work around the house.

I didn’t ever have the chance.

THERAPIST:  It’s sad that I don’t have the freedom. It’s sad that I’m trapped.
I feel sad that my teens and early 20s, when I could be having
fun . . . [conjecture]

CLIENT:  There’s no support at all. It just makes me feel locked up

instead.
 Empathic Attunement to Affect  •  135

THERAPIST:  What is it like to feel so trapped? [exploratory question]

CLIENT:  Feels very depressing. You wake up every day, and it’s just
another day, here it goes again. You don’t feel joy, you don’t
feel the hope for the future. You don’t feel, you just feel dead.
[external]

THERAPIST:  Feel sad that there’s nothing to look forward to but to earn
money and pay the bills. I feel so sad. I used to want things,
and now I don’t. [internal focus]

CLIENT:  And the future, it just doesn’t—doesn’t feel there’s a future

ahead of me, just feels there’s a huge question mark in front
of me. And then it’s like growing up . . . you have to wonder
through that question mark, like what’s the next thing that’s
going to happen. I don’t have a normal plan, a concrete plan of
what I’m going to do. When I think I’m able to do this, it turns
out . . . [reflexive]

THERAPIST:  How are you feeling right now? I sense some sadness. [internal,
exploratory]

CLIENT:  Ya, just sadness only. The anger just gives way to sadness,
I don’t feel anger. The anger switches off, and it’s sadness.
[internal]

THERAPIST:  How do you experience this sadness in your body sadness

within? [exploratory question, internal]

CLIENT:  I feel it on my shoulders. It’s just like the only thing I can do is
to smash it. [internal]

THERAPIST:  I feel so heavy on my shoulders. I feel so burdened and tired,

and I can’t get it out. I can only harm. [internal]

CLIENT:  Then, sometimes, you take the chisel, and you work on
chipping everything off one by one, and it’s so many things.
[reflexive]

THERAPIST:  I just feel so overwhelmed, so overloaded, feel like the weight

is crushing me down. No choice but to keep going with this
heavy weight upon my shoulders. [internal conjecture]

CLIENT:  Ya, that’s the only thing I can do. That’s the only thing I can do
for my mom also. [external]
136  •  Changing Emotion With Emotion

It is important to remember that people’s internal emotional signals might

be so slight and may speak in a voice so soft that it may be hard for them
to hear their own voice. Clients may need to be helped to pay attention to
their soft, inner voice, and they may need to have therapists run the clients’
experience through them, acting as a type of surrogate experiencer who is
trying to find words to describe the experience. Therapists help clients make
more attention available to listen to their internal voice. They do so first
by providing safety and, second, by focusing on the leading edge of clients’
experience. Safety helps clients increase the amount of attention available
by reducing their interpersonal anxiety.
Earlier, I commented on the centrality of exploratory empathy for general
outpatient populations, but I also have found that with more disorganized
clients and with more alexithymic clients—those who do not have words
for feelings—and for clients who are blocked, emotionally unskilled, or
emotionally illiterate, that empathic conjectures often are the most helpful
responses. Here, the therapist is more inferential and reaches in and speaks
the unspoken, and symbolizes in words the probably not yet fully formed,
not yet felt emotion. Therapists learning an emotion-based approach often
find these the most challenging types of responses to include in their
repertoire because they have been trained to be more nondirective, to
not lead the witness or not put words in their client’s mouth but, rather,
to ask questions. Some therapists seem to be concerned that when they
name a person’s experience, it deprives that person of the opportunity to
express it or name it themselves. I find that this is not really true; often it
brings clients more into the present moment and helps them be in touch
with themselves.
Psychotherapists are often taught to ask clients questions such as,
“What did you experience?” Although standard therapeutic interviewing
practice, asking questions about feeling when a client is not emotionally
aroused often does little to further therapeutic exploration; such questions
guide attention to provide more cognitive answers or to analyze what is
going on. It is far better for therapists to notice what is actually unfold-
ing in front of them in the present moment and to reflect what they see
and hear. When therapists reflect the client’s experience with compassion,
curiosity, and transparency, people typically feel more understood and
connected.
Trainees often fear that if they conjecture, they may not get it right or
the client will feel intruded on or pushed, or both. The problem is that with
clients who are emotionally blocked—like many clients who have eating
disorders or a large proportion of men who avoid emotions—it is necessary
 Empathic Attunement to Affect  •  137

to use a lot of emotion language to help them begin to identify emotions.

Also, conjectures are offered, not from an expert stance of telling clients what
they feel but in a collaborative, tentative, and exploratory fashion.
Some support for offering conjectures to help people symbolize what
they feel comes from memory research, which shows that recall memory
is much more demanding than recognition memory. Recalling something
involves deeper processing and requires more time. If I ask what you had
for breakfast this morning, it involves recall. If, instead, I say, “Did you have
an egg for breakfast?” it involves recognition—that is, you have the word
and check it against memory. Recall requires deeper processing than does
recognition. Checking whether you had an egg for breakfast is a type of
processing that occurs much more rapidly. When I offer the client a feeling—
“I imagine you may have felt kind of humiliated or ashamed”—the client
can check what I offered against what they felt and quickly either say, “Yes,
exactly” or say, “No, not ashamed, just so afraid.” In either case, it is much
easier for the client to symbolize what was felt than if asked the question
“What did you feel?”

Empathic Validation of Needs Versus Confrontation

In working empathically, the therapist adopts a nonexpert, validating stance.

Confronting clients with discrepancies in what they say and do or suggest-
ing that they are responsible for their problematic behaviors—when they
themselves are not yet able to recognize this—is an intervention discussed
in the literature (Adler & Myerson, 1973; Kernberg, 1984; Sachse, 2019)
that automatically puts the therapist in the stance of a more challenging,
knowing expert. To manage these situations empathically, the therapist first
needs to talk about their own experience that they want to share with the
client rather than about objective realities that define the client. Second,
the therapist needs to validate the visible maladaptive behavior and emo-
tions (“I understand how angry that made you feel”) and recognize it as
an important self-protective strategy from the past (“No wonder given how
your father always criticized you”). Third, the therapist needs to try to go
one level deeper and empathetically conjecture into the underlying vulner-
able emotions (“But I guess you felt your efforts were so unrecognized”).
Fourth, the therapist needs to link this to the unmet need (“And you have
missed this all your life”).
Most difficult interpersonal moments that arise in therapy can easily be
bypassed without having to confront clients with counterproductive behavior
or to contradict or challenge them. For example, imagine you have a client
138  •  Changing Emotion With Emotion

who frequently veers off topic into long monologues or stories rather than
stays focused on the task at hand. Instead of saying, “You sometimes talk
a lot, and I think you do this to avoid dealing with your own feelings,” an
empathic therapist would say something like the following:
I really get that you need me to understand you, and when I miss meeting
what you need, it leaves you feeling this terrible feeling of being unimportant
and unseen, so you sometimes respond by telling a story or moving over to a
topic you’re interested in. And I really understand you missed the validation of
your parents so much when you were a child, and it left you feeling sensitive
to not feeling understood by people. But, somehow, right now, when you start
off on a story or comment on current events, it doesn’t really help me to grasp
what is going on inside of you. And then, when I don’t get you, it doesn’t help
you to get what you really need from me. So, I guess the thing we have to focus
on is how to deal with this deep feeling of being unimportant in a way that
helps you to get the validation you really need.

If you have a client who withdraws rather than fills the air with off-topic
narrative, you can adjust your empathic response by saying, “When you stop
talking, I am unable to understand your need, and, consequently, you aren’t
able to get what you need from me.”
In sum, the steps of dealing with these difficult moments rather than
confronting are:

1. Talk about the therapist’s own experience.

2. Validate the client’s need (what the client really yearns for).

3. Link the unmet need to the maladaptive emotion (“When your need for
validation is not met, it leaves you feeling unimportant”).

4. Link the maladaptive emotion to the secondary emotion or the reactive

behavior (“And then, when you feel unimportant, you withdraw/talk
a lot”).

5. Emphasize and validate that the secondary emotion/behavior does not

really help to get the need met (“But, somehow, withdrawing/talking a
lot doesn’t really help me to see you and for you to feel understood”).

6. Guide the client’s attention to the painful underlying maladaptive emo-

tion that needs to be processed (“And, therefore, we have to help you deal
with your feeling of being unimportant in a different way”).

7. End by focusing again on the unmet need (“What you really need is
validation”).
 Empathic Attunement to Affect  •  139

Compassion

Another important aspect of the process of attunement to affect is the

experience and expression of compassion. Rogers’s (1957) unconditional
regard is the closest to describing compassion. Therapists need to be present
and have empathy to develop compassion. We (Geller & Greenberg, 2002)
have proposed that therapeutic presence is a necessary foundation for the
development of empathy. To empathy, compassion adds a deep caring and
respect as well as a desire to reduce suffering. Compassion, empathy, and
presence are all necessary for the development of a strong, effective thera-
peutic relationship and for emotional change in psychotherapy.
Compassion allows therapists to not focus on their own needs and
issues but, rather, focus on the client’s pain and suffering. Compassion does
not have a distinct facial expression, but it does involve a look of intense
interest in the other person (Davidson & Harrington, 2002). From a Buddhist
perspective, compassion is defined as “the wish that all beings be free of
suffering” (His Holiness the Dalai Lama, 2001, p. iv). From this perspec-
tive, compassion implies care for alleviation of the other’s suffering but
also implies engaging in some action to bring about that lessening in the
other’s suffering.
Compassion is not simply a sense of sympathy or caring for a person’s
suffering, and it is not simply warmth or the understanding of their needs
and pains. Although compassion encompasses these, it also involves the
sustained determination to do whatever is possible and necessary to help
alleviate the other’s suffering. One has the feeling of caring for another
person and their suffering, and the desire to reduce that suffering, but also
the taking of some action to help reduce the other’s suffering. Compassion is
not true compassion unless it involves action. Therapists need to be involved
in engaging in whatever actions they can to alleviate their client’s suffering,
such as making calls, writing letters, coordinating with other helpers, and
making referrals.

CASE FORMULATION

Empathic attunement is also aided by having a case formulation. Given that

working with emotion focuses on accessing and transforming core painful
emotions, and even though attunement is an automatic process coming out
of being present in the moment to client’s emotional states, it helps to have
an understanding of what a client’s core pain is. Goldman and Greenberg
140  •  Changing Emotion With Emotion

(2015) elaborated on how to construct emotion-focused case formulations.

These formulations have a unique dual focus privileging emotional process
first but always understanding it in the context of narrative meaning-making.
This supports the effort to build a picture of the case with the core emotion
scheme at the center. Identifying the core painful emotion scheme is central
to emotion-focused formulation.
Case formulation is helpful in facilitating the development of a focus.
It is the client’s presently felt experience that indicates what the difficulty
is and indicates whether problem determinants are currently accessible
and amenable to intervention. A collaborative focus and a coherent theme
develop from a focus on current experience and an exploration of particular
experiences to their edges within the context of the task-focused work at
markers. It is by going deeply into experience in specific situations rather
than by establishing patterns across situations that a focus is established.
Markers are in-session states that reveal that the client is in a particular type
of problem state that is an opportunity for a particular type of intervention
(Greenberg, Rice, & Elliott, 1993). Formulations need to be coconstructions
that emerge from joint understanding rather than formed by the therapist.
In addition, all formulations are held tentatively and are repeatedly checked
with the client for how well they fit and if they seem relevant to the client’s
aims. A client’s moment-to-moment processing in the session, however,
is the ultimate guide as to what the therapist does in the moment.
Therapists adopt the notion of a “pain compass” that guides formulation.
The compass directs the therapist to the client’s chronic enduring pain
(Goldman & Greenberg, 2015; Greenberg, 2015; Greenberg & Paivio, 1997).
The therapist follows what is most painful or poignant, which will lead to
the client’s core painful emotions. The goal of the treatment becomes to
resolve this painful issue. Emotional pain is a strong cue that something for
the client is feeling broken or shattered (Greenberg & Bolger, 2001). Using
all of their sense mediums, therapists need to hear people’s pain.

CONCLUSION

In this chapter, I attempted to highlight that empathic attunement to affect

goes beyond empathy as generally understood to be the offering of under-
standing. Both empathic understanding and empathic attunement to affect
are important, but affect attunement is more focused on emotion than
meaning, and it is a more resonant, bodily mirroring of the client’s affec-
tive contours. Creating an alliance to work on emotion is the entry point to
 Empathic Attunement to Affect  •  141

attunement, whereas internal tracking is the key to maintaining an attuned

connection.
Building on the ability to be present, and having as a first step letting go
of personal distractions and any preformed ideas about clients, therapists
need to engage in the following steps to be empathically attuned (Barrett-
Lennard, 1993, 1997; Elliott et al., 2004). They need to enter the client’s
world, trying to become the client and attempting to see things as the client
sees them rather than looking from an outside perspective. In supervision,
I stop the supervisees’ video recording and ask them, “Become your client.
As your client, what is it you are feeling?” Then, therapists need to resonate
with their client’s experiencing by attending to what in them responds in
kind (i.e., echoes, reverberates) to it. They need to identify in themselves
what it might feel like to feel this. This is where the activation of mirror
neurons and the brain’s simulation of what it feels like to feel what they
are imagining plays a role. Next, therapists need to search for, grasp, and
capture what their client’s core painful feelings are, aided by attending to
their sense of what it might feel like for the client. Finally, therapists need
to put words to their client’s feelings. Symbolizing feelings in words helps
clients externalize their feelings, look at them, and talk about and differen-
tiate them to make new meaning.
Therapists using these steps always privilege affect over meaning, and
responses are focused on attending to the client’s core painful feeling. In
focusing like this on core painful emotions, which clients find difficult to
feel, therapists continually remind clients that they are in charge of the
process and need go only as far as they can tolerate. They also remind them
that it is the clients who are the experts on their own experience: They know
best what hurts and that the therapist is searching with them to help them
discover and experience their core painful feelings. In this regard, therapist
curiosity and an inquiring attitude are important. Therapists need to adopt
a not-knowing position, even when conjecturing about what the client feels.
Therapists do not assume that they know but more are curious and work
hard to understand the other, who remains somewhat of a delicate mystery.
In addition, therapists convey the message to clients that, ultimately, the
road to change lies within themselves and involves reclaiming disowned
feelings, having new emotions to change old emotions, or both.
One of the things that was most helpful to me when I started off as a
therapist in training, having come from South Africa to Canada and having
changed my professional career from engineering to counseling, was that
everything was completely novel: a new country, a new profession, the new
activity of counseling. I experienced myself as something like a cultural
142  •  Changing Emotion With Emotion

anthropologist trying to learn about this new culture. My previous stereo-

types, assumptions, and prejudices did not fit. I saw the Canadians and
Americans (of whom there were many because of the Vietnam War), with
whom I was in touch in and outside of counseling, as unusual creatures
whom I had to learn about. This was incredibly helpful in being able to be
nonjudgmental, accepting, and empathic, and in being able to simply listen
carefully and try to understand.
In the next chapter, I elaborate more on the bodily experience of attune-
ment. In the safe environment that empathic attunement makes possible,
we therapists can invite clients to attend to, welcome, symbolize, and explore
their more painful feelings.
6 FOCUSING ON BODILY
FEELINGS
When Words Are Not Enough

In the ongoing practice of psychotherapy, a client and their therapist exchange

many words in an attempt to make the therapeutic conversation come alive.
In the midst of all the verbal communication, frequently missing is the sense
of the client’s experiencing what they are talking about at some depth and
of both people’s being emotionally engaged in the process. Therapy can
too easily become reduced to people-talking: communicating with words
but often ignoring the intense sense of life that can emerge if they tap into
immediate emotional and body-centered experience. Becoming aware of
bodily felt emotion is more important than awareness of thought.
In this chapter, I present different forms of guiding awareness to bodily
felt experience with an emphasis on putting words to body experience.
I look at the difference between experiencing and emotional arousal, and
the importance of each in therapeutic change. I also delineate three general
methods: awareness and symbolization of inner bodily feelings, expression
of emotion, and observation of nonverbal behaviors. Finally, I present and
illustrate through clinical examples methods of focusing on a bodily felt
sense, promoting the vivid expression of emotions, and working on what the
body expresses nonverbally.

https://doi.org/10.1037/0000248-007
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

143
144  •  Changing Emotion With Emotion

One of the key aspects of emotion-focused work is that it is experiential.

Emotion-oriented therapists work actively to help clients become aware of
their inner bodily felt experiences. It is new experience, not insight, that is
viewed as changing the brain. The purpose of this work is to reclaim one’s
experience and action tendencies, and to reown emotions. Experiential work
as opposed to insight-oriented psychotherapy teaches clients to work with
their bodily felt experience and with emotional expression more than with
understanding. The following example illustrates the difference between an
experiential response and an understanding or insight-oriented one:

CLIENT:  My boss really upset me this week. I did a huge project for him,
spent the night working at home. It wasn’t really even my job, and
he didn’t even say thank you. Then I heard yesterday that he talked
about it in a meeting like he had done all the work.

SAMPLE UNDERSTANDING RESPONSE:   Sounds like you are being taken advan-
tage of. You’re extending yourself and getting no appreciation.
[This might include an additional insight-oriented component:]
Does this remind you of your relationship with anyone?

SAMPLE EXPERIENTIAL RESPONSE:   Let’s try and slow down so you can stay
with what is happening inside right now as you tell me this. [This
might include a process-guiding component:] Maybe you can go
inside to that place where you feel your feelings and see what you
feel there right now.

The latter response differs from the more understanding/insight response,

in which the therapist might adopt a following response, rather than a guiding
one, that focuses more on the content of the story and possibly offers an
interpretative aspect to help create meaning. The best way to be experiential
in therapeutic work is to be present centered and to focus on bodily felt
experience, In Chapter 5, I discussed the importance of empathic attune-
ment to affect as a baseline skill for doing this. Another major method is to
guide the client’s attention to their bodily felt experience.

GUIDING ATTENTION TO PRESENT EXPERIENCE

Early on, William James (1890) pointed out, “My experience is what I choose
to attend to” (pp. 403–404), adding that without selective interest, expe­
rience would be chaos. In the 1950s, Gestalt therapy, influenced by Zen
Buddhist practice, introduced present-centered awareness exercises that
helped people focus attention on their current body sensations and feelings
 Focusing on Bodily Feelings  •  145

(see Chapter 5, this volume, for a more detailed discussion of these exercises).
Such awareness practices that link sensory awareness and thinking highlight
the constructive nature of experience. Someone shuttling between inner or
outer sensory awareness might say, “Now I’m aware of a tightening in my
chest, and I imagine I am having a heart attack.” This method of verbalizing
present awareness is helpful in bringing awareness of bodily experience to
the fore because body experience is always what is occurring in the present.
One thus can suggest to clients—especially when they are unsure what
emotions they feel or when they seem wrapped up in logistical details of
a story—that they come into the present and, over the next few minutes,
describe at each moment what they are aware of. The therapist can suggest
the client begin every sentence with “Right now . . .” or “At this moment . . .”
and complete it with their immediate experience.

Mindfulness
Mindfulness, in my clinical experience, is attending to present-moment
experience with equanimity. This means maintaining a moment-by-moment
awareness of thoughts, emotions, and bodily sensations with openness and
curiosity. Mindfulness can be described as the practice of paying attention
in the present moment and doing it intentionally and with nonjudgment.
Mindfulness meditation practices refer to the deliberate acts of regulating
attention through the observation of thoughts, emotions, and body states.
Typical mindfulness activities include nonjudgmental awareness of breath,
body, feelings, emotions, thoughts, or all of these in sitting meditation practice
or throughout the day.
Mindfulness can be thought of a “state,” a “trait,” or a “practice.” One can
have a moment of mindfulness, which is a state of mind in the moment.
One can also have a sustained experience that is more like a habit or strong
tendency to be mindful—a trait. Or one can engage in a more intentional
practice of mindfulness by using different forms, postures, and activities, such
as seated mindfulness meditation, mindful walking, and mindful eating.

Focusing Approach
Gendlin (1981) in his focusing approach proposed a process of guiding
attention to a different target: a bodily felt sense, the sensations in a person’s
body that provide information about situations, thoughts, and feelings.
The felt sense differs from the more concrete-in-the-moment awareness
of what one is. In focusing, therapists invite clients to go to that place inside
where they feel their feelings, learn to “stay” with this felt sense, and follow
where it goes once symbolized in awareness (Gendlin, 1969, 1991).
146  •  Changing Emotion With Emotion

The intention in focusing is to deepen bodily felt experience, which might

simply involve gently asking, “What is it inside?” and waiting for an answer.
The client can then let words come from the bodily sensed feeling and maybe
get a sense of the problem as a whole—and then let what is important
about it come up from that bodily sensing. This is the focusing process and
represents a basic style of engagement with internal experience that I am
encouraging for working with emotion.
Focusing introduces a style of guiding and giving directions that goes
beyond the relational aspect of therapy. The therapist is not only in dialogue
with the client using empathic responses but is now guiding the client to
engage in a new kind of relationship with themselves—to pay attention to
their bodily felt sense. Focusing, then, is a powerful addition to the thera-
pist’s tool kit. It can be said that working with emotion stands on two legs:
empathic attunement to affect and focus on the bodily felt sense. Therapists’
empathic attunement to affect and exploratory empathic responses that focus
on the leading edge of clients’ experience have some of the effect of focusing
by, to some degree, guiding attention to the implicit. Focusing as an inter-
vention, however, does this more directly: It helps clients target their deeper
“felt” sense of what they are talking about by guiding them to pause and stay
with what they are feeling, to pay attention to their bodily felt sense, and
to ask them how “all that” feels in their bodies. Only clients can know what
they feel, and they can fully know only through paying attention to their own
experiencing and finding ways to formulate it and carry it forward. Focusing
is about clients’ paying attention to their bodily felt sense.
How do therapists know when to use focusing as an intervention? Often
therapists seamlessly guide their clients to focus on the felt sense in the
ongoing interaction when, out of their own felt sense of what is needed, they
slow the client down when some feeling is being expressed or simply ask
the client to pay attention to what they feel inside. At other times, however,
when there are specific indicators—what I have called “markers”—this is a
time to use focusing. The classical markers for focusing are when the client
refers to a vague or unclear felt sense or seems to be on the surface of some-
thing important but is unable to sink down into it. These are opportunities
for a more major focusing intervention.

The Felt Sense

The notion of felt sense is important in understanding focusing, and I elabo-

rate on it in this section. Focusing is neither getting in touch with feelings nor
doing a rational analysis of a situation. Rather, it involves giving attention to
 Focusing on Bodily Feelings  •  147

the feel of the situation as a whole. For example, our sense of a situation as
a whole might be that there is something “unfair” about it. We try that word
out, and then it seems that it is not so much “unfair” as “diminishing.” Our
attention moves back and forth between the words we are trying out and
something else. The “something else” is not exactly a thought or an emotion
but a bodily feeling—the feeling of the whole situation. This is called a
bodily felt sense and is similar to having a word on the tip of your tongue,
but, this time, it is a feeling that is felt somewhere in the body. When people
are eventually able to put words to it, it is often not a basic emotion like
anger or sadness. Rather, it is a complex felt meaning of the whole situation,
full of implications, such as feeling “over the hill,” “all washed out,” “fulfilled,”
or hurt, disappointed, small, or unsupported.
Focusing is a process of interacting with the felt sense of something.
Suppose you look at a particular piece of art. You may think it was done by
an impressionist, or it may evoke a feeling of sadness. As another option,
you may focus on a felt sense of the whole picture and say, “It’s filled with
energy, unconstrained,” or you might not even find any words, yet the felt
sense is still there. The felt sense—the focused feel of the whole picture—is
not a thought or an emotion, and it is also different from the initial unfocused
experiencing of the picture.
Focusing involves moving back and forth between the bodily felt sense
and words that symbolize it. Focusing is a way of helping to make the
implicit explicit, and it helps to clarify what the process of “staying with” or
“working through” actually entails. It is a matter of taking a bit of time to
allow a felt sense to form and to then give it attention. Some people do this
without having been taught to do so. Some clients do it naturally in therapy,
and those who do tend to be more successful than those who do not. Research
has provided evidence that clients who focus on the felt sense of their situa-
tion tend to make better progress than clients who do other things or talk in
other ways (Hendricks, 2002).
Focusing shows that one’s experiencing can be formulated in many ways
but not in any old way (Purton, 2004). Someone who is focusing may first
symbolize their experiencing as “feeling embarrassed.” Then, they sense
that this is not quite right. They go back to the felt sense of the situation that
they are working with, and now it seems to them that it is not embarrass-
ment they feel but humiliation. And then, with further focusing, an aspect
of sadness comes to the fore. In the felt sense, all these formulations are
implicit. It is not a matter of one of them being the truth and the others
being mistaken. They each have their truth—at least at the time when they
are felt. But that there are multiple formulations does not mean that the
148  •  Changing Emotion With Emotion

focuser could formulate their experience in any way they choose. Certainly,
they are not feeling happy or jealous! And if their therapist tries out the
suggestion that they are feeling regret, something in them will clearly say no.
The felt sense determines precisely what can be said, and yet what is said
may not be the only thing that can be said (Purton, 2004).
It is important to recognize that what people feel, in part, depends on
how they describe it. Naming an emotion, however, is not simply discovering
the right words to fit the feeling, like finding the right key to fit a lock. There
is not only one correct word. Feelings are not sitting inside fully formed and
articulated, and waiting to be named. People actively create what they feel
by the way they describe the feeling. Helping a person articulate how they
feel is more like the process of looking at the clouds and “seeing” a rabbit
in the cloud than like the process involved in the seeing an actual rabbit
hiding behind a tree. Emotional naming involves as much creation as it does
discovery. This is all in line with the dialectical constructivist perspective
discussed in Chapter 1.

Use of Focusing Techniques

A number of studies have been done in Japan, North America, and Europe
on factors that enhance the effectiveness of focusing. For example, Morikawa
(1997) factor analyzed questionnaires from focusing sessions and found
that “clearing a space,” “finding a right distance,” and having a listener refer
to their experiencing each helped clients focus. Iberg (1991) found that clients
reported an increased impact of sessions in which therapists used focusing-
type questions. Leijssen (1998) investigated whether focusing enhanced
client-centered therapy. In an initial study, she took sessions with explicitly
positive and negative evaluations by client or therapist and found that 75%
of positive sessions contained focusing steps and 33% of negative sessions
contained focusing. In a second study, Leijssen (1996–1997) looked at the
video recorded therapies of eight clients who successfully terminated therapy
in less than 20 sessions: Prominent use of focusing occurred in all eight cases;
almost every session acquired an intense experience-oriented character in
which the client discovered aspects of the problem that had formerly remained
out of reach. All of these clients achieved contact with their bodily felt expe-
rience without being flooded by it.
Leijssen (1998) also investigated whether long-term clients deemed to
be stagnating in their therapy could be taught to focus and to increase expe-
riencing level. Of the four clients who were taught focusing, all returned
to their regular therapy. She found that two of them who returned to their
 Focusing on Bodily Feelings  •  149

previous and less deep levels of experiencing in therapy expressed unhappi­

ness with their regular therapists; they conveyed a wish to continue with the
focusing trainer. For clients with initially low levels of experiencing, it appears
that clients do not easily learn the skill; thus, for focusing to take place and
be sustained, continued process direction is required (Leijssen et al., 2000).
In introducing focusing, the therapist might suggest to clients that it could
be helpful to focus on the feeling that they had just talked about and then
give some focusing instructions (Gendlin, 1981, 1996). The therapist might
simply say, “Close your eyes and go inside to that place inside where you are
feeling this feeling. Just stay with it and see what you feel now in your body,
and let whatever comes come.” The client then needs to stay very gently
with the feeling, and the therapist needs to encourage them to welcome it,
rather than try not to feel it. It can be helpful to tell the client to pay attention
to any images that may come even before words.
The intervention might start with guiding the client to clear a space in
their mind to pay attention inwardly to their body and see what comes there
when they ask themselves, “What is the main thing for me right now?” Then,
the therapist asks the client to put the concern aside, like pushing a piece
of furniture to the side of a room to clear a space in the center. The client is
then asked to select one personal problem to focus on and to pay attention
to that place in their body where they usually feel things. There, they get a
felt sense of what all of the problem feels like. The therapist guides the client
to first get at the sensory quality of this unclear felt sense—like “tight” or
“heavy” or “dark”—and then get to words or phrases or images to describe
in words the felt sense. Next, they are given time to check that the words
fit and to go back and forth between the felt sense and the words to see in
their body that they feel the words fit. They then are guided to ask what is it
about this whole problem that makes it feel this way and to see if there is a
felt shift in the felt sense in the body. The last step is to receive and welcome
whatever comes. It is helpful for the therapist to point out that whatever
comes is just a step, and more steps will come, and no bad feeling is the last
feeling. The therapist will probably continue after a little while but will stay
here for a few moments.

A Clinical Example of Focusing and Experiencing an Emotional Shift

Let’s look at a more specific example. Jonathan, a 59-year-old academic at

a university, is feeling upset about not being awarded a grant he applied for.
He found out this morning and has been busy since. He has felt tense and
upset throughout the day, but this is the first time he is talking about it.
150  •  Changing Emotion With Emotion

He says to his therapist, whom he has being seeing for a few months for
anxiety and problems in living, that he is shocked because he was sure he
would get the grant. After talking about it for a while and saying how upset
he is, he says he does not really know what he feels.
The therapist suggests that Jonathan focus. The process of arriving at his
feeling goes something like this: After focusing his attention on the unpleasant
sensation in the center of his chest, Jonathan first says it is a tight knot and
then a kind of sinking feeling. He then says, “I feel really disappointed.”
As he continues to focus inside on the feeling in his chest, he imagines the
review committee sitting at a table criticizing his proposal. What comes for
him is, “I feel like a failure. I’m also a bit ashamed.” His body sense changes.
New words come from this sense: “I’m unsure about what this means for the
next steps of my life. Maybe I’m on the wrong path.” His feeling develops
slightly as he stays over time with his body sense of it. What comes next is,
“I’m a bit embarrassed, but most of all, I’m tired and discouraged. I don’t want
to keep trying and repeatedly not have my efforts pay off. I feel powerless.”
At this point, Jonathan stops, takes a breath, and says, “That’s it! I feel
so powerless. That’s what is so disturbing.” The tightness in his body now
releases a bit. He feels something shift. The therapist encourages him to
stay with whatever is new or fresh that comes from the feeling. Then, out of
another place in his body, what emerges is: “I feel angry at the unfairness.
A lot of it is politics and image management.” His anger feels better than
feeling powerless. What comes next is: “Maybe I was shooting too high.
I didn’t really want to do this; it’s not really where my heart is. Maybe I need
to reorganize my priorities.” Notice how nonlinear this is; accessing his
anger allows him to let go of, or reorganize, around the goal that has been
frustrated. At this point, either this emerging sense—that it is not so important
to him—feels right to him or doesn’t. His bodily sense, if he really listens
to it, will tell him if this meaning fits. If it does, he will again feel a shift
in his body. The bad feeling will continue to open up and lighten. It will no
longer be a tight knot. It will begin to move and become more fluid, spiral-
ing into a different pattern, letting in more air and lightness. Something will
have shifted.
This shift is quite different from what occurs when the meaning created
is an excuse, a type of self-deception to save face or deceive himself. In the
preceding example, Jonathan’s saying “I didn’t really want this” could be an
excuse if, deep down in his heart, he was still set on doing this type of work
and was trying to convince himself that he did not care anymore. Then,
his inner bodily feeling might change but in quite a different way: It would
become tighter. His shoulders might tense up, and his voice might become
 Focusing on Bodily Feelings  •  151

strained even if it is only the voice in his head. He will tense some part in his
body in his efforts to distance himself from the disappointment to support the
deception and to protect himself from some feeling he feels that he simply
cannot bear.
The whole process in which the therapist has encouraged him to engage
is not one of thinking about the issue in any effortful sense. Rather than
rationally explaining, Jonathan is paying attention to his body. Words and
pictures are coming from the felt sense. This is quite different from a reason-
ing process. Here, it is more like seeing than doing. It is a process in which
he is more a recipient of impressions than an active problem-solver. This
process has more in common with free association than reasoning, but it is
highly body focused.
Whatever way he resolves it, it was feeling something new that led to
change. He might begin to clarify: “Really, I don’t want to keep working
so hard. I’ve reached my ceiling. Maybe I will retire. I’ve always wanted to
travel and read more. Maybe this is an opportunity in disguise.” Or, he might
say, “I’ll change my focus. I really wasn’t going with my strengths in that pro-
posal. I need to reorient myself.” Whichever solution emerges, it came about
by a body-based feeling process that leads to the creation of new meaning.

MEASURING EXPERIENCING

To deepen bodily felt experience through a technique such as focusing,

it can be helpful to use the depth of experiencing (EXP) Scale (Klein
et al., 1969) to analyze video recorded sessions. Clinicians also can benefit
by looking at the moment-by-moment impact on EXP of their empathic inter-
ventions or any intervention they may make to see if they deepen experi-
ence. Klein et al. (1969) developed the scale to measure EXP. The EXP Scale
defines clients’ involvement in inner referents of experience as moving from
talking about things in impersonal way (Level 1), to describing one’s expe-
rience at a superficial level (Level 2; e.g., “It’s hard for people in close rela-
tionships to be angry at each other”), to expressing externalized or limited
references to feelings and reactions (Level 3; e.g., “And then I got annoyed
at what he said”), to a clear shift inward to directly focus on inner expe-
riencing and feelings (Level 4; e.g., “I felt myself getting more and more
upset, kind of like tightening up inside—inside, like wanting to explode,
feeling, uh, both insulted and angry”). Level 4 is the point at which focusing
on a felt sense is achieved. Now, the client’s process shifts to questioning or
propositioning about the self’s internal feelings and personal experiences
152  •  Changing Emotion With Emotion

(Level 5); to a synthesis of readily accessible and newly realized feelings and

experiences to resolve personally-significant issues (Level 6; “Yeah, I realized
that this feeling of anger and feeling insulted and wronged finally gave voice
to what I have been carrying with me for a long time, and now there’s no
turning back”); to a point at which there is a full, easy presentation of expe-
riencing. All elements are confidently integrated in an expansive, illuminating,
confident, buoyant manner (Level 7).
When clients are processing at a low level of EXP, the therapist facilitates
deeper experiencing sometimes by symbolizing feelings in words by empath-
ically exploring or conjecturing as to what clients are presently experiencing.
Or, the therapist may guide attention inward to focus directly on bodily
felt experience. Promoting awareness of these bodily felt feelings involves
engaging people in a real internal experiential search for what they are feel-
ing. Here, the core feeling is often unclear or is initially even absent from
awareness. There is something there—a felt meaning that can be sensed.
It is in their bodies, but they do not yet know what it is.
Having just looked at how focusing works, let’s now look at working with
expressing emotions.

WORKING WITH EMOTIONAL AROUSAL AND EXPRESSION

The process of emotional arousal and expression also involves the body.
Now, however, the process is not one of attending to the body but, rather,
engaging the body in expressive action. It offers another way of working
with emotion. It involves stimulating feelings, intensifying them so that
they spontaneously break through the intellectual veil of words and express
themselves in tears, in shakiness, or in anger. They are experienced in some
visceral way in the body. In contrast to focusing on the bodily felt sense to
create new felt meaning, in the arousal process, the emotion is evoked, and
the client moves toward unrestricted expression. Instead of developing a
form of knowing, the client develops a form of doing. In the focusing process,
words bring out feelings not yet felt; in expression, felt feelings lead to words
that make meanings. In focusing, the feeling does not rise up as readily as
in the case of expression. Rather, the feeling is waiting in the felt sense to
be formed into meaning, and the feeling is implicit in the person’s body.
One could ask, Is it better or more therapeutic to work with emotional
arousal or with the felt sense? I think that a strict focus on either alone can
limit therapeutic possibilities. To be therapeutically effective in changing
emotion with emotion, we therapists need to value both working with
 Focusing on Bodily Feelings  •  153

expressed emotion and the felt sense, and recognize that the way of work-
ing directly on emotional expression differs from the way of focusing on
the felt sense. Each of these processes—attending to bodily experience and
expressing aroused emotion—are central to emotion work, and both are
important processes of change. Also important is this: In talking about emo-
tional expression, we are talking about expressing previously unexpressed
emotion in therapy. We are not encouraging unbridled expression of emotion
in the real world, which can be highly counterproductive.
Emotion arousal involves the visceral experience of the emotion and a
state of heightened physiological activity. It manifests itself in some form
of heightened overt and covert bodily activities that create a readiness for
action. Arousal, then, is a state of heightened activity in both body and
mind that makes us more alert and acts along a spectrum from low to high.
One can be slightly aroused, or one can be extremely highly aroused. Acute
states of arousal characterize all vital emotions, and the subjective experi-
ence of these acute states is part and parcel of all strong feelings. Emotional
arousal is consequently an essential component of such experiences as
sadness and happiness, love and hate, despair and elation, grief and joy,
anger and calm, pleasure and displeasure, and so on.

Stimulation

Arousal is the result of stimulation. When people are stimulated appropri-

ately, then we become aroused. With greater stimulation, we become more
aroused. Arousal in an emotion-focused view typically happens when the
body releases chemicals into the brain that act to stimulate emotions,
reduce cortical functioning and hence conscious control, and create physical
activation and readiness for action. Arousal starts in the primitive brain stem,
proceeds through different parts of the brain, and engages the endocrine
system. It increases oxygen and glucose flow; dilates the pupils (so one can
see better); and suppresses nonurgent systems, such as digestion and the
immune system. Arousal is spread through the sympathetic nervous system
with effects, such as increasing the heart rate and breathing to enable phys-
ical action and perspiration to cool the body. Clearly, it involves a change in
experiential state. Expressing how one feels is not always easy to do.
When emotional arousal and expression occur in therapy, a strong feeling
rises up for the client, washes over them, and takes over what they say. There
is no need for the person to go looking for this emotion; it comes to the
person very clearly. People, who have words for emotions, describe them
easily with such words as “I feel angry, sad, or afraid.” Expressing the feeling
154  •  Changing Emotion With Emotion

promotes the experience of it. A person might then say, “I miss him” and
burst into tears or say, “I hate you” to an imagined other in an empty chair
and feel the anger. When expressed, the emotions become readily available
and intensely felt. As people express these clearly felt emotions, they begin
to speak from them, and more meaning emerges. People then begin to speak
from the strong feeling and say, “I feel so empty without him, like I don’t
quite have my bearings” or “I can never forgive him for what he did.” This is
the process, of expressing aroused emotion in words.
Emotion can be expressed at differing degrees of arousal in different
ways: verbally in conversation, in writing (e.g., a diary), or in movement.
Sometimes it helps to use more nonverbal means to express emotion. Asking
people to paint what they feel, sculpt it, or play it in music can offer release
through creativity, but then, in therapy, it is usually advantageous to try and
help them put what they have expressed nonverbally into words.
Once people have words, it is easier to work with their emotions. For
example, say a client has difficult feelings regarding her father’s abandon-
ment of her as a child. The therapist helps her to attend to and explore her
bad feeling. The client feels many emotions: feelings of sadness, anger at
the father, pain and fear of being left alone in the world, grief and anger at
her mother for not being there for her, and fear that an expression of anger
would result in the loss of her father’s and mother’s love. At some point in a
session, the therapist, sensing that the client’s fear interrupts her expression
of anger at her father, helps her to access her anger rather than interrupt it
by expressing her anger at him in an empty chair. The client, in imagination,
becomes the 4-year-old child and expresses to the imagined father of her
childhood the sadness of her unmet longings for comfort and protection.
After expressing her unmet need, the anger comes to her—the anger that he
had been blind to her pain.
As the process continues, having expressed her sadness, her need, and
her anger, the client’s sense that her father abandoned her begins to change
and becomes a sense that he actually was not able to support her and
that he would have responded to her if he had known how. In this way,
by accessing and expressing emotion, she was able to work through and
transform her sadness and anger toward him, and grieve fully for her losses.
This is a different process from focusing. It spans a larger period of time
than the moment-by-moment process of finding words to express feelings
along the way. This process of stimulating arousal and expression also uses
both empathic attunement to affect and focus at moments in the process.
However, the aim of the whole process goes beyond conveying empathic
understanding and beyond focusing on a bodily felt sense to help the client
put words to feelings.
 Focusing on Bodily Feelings  •  155

Exploration to Activate Emotion

In addition to expressive stimulation, therapists also promote exploration

to access emotion. They ask exploratory questions, such as: “How does this
emotion make you feel?” “Where do you feel it on your body?” “Where is it
coming from, and what triggered it?” and “How do you feel afterward?”
They are a sort of cross between asking the person to express to stimulate
and focusing on the body felt sense to stimulate. The aim of exploratory
questions is not to gain information but to activate by helping people attend
to and express what they feel.
But focusing is alive and well in the stimulation process described earlier.
First, the client is working with her whole sense of her relationship with
her father—a holistic feeling that cannot be divided into distinct emotions.
At times, she focuses, or the therapist guides her to focus, to get at the idio-
syncratic flavor of the whole experience of her relationship with her father,
such as her anger about her father’s being blind to her pain. Here is a piece
of focusing in action to capture this felt meaning. She is not just expressing
anger; she is also differentiating it by focusing on it and finding words to
make sense of it. However, her arousal and expression of it comes from
stimulation by imagining her father in an empty chair and from the evoking
of emotion schematic memories. Her image of herself as a small child that
needed protection is not separate from her memory of that time nor from
her emotion of longing to be protected. Here, the therapist, in stimulating
arousal and expression, is not working just with the client’s emotional arousal
but with the client’s total response to her situation. In the final analysis,
work on expressing of aroused emotion and work on focusing are integrated
in a seamless fashion.

MEASURING CLIENT EMOTIONAL AROUSAL

As with measurement of a client’s EXP, it can be clinically useful to quantify

emotional arousal. Clinicians can benefit from analyzing video recordings
of their sessions to see which interventions aid and which hinder emotional
arousal in their clients. To capture the difference between EXP and arousal,
two overlapping but different processes, Warwar and I (Warwar & Greenberg,
1999) developed the Client Emotional Arousal Scale-III-R (see Exhibit 6.1),
which rates the degree of arousal in expression as opposed to attention to
a bodily felt sense. In this scale, what is being rated is clients’ intensity in
voice and body, degree of overflow, and degree of restriction of experience
and expression. At Level 1, the person does not express emotions and voice,
EXHIBIT 6.1.  Client Emotional Arousal Scale-III-R
1 Person does not express emotions
Voice or gestures do not disclose any emotional arousal
2 Person may allow some emotion, but there is very little arousal in voice or body
•  There is no disruption of usual speech patterns
•  Any arousal is almost completely restricted
3 At this level of arousal as well as higher levels, the person allows emotions
Arousal is mild in voice and body
•  There is very little emotional overflow
•  Any arousal is still very restricted
•  Usual speech patterns are only mildly disrupted
4 Arousal is moderate in voice and body
• Emotional voice is present: Ordinary speech patterns are moderately disrupted
by emotional overflow as represented by changes in accentuation patterns,
unevenness of pace, changes in pitch
• Although there is some freedom from control and restraints, arousal may still
be somewhat restricted
5 Arousal is fairly intense and full in voice and body
• Emotion overflows into speech pattern to a great extent: Speech patterns
deviate markedly from the client’s baseline and are fragmented or broken
•  There is elevated loudness and volume
•  Arousal seems only slightly restricted
6 Arousal is very intense and extremely full as the person is freely expressing
emotion with voice and body
• Usual speech patterns are extremely disrupted as indicated by changes
in accentuation patterns, unevenness of pace, changes in pitch, and volume
or force of voice
• There is spontaneous expression of emotion and there is almost no sense
of restriction
7* Arousal is extremely intense and full in voice and body
•  Usual speech patterns are completely disrupted by emotional overflow
•  The expression is completely dysregulated and unrestricted
•  Arousal appears uncontrollable and enduring
• There is a falling apart quality: Although arousal can be a completely
unrestricted therapeutic experience, it may also be a disruptive negative
experience in which the clients feels like they are falling apart
Note: control = containment in contrast to control = restriction
*The distinguishing feature between Level 6 and Level 7 is that in Level 6,
there is the sense that although a person’s expression may be fairly unrestricted,
this individual would be able to contain or control their arousal, whereas in
Level 7, a person’s expression is completely unrestricted and there is the sense
that emotional arousal would not be within this person’s control.

From Client Emotional Arousal Scale–III–R [Unpublished manuscript], by S. Warwar and L. S. Greenberg,
1999, York Psychotherapy Research Clinic, York University. Copyright 1999 by Serine Warwar and
Leslie S. Greenberg. Adapted with permission.
 Focusing on Bodily Feelings  •  157

or gestures do not display any emotional arousal. At Level 2, there is a

little arousal in voice or body with no disruption of usual speech patterns.
At Level 3, the person allows emotions, but the expression is mild in voice and
body, there is little emotional overflow, and any arousal is still very restricted.
At Level 4, one gets a noticeable level of arousal that is now moderate in voice
and body. There is some freedom from control and restraint, but arousal is
still somewhat restricted. At Level 5, arousal is now fairly intense and full
in voice and body, and arousal seems only slightly restricted. At Level 6,
arousal is intense and extremely full because the person is freely expressing
emotion; there is almost no sense of restriction. Level 7 takes a turn in that
it represents dysregulation.
This is not a linear scale. Levels 1 to 6 are viewed as increasing step by
step, so the more, the better. However, Level 7 represents too much of a
good thing because it produces an undesirable state. At Level 7, arousal is
extremely intense and full, the expression is completely dysregulated and
unrestricted, and arousal appears uncontrollable and enduring. The dis-
tinguishing feature between Level 6 and Level 7 is that, at Level 6, there is
the sense that although a person’s expression may be fairly unrestricted, this
individual would be able to make cognitive sense of their emotion, which
is still sufficiently contained or under control. At Level 7, on the other hand,
a person’s expression is completely unrestricted. There is the sense that
emotional arousal is not in this person’s control, and cognition cannot be
brought to bear on it to make sense of it.
Using this scale (see Exhibit 6.1), an emotional response is indicated when
a person acknowledges having experienced an emotion (e.g., “I feel afraid”)
or demonstrates an emotion action tendency (e.g., covering one’s head in
shame or shrinking back in fear). Warwar and I (Warwar & Greenberg, 1999)
found 15 emotion categories most relevant to psychotherapy sessions. Before
a segment can be rated on arousal, it first must be categorized according to
the following emotion list. If the segment does not fit into any of the cate-
gories, it is considered unclassifiable and cannot be rated using the Client
Emotional Arousal Scale-III-R (Warwar & Greenberg, 1999):

 1. Pain/Hurt
 2. Sadness
 3. Hopelessness/Helplessness
 4. Loneliness
 5. Anger/Resentment
 6. Contempt/Disgust
 7. Fear/Anxiety
 8. Love
158  •  Changing Emotion With Emotion

 9. Joy/Excitement
10. Contentment/Calm/Relief
11. Shame/Guilt
12. Pride/Self-confidence
13.  Anger and Sadness (both present simultaneously)
14.  Pride (Self-Assertion) and Anger (both present simultaneously)
15. Surprise/Shock

PRACTICING BODY WORK: OBSERVING NONVERBAL BEHAVIOR

There are a number of different ways of working even more directly with the
body as a carrier of feeling and meaning. Body work is a relatively newer,
less-investigated area of clinical practice in emotion work (Totton, 2003).
The first step toward working with the body in therapy usually involves
therapists’ noticing and guiding attention to outward signs of internal expe-
rience. This form of working with the body involves taking an observational
stance and giving the client feedback or guiding their attention to observ-
able expressions. Bodywork most generally focuses on drawing attention to
the client’s gestures or body positioning.
A therapist, for example, might ask the client to bring attention to a
gesture, ask what those gestures feel like, and then facilitate further discus-
sion about these feelings. This form of intervention is based on the idea that
inner states and implicit models of the world express themselves through
nonverbal expressions, such as gestures, postures, pace, tension, or relaxation
of muscles and other subtle somatic communications. Working with bodily
expressions moves therapy from focusing on verbal consciousness and narra-
tive description to deepening into the body. For example, if a client seems
to be tightening their jaw when talking about their job, therapists might
contact their feeling states by saying, “Your jaw seems like it is clenching.”
This is to help immerse people in the experience. The therapist might then
say, “Just let yourself stay with that and invite that feeling in.”
One good way therapists can help themselves develop or enhance this
skill is to keep asking themselves, “What is the client doing right now?” For
instance, the person could be looking down, looking away, moving in their
seat, or perhaps frozen. Each indicates an internal experience that underlies
the person’s behavior. The therapist also listens to the voice: How much or
how little emotion is contained in somebody’s voice? Is the tone of their
voice weak, loud, quiet, or strong? What is the verbal pace and tonal quality? Is
the person’s speech pace fast, slow, or does it vary? Is the tone of their voice
harsh, even, melodic, monotone, or soft?
 Focusing on Bodily Feelings  •  159

The therapist observes the body: What’s the body’s position? How is the
body in relationship to gravity? What images does the body evoke? Is the
body grounded? Is it constricted, flaccid, or tight? What are the movements?
Are the person’s movements relaxed or active? Are their movements jerky
or smooth, controlled or spontaneous? What are the gestures? Does the
person move or gesture? Is their gesture repetitive? What is the quality of
the gesture? Is it gentle, aggressive, or abrupt? What are the postures? Is the
posture rigid, collapsed, threatening, overgrounded, ready to spring into
action, or expressive? What do the eyes say? Do the eyes look glazed? Do
they lack luster or liveliness? Do they look scared, defiant, or threatening?
What about muscle tension and relaxation? Notice the patterns of tension
and when the client changes. Is the client in touch with their breathing?
Does the client feel the ground beneath them, or is most of their awareness
above the neck? Much of the unconscious is present on the surface.
How people walk, talk, shake hands, or move are all holographic frag-
ments of how they are psychologically organized in the larger arena of their
lives. Through the process of awareness, therapists help the person stop
what is an automatic habit pattern and start to be aware of themselves.
This allows a more intimate understanding of how their body is organized
and what is going on below ordinary consciousness. Interventions may
involve experiments, such as having clients change a position or posture
and experience what that is like, or working with gesture and asking clients
to repeat or even exaggerate them. A study published in 2009 (Levy Berg
et al., 2009) demonstrated greater improvement in participants who received
affect-focused body psychotherapy than in those who received the standard
treatment.
Body-focused work also incorporates working with touch, breathing,
and movement. Working with movement and increasing the sensorimotor
awareness help people learn to modulate their traumatic experience and
increase their capacity for self-regulation. Ogden (2015) developed a sensori­
motor approach that helps individuals in therapy reexperience traumatic
events in a safe environment and carry out any previously unfulfilled actions
to achieve feelings of completion and closure. Here, clients complete the
movement that was truncated in the original situation, thus giving them
an experience of triumph that they can savor and integrate into their nervous
system. Levine (2010) developed an approach to body work called somatic
experiencing, which is partially based on the similarities between the regu-
latory systems of animals and humans in dealing with traumatic events. It
teaches people how to slowly and safely complete survival actions, inter-
rupted at the time of trauma, as they learn to renegotiate their traumas
160  •  Changing Emotion With Emotion

rather than relive them. These approaches all privilege body movement over
talk as crucial in change in psychotherapy.
In working with the body, once the therapist has noticed the physical
aspects of an individual’s experience and drawn attention to it, the next
step in body-centered process is to allow the experience to move or unfold
toward core painful emotions that organize these expressions. When clients
are immersed in their actual experience, they have the opportunity to bypass
usual responses and protective defenses. They can now explore, in a more
visceral fashion, what underlies their perceptions, behaviors, and feelings.

CONCLUSION

In this chapter, I presented how to go beyond words to gather information

from the body that only later is put into words. This is done by attending to
the felt sense both through expressive arousal and observation of nonverbal
behaviors. In line with the importance of new experience as the key change
process, the body is the seat of experience, and therapists need to pay
attention to the information in the body. As mentioned, the brain talks in
two languages: (a) the verbal conceptual language of the prefrontal cortex
and (b) emotion in which the brain speaks through the body with a sensory
motor tongue. Therapists, therefore, need to listen to the body if we are to
access the brain’s intelligent emotion system.
7 BLOCKS TO EMOTION

At times, some clients stop themselves—deliberately or automatically—from

having certain feelings. They might say something like, “I can feel the tears
coming up, but I just tighten and suck them back in. No way am I going
to cry.” What is occurring in clients who have difficulties accessing emotion,
who cannot locate feelings in their body or simply do not allow themselves
to feel or express emotion? In this chapter, I discuss how to understand what
is happening internally in people who lack emotional awareness or, more
specifically, have difficulty identifying and describing feelings or experienc-
ing the bodily sensations associated with emotions, or both.
Two possible processes are involved in the nonawareness or lack of
expression of emotion: The first is a deficit in learning; the second, defense
or inhibition. Deficits refers to clients who have never learned to pay attention
to or to label emotions. They simply have no words for emotion possibly
because they were brought up in environments where emotions were dis-
regarded and never learned to pay attention to, or talk about, emotion.
Defense assumes that emotional experiences are kept out of awareness
through intentional (e.g., suppression) or unintentional (e.g., repression)
mechanisms because of their threatening nature.

https://doi.org/10.1037/0000248-008
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

161
162  •  Changing Emotion With Emotion

Therapeutic work with clients who have no words for emotion differs
from work with clients who are inhibiting and blocking emotion. Some clients
have difficulties with identifying, naming, or expressing—or all three—emotions
that are deemed socially appropriate, such as happiness on a joyous occasion.
Treatment involves skill training, which starts with being aware of physio-
logical responses and journaling about emotions, and involves concentrating
on building a foundation for naming emotions and appreciating a range of
feelings. The process likely includes both consideration of the experiences of
other people and self-reflection. Although this may seem basic, it is difficult
for some people, such as those with alexithymia, a term that describes people
who have difficulty finding words to express their emotions.
Other clients have the ability to name their emotions, but they inhibit
them and do not allow themselves to experience or express them. They
know they have them, but they disown them as “not me” and disclaim the
action tendencies in their emotions. In this chapter, I describe inhibition as
a process by which people interrupt or block emotion, and I view this process
as involving action by the self on the self to prevent the experiencing of
emotion. Seeing interruptive processes as clients blocking their emotions
highlights that clients are active agents in the process of not being aware of
emotions. They are not passive recipients, as implied in statements like,
“I just went blank” or “My sadness suddenly disappeared.” In therapy, clients
are helped to see themselves as agents who do things to interrupt their
experience and block their expression of emotion, and to see that they cut
themselves off from the adaptive information associated with the emotions.
In this discussion, I stress the therapeutic importance of seeing inter­
ruptions and blocks as self-protection, and as a means of coping rather than
as the avoidance of pain. In this way, blocks to emotion, which are often
referred to in the literature as “avoidance” or “defense,” are revisioned as
coping strategies coming out of people’s attempts to prevent falling apart.
Blocking emotions are thus seen as survival efforts and attempts to enhance
coping. Therefore, it is important that, as clinicians, we help people approach
dreaded emotions by first validating their fear that allowing the emotion
will result in falling apart.
First, I discuss psychoeducative forms of intervention for people with
emotion learning deficits. After that, to more deeply understand the clients
in-session process and internal experience of blocking, I engage in an in-depth
discussion of the results of task analyses and grounded theory qualitative
analyses of the process of interruption. Understanding these processes is key
to informing the therapist how to best facilitate the unblocking of dreaded
emotions.
 Blocks to Emotion  •  163

HAVING NO WORDS FOR EMOTION

When clients first enter therapy, it often is surprisingly difficult for them to
answer, “How are you feeling?” Answering that question can be even more
of a challenge for clients who have alexithymia, which may appear as a
clinical feature in clients with autism spectrum disorder, depression, eating
disorders, posttraumatic stress disorder, or other diagnoses. These clients
present behaviorally or cognitively, are external and intellectualizing, or
are somatizing and have psychosomatic symptoms or are anorexic and have
little or no access to feeling and have no capacity to focus internally. They
are organized characterologically to not show any emotions. They differ
from people who have emotions that they are aware of having but suppress
them or actively block them. People who are alexithymic have difficulty
finding words to describe their emotions, are often imaginally constricted,
and have an externally oriented cognitive style (Bagby et al., 1994). These
clients seem to have little access to emotion, and therapists often end up
feeling unable to work with them in an emotion-focused way. But all people
have emotions, so it is not a matter of absence of emotion but a lack of
emotional competence in describing emotion.
When a supervisee says something to me like, “My client has difficulty
getting in touch with his emotions. I’ve tried to get him to focus on his
feelings, but he just doesn’t seem to have any, maybe I should do something
else?” my response is usually to ask, “What is your relationship like?” As
therapists, we deal with clients talking to us about their emotions. They are
in relationships with us, so it is not a simple matter of the client’s character-
istics alone. It is also an issue of what the therapist is like, the nature of the
relationship, and whether an alliance between client and therapist to work
on emotion has been established.
Establishing an alliance to work on emotion means therapists must
understand that most people feel vulnerable expressing emotions. This is
probably because society has deemphasized emotions and has cast emotions
as weak, needing to be controlled, irrational, and potentially dysfunctional
such that people do not feel safe talking about emotions. In addition, if their
life experience included growing up in emotion-unfriendly environments
at home or in school, they learned languages other than talking feelings.
If you do not speak an emotion language at home, how can you suddenly
come into therapy and speak about emotion? It is like expecting someone
to suddenly be conversant in Mandarin having never been exposed to it or
taught it. What is needed first to help people who lack words for emotion to
speak the language of emotion is an emotion-friendly and permission-giving
164  •  Changing Emotion With Emotion

environment. Therapists need to explicitly give people permission to be

emotional by saying, “This is a place where your feelings are welcome. Even
more, they are desirable.”
When my supervisees or trainees ask how to work with people who do
not have emotion, my first answer is to ask about the nature of the thera-
peutic relationship to highlight that it is not simply an intrapsychic issue but
an interpersonal one. Clients need to feel safe and trust the therapist before
they will attend to their emotions. I then suggest that they focus on clients’
sensory and motor experience—not on feelings but on sensations because
those are more easily accessible, especially to men—and be attentive to non-
verbal communication. I often say, “Don’t think about what’s coming out of
people’s mouths but think about what’s going on in their stomachs. What is
their visceral experience?”
How does one work with clients who are alexithymic? Empathic attune-
ment to affect, present-centered awareness, and focus on instructions covered
in Chapters 5 and 6 are helpful as baseline skills. However, given that the
difficulty is a lack of emotional competence, and the problem is, to some
degree, a deficit in learning, guiding clients toward their feelings is insuf-
ficient. The first form of intervention I suggest is experientially oriented
psychoeducation.

TEACHING CLIENTS WORDS FOR EMOTION

At the most basic level, the client has to be aware of any emotion they may
have and attend to it. Clients often are unaware of their emotional experi-
ence and responses. For example, they might nonverbally express emotions
without being aware that they are doing so. A client, while talking about
his abusive mother, for instance, may clench his jaw or speak with an angry
tone, but when he is asked by his therapist what he is feeling, he responds
that he feels nothing. Although the client may be visibly distressed or angry,
he is unaware of what he is feeling. In situations of this nature, therapists
can help clients increase awareness of their emotion by focusing attention to
their nonverbal actions (e.g., “I’m aware of you clenching your jaw. What’s
that feel like?” “I hear some anger in your voice. Are you aware of feeling
angry?”). Attention is guided to nonverbal expression, to bodily experience,
and to internal physical sensations.
Therapists need to focus on a client’s sensations and the bodily felt sense,
inquiring into internal experience and asking them to describe what it is
like inside. Nonverbal aspects of expression, especially facial expression,
 Blocks to Emotion  •  165

quivering lip, and sagging cheeks as well as general posture, need to be

attended to and the experience invited to come more fully. Sighs need to
be noticed; they are important expressions of core experience and often
indicate either an underlying unacknowledged sadness or a sense of having
touched on it. Ask clients to sigh again and to take a breath because doing
so allows the feeling to intensify. Ask them to put some words to the sigh
to help them symbolize the feeling behind it. Evocative language and
metaphor, such as “It’s like wanting to cry out but being afraid that no one
will hear me,” can help evoke the feeling. Memories of situations in which
this feeling was felt can be evoked by using imagery to make the feelings
as concrete and vivid as possible.
Once an experience is felt in awareness, it has to be symbolized (i.e.,
generally in words but it could be in painting, movement, and so on) to be
able to fully use it as information. Naming emotional responses and describing
what they feel like enables clients to use the informational value inherent
in their primary emotions. Exact labeling of emotional experience is not
what is needed; rather, clients need to be engaged in a process of trying
to symbolize what they are experiencing. Description of emotion can be
promoted in dialogue with the therapist or in homework, such as writing
about the emotion in a diary. Using more nonverbal means, such as asking
people to paint what they feel, to sculpt it, or to play it in music, also can
be helpful. Later, clients can put these expressions into words. The ability
to label and describe emotions helps clients to be able to work with their
emotions to solve problems. The goal of describing feelings in words is to
help people speak them rather simply act them out. A parent coaches a
child in naming emotions, first by giving words to the child’s experience by
saying, for example, “Johnny is angry” when Johnny yells and grabs his toy
from another child.

Being a Surrogate for Others’ Personal Experience

Through empathic attunement to affect, therapists try to help clients enter

the highly subjective domain of their unformulated personal experience. For
example, the therapist here offers words to help the client symbolize what
he might be feeling:

CLIENT:  I don’t know what I feel. It wasn’t good, though.

THERAPIST:  Something like “it was like a loss.” Maybe you felt sad or dis­
appointed.

CLIENT:  Yeah, I guess that is what it is. It just wasn’t what I expected.
166  •  Changing Emotion With Emotion

Therapists serve as surrogate information processors and are constantly

engaged in helping clients to put words to what they feel. In the dialectical
constructivist view I propose for emotion work, meaning is created in the
process of symbolizing the emotion. In other words, emotion is not sitting
fully formed inside a person. However, there is an emotional experience there,
and that emotional experience constrains but does not fully determine how
it can be symbolized. Thus, how emotions are symbolized influence what
they become.

Using Structured Homework for Identifying Emotions

Often the best place to go next is the use of structured homework exercises:
keeping an emotion log or a diary. Homework exercises can be helpful to
clients to track their emotions during the day (see, e.g., Greenberg, 2015).
The first way is by keeping an emotion log. The therapist might suggest
that at three appointed times during the day, the client write down the last
emotion they experienced and describe anything it led them to think or do.
Keeping an emotion log may be easier for some people than keeping a diary
because the log is more structured; in addition, rather than logging emotion
three times a day, the therapist can ask clients to keep the log at the end
of the day or before bed. On a sheet, the therapist provides a list of emotion
words to the client and asks the client to check if they felt this feeling
during the day and when. The client also marks on the sheet what feeling they
are feeling at the moment. This begins a training in emotion labeling, which
itself has been shown to lead to beneficial emotional processing (Kircanski
et al., 2012).
The therapist can ask the client to write down a name for the emotion
and suggest that, rather than writing frequently used words like “frustrated”
or “happy,” the client try to find more varied and differentiated words like
“annoyed,” “angry,” or “furious.” The client also can be asked to describe any
body sensations they may have had that accompanied the emotion. Then,
the following week, the therapist can ask the client to add comments on
whether it was a sudden-onset emotion or a more enduring mood, and how
long it lasted.
In the session, the therapist can ask the client to describe the last time
they felt one of the following emotions: anger, sadness, fear, or shame. The
therapist then describes this feeling to the client to help them understand the
situation, how the client reacted, what happened in their bodies, how they
felt, and what they did. The client can also be asked to consider how long
 Blocks to Emotion  •  167

the feeling lasted, how intense it was on a scale from 1 (not at all) to
10 (very high), how frequently they experienced this emotion, and whether
the emotion was generally helpful or was a problem for them.

Slowing Down

To enter states of feeling, which are quite different from states of thinking
or acting, people need to be able to slow down to smell the coffee or to feel
the feeling. To feel is a slow process. Feelings cannot be felt when clients are
talking rapidly, concentrating on content, or even trying to communicate
to the therapist. It, therefore, is important in sessions to help clients to stay
with a feeling they may be beginning to have by guiding them through the
following four steps. Creating a space for feeling is one of the most basic
processes in working with emotion. It is simple but crucial. Therapists can
help clients create a space for an emotion by saying phrases like:

1. Stay very gently with what you are feeling.

2. Make a space for it in your body and just feel it. Put some words to it.
3. Receive and welcome the feeling.
4. Feel it fully.

If clients enter their emotional states but then interrupt the experience,
the therapist needs to guide them to become aware of how they do this
interruption. Maybe they think of something else; get scared; or say, “I can’t
handle this.” Help them become aware that they are interrupting and then
guide them to choose to attend to their experience.

ENGAGING IN SELF-INTERRUPTION

For those clients who have words for emotions but find allowing emotional
experience so difficult that they quell their primary emotions and any asso­
ciated tendencies, psychoeducation as suggested for alexithymic clients is
not the intervention of choice. This form of inhibition in which emotional
experience is interrupted and prevented from blossoming into full emotional
experience and expression then becomes an important focus in therapy and
needs to be worked with in a way more suited to it.
Self-interruption of emotion (SIE) has been described as the client’s engage-
ment in action against the self (Greenberg, 2002; Greenberg, Rice, & Elliott,
1993). Actions against the self-involve such things as physiological control
168  •  Changing Emotion With Emotion

over visceral experience, muscular tightening against the expression of

emotion, negative beliefs and thoughts that serve to quash emotion, or
avoidant behaviors like laughing or joking to ward off painful emotion (see,
e.g., Perls et al., 1951). In addition, secondary emotion often can prevent
experience and expression of an initial primary emotional experience, such
as when fear of sadness obscures the sadness.
The process of interruption of emotion has possible roots in early rela-
tional experience in which attempts to express feelings and needs as a child
were consistently met with disapproval, humiliation, or abuse. The indi­
vidual then began to function as a “divided self”: One part of the self engaged
in activity to control the expressive action of another experiencing part
of the self. The end result is that the person develops processes of self-
control to guard against vulnerability or painful experience. This process
may result either in awareness of the inhibitory process itself, such as
choking back tears, or in awareness of a lack of feeling, muscular tension,
or psychosomatic symptoms without any awareness of the self-interruptive
processes. From a transdiagnostic perspective, limited emotional awareness
is a major underlying determinant of many major disorders, including
posttraumatic stress disorder, anxiety, depression, eating disorders, addic-
tions, and personality disorders. Therefore, it is vital that the self-interruptive
process is brought front and center in the case formulation and treatment
plan for many clients.

HELPING CLIENTS SEE HOW THEY SELF-INTERRUPT

Therapists can help clients overcome blocks to emotion by making the inter-
ruptive activity against the self more explicit. First, the therapist helps the
client become aware that they are interrupting. Next, and most importantly,
the therapist demonstrates how the client is interrupting (not why). Once
the client understands this, only then do they truly experience what they are
interrupting. Helping clients experience a sense that “it is me doing this to
myself” leads to the possibility of choice to not do it any longer. The recog-
nition of personal agency in the interruptive process—that is, the experience
that it is me doing this to myself—is a primary aim.
After becoming aware of how they interrupt themselves, clients develop
the capacity to undo the interruption or at least develop some tolerance
of the vulnerable emotion rather than completely suppress it. Undoing inter-
ruption ultimately leads to experiencing the blocked emotion. For example,
clients can be helped to become aware that they are blocking whenever
 Blocks to Emotion  •  169

they talk, for example, about their mother and become aware of their
muscular tightening or breathing constrictions as a means of interrupting
their experience. Once aware of how they are blocking and experiencing
what they are doing to themselves, they then can stop doing these things
and have the option to let the feeling emerge.

Process of Self-Interruption and Blocking of Emotion

In this section, I discuss what we have learned about clients’ observable

processes and subjective experiences of the blocking of emotion. This dis-
cussion informs when and how to intervene. At York University, over the
past 20 years, my students and I have engaged in a number of grounded
theory and task analytic studies of both the blocking and allowing of emo-
tion (Bolger, 1999; Vrana, 2020; Weston, 2018). Grounded theory (Glaser &
Strauss, 1967) is a qualitative method of discovering emerging patterns in
data. People are interviewed about their experience, and a rigorous analysis
of the client self-reports of their experience leads to the building of a set of
descriptive categories and ultimately a grounded theory of the phenomena
or process of interest. In contrast, a task analysis (Greenberg, 2007) studies
clients’ actual performance in sessions and, by a similar method of building
descriptive categories, constructs a model comprising the components of
resolution of the phenomena under study. Measurements of the components
are developed, and the model is later tested and validated.
In these studies, the first step involves defining a marker of self-
interruption by observing therapy video recordings and interviewing people
about the experience of self-interruption (Greenberg, Rice, & Elliott, 1993).
An in-session marker of self-interruption is a statement made by the client
or therapist indicating the client’s opposition toward allowing themselves
to fully experience or express an emotion. This opposition may either
be automatic or deliberate. Two possible aspects of what is blocked are
(a) the internal experience of emotion with its subjective sense of arousal
or (b) the outward expression of emotion in words or expressive actions.
SIE is viewed as involving two parts of the self in which the one part
limits the experience or expression of a feeling, and experiences distress as
a result (Greenberg, 2011; Greenberg, Rice, & Elliott, 1993). Individuals
interrupt their emotional experience in many different ways: The client can
constrict, stop, or distance the self from the experience or expression of a
feeling. When a primary emotional experience (e.g., anger, sadness, vulner-
ability) is emerging, it may be abruptly followed by a client’s inhibition of
the experience via some secondary emotion (e.g., anger to cover fear or
170  •  Changing Emotion With Emotion

shame). Emotions also can be interrupted via client cognition, including

injunctions against feelings (e.g., “Anger is a sin,” “Crying is feeling sorry
for oneself”). Catastrophic expectations about emotional experience and
expression (e.g., “If I start crying, I will never stop”) block emotions. Some
clients also may believe that they have no right to feel angry or sad. More-
over, automatic physical and physiological processes like squeezing, holding
one’s breath, and deflecting attention are often ways of interrupting without
any awareness.
When clients make statements in sessions opposing, fighting against,
or stopping the initial feeling or expression of emotion—or both—or make
statements indicating physiological changes that serve to restrict or constrain
the emotion, such as swallowing or squeezing down feelings, the clients are
seen as engaging in an interruption of their emotions. Their statements also
need to include paralinguistic communication (i.e., sighing or silence, which
indicate the effort in stopping emotion) as well as indications that the initial
experience of emotion has disappeared. For example, a marker of SIE might
involve acknowledging an experience of emotion that quickly is followed
by the action of “sucking it in” or a desire to not allow the emotion, which
is followed by an awareness of the absence of feeling. The following are
examples of markers of SIE:

CLIENT:  Ooh, very sad!

THERAPIST:  Very! Sad, uh-huh. (Client sighs.) Can you let yourself feel the
sadness?

CLIENT:  (Is silent for about 6 seconds)

THERAPIST:  Let the tears flow if you need to?

CLIENT:  (Is silent for about 6 seconds) Oh, a part of me is fighting it, too.
[Another client interrupts; anger]

THERAPIST:  What’s happening inside now?

CLIENT:  Ooh! I’m just (sighs)—I’m, oh! I want to scream at him so

badly.

THERAPIST:  What do you want to scream at him?

CLIENT:  Ooh! He just—oh, I can’t even express it, I’m just so! Furious
with him (gives a big sigh). I can’t tell him that. I can feel my—
I am just sucking it all in.
 Blocks to Emotion  •  171

Here is an example of the blocking of tears:

THERAPIST:  So, what’s happening for you now as you speak?

CLIENT:  Um (pauses). I’m feeling kind of tearful.

THERAPIST:  Can you stay with that, see what words come? Tearful? Sad?

CLIENT:  I don’t want to feel tearful.

Protection From Dangerous Emotions

In a study, one of my doctoral students (Weston, 2018) observed a number of

client video recordings in which self-interruption occurred and interviewed
some of these clients using interpersonal process recall. This is a method in
which clients are asked to look at a video recorded session involving their
process of SIE and talk about their internal experience at the time of inter-
ruption. My student titled her dissertation Protection from Dangerous Emotions:
Interruption of Emotional Experience in Psychotherapy. This investigation
supported that SIE was a process of providing self-protection initiated at
moments in a therapy session during which clients experienced a sense of
threat or danger from their own emotional experience or expression. Findings
showed that client’s awareness of the self as vulnerable was a central feature
of the interruptive process. This awareness of vulnerability was followed by
self-protective secondary emotional reactions like fear, self-protective acts of
control or avoidance, or both.
Weston (2018) found that clients’ process of SIE in therapy sessions
involved six steps. Self-interruption begins with the activation of emotional
experience, expression that is soon followed by the client’s awareness/
expression of an emotionally vulnerable sense of self. This awareness of vul-
nerability then gives rise to opposition to emotional experience, which is
the marker indicating the presence of SIE. The process of opposition to
emotion involves the client’s experiencing secondary reactive emotions,
controlling or avoidant inhibitory behaviors, or both. That is, the experience
of an emotion is interrupted either by the experience of another emotional
reaction to the first emotion or by some active process of blocking. The
process of SIE culminates in the client’s awareness of limited emotional
experience.
Self-interruption, then, involves some initial awareness/expression of
an emotionally vulnerable sense of self, followed by the enactment of an
interruptive process, and a final recognition of having limited or no emotion.
172  •  Changing Emotion With Emotion

Feeling vulnerable to an emerging emotion evokes a variety of secondary

emotional reactions with fear being the most predominant one. Clients
fear physiological arousal and falling apart, and it is often the intensity
of feelings that leads the clients to fear them. They fear that if they fully
acknowledge these dreaded negative feelings, these emotions will be bottom-
less and engulfing, and the clients will lose control and be overwhelmed by
these emotions.

Activation of Emotional Experience

Self-interruptive process can be seen as starting with the rising awareness of
some emotional experience. The client may only vaguely sense the emotion
and may express a vague or limited awareness of undifferentiated, mean-
ingless bodily sensations or a general sense of physiological arousal. For
example, one client cried and then asked, “Why do I do this?” in reference
to crying and some limited awareness of what she called “that feeling.” One
client described awareness that she was teary and “choked up,” and then
said, “I don’t know why.” She differentiated this inchoate experience first as
feeling “upset” and then as feeling “very sad.”
Other clients, however, may be consciously aware of their emotional
experience. For example, one therapist asked a client how she felt as she
described how her parents were critical and unaffectionate toward her. The
client reported clearly, “I feel sad.” There may be descriptions of an increase
in arousal that is defined by physiological correlates of a particular emotion,
such as fear and related changes in breathing patterns; anger and a roiling,
churning sense in the stomach; hurt and a feeling of bodily pain; sadness;
and a physical sense of loss.
Clients’ emotional experience generally is activated or “triggered” in the
therapy session in response to their own thoughts, perception, or memories.
Memories related to loss or to traumatic experiences in childhood or adult-
hood are major precipitators of emotion. Specific types of therapist inter­
ventions also evoke emotion: empathically reflecting: “My sense is that there’s
a kind of sadness that you still feel”; paying close attention to and inquiring
about feelings: “What does it physically feel like in your body?”; directing
the client’s attention inward to emotional experience or outward to the
expression of emotion: “There’s a sadness there. Somehow, we need to find
words to put to that. I’m sad that . . .”; or offering an image to capture
emotional experience: “It’s as if he took a knife and just slashed through
all you had had together.” All can evoke an emotion. Emotion might also
be activated in connection with clients’ subjective sense of contact with the
therapist: “He was just going close to me with his words, and I felt sad.”
 Blocks to Emotion  •  173

Clients often say feelings were just suddenly “triggered” in their bodies;
for example: “When my therapist said what is so undeserving about me,
I suddenly got really sad.”
Emotions are experienced as dangerous, and this is what produces the
sense of vulnerability. Clients used metaphors to describe emotion, such as
a “monster,” “alien,” or a “wave” of tidal proportions felt inside the body.
Self-interruption is a self-protective act; it protects against dangerous emo-
tions. Fear, other secondary emotions, or both, and suppressive behaviors are
engaged in to help protect against the emotions. Behind the self-protection
is not so much the pain of the emotion that the client is avoiding but the
feared consequences of falling apart and being unable to cope.
The following are clients’ reports of their experience of the dangers
(Weston, 2018). Some participants described how the experience of emotion
earlier in life was dangerous because it rendered them vulnerable to harsh
consequences: “I wasn’t allowed to cry, so, obviously, emotion must be a bad
thing to feel. But I also equated feeling emotion with getting beaten.” One
participant described his adolescent experience of emotion as one of being
trapped in a “black hole of despair”:

It’s terrible. It’s a feeling of your worst nightmare and a tremendous amount
of fear. You can’t control the situation, and you just want to get the hell out
of there. And it’s a very terrifying place because you feel physically sick, your
stomach gets into knots. I can feel the nausea.

Another reported, “When my mother was hitting me, I wasn’t allowed to cry,
and if I held my breath really hard, I could never cry.” One woman described
how she used to distract herself from feeling sad or bad by singing when
she was a child. She explained that, as an adult, she only likes pursuing the
issue of how she is feeling “intellectually.” Another participant described
how she avoided the danger of showing sadness in public by habitually not
paying attention to sad feelings. She explained, “Rarely do I address it even
when I’m alone . . . I don’t want to make it a pattern. I don’t want to be
like that . . . I don’t want it to become a part of something I’m gonna do
whenever I feel sad is show it.”

Vulnerability

This danger of emotions produces a sense of vulnerability to the self often

associated with awareness of the visceral experience of emotion (Weston,
2018). Clients may make explicit statements about a sense of vulnerability
associated with the emotional experience. One client, in her recall interview,
described her sense of sorrow as “vulnerability, loss. I would say something at
174  •  Changing Emotion With Emotion

the very core.” She recalled “how deep the emotion is, and how vulnerable
I feel.” Another client recalled how she felt “very vulnerable” when she was
sad. Other clients described awareness of feeling exposed, unprotected, or
at the mercy of a powerful force they might not be able to survive. Overall,
the experience of vulnerability in the context of emerging emotional experi-
ence involved a sense or a clear feeling of a threat to physical self-integrity,
to psychological self-cohesion, to existence, or all three.
Some participants recalled awareness of how they felt an extreme sense of
hurt. One man recalled how he felt a “strong, strong hurt” while recalling a
childhood incident in which he was bullied. Looking at the video recording,
he explained, “This is where I really started getting into the body. I’m getting
into the feelings of what’s happening . . . I heard all the laughter around me
in my head . . . I hurt so much.” Anger was also described in terms of aware-
ness of intense feeling. One man recalled, “I’m aware of having those angry
feelings. . . . It’s high intensity.” Some also recalled extreme feelings of fear.
One woman described a “sense of fear or threat” that was “slightly less than
panic.” She explained, “It feels very frightening” Another woman recalled,
“The feeling I had there was a total feeling of fear.” The preceding examples
demonstrate that it is an awareness of the intensity of feeling emotion that
is so threatening and produces the sense of vulnerability.
Vulnerable feelings are threatening partly because they are experienced
as happening to us. They are experienced as rising up in our bodies. One
person, for example, reported, “There I was, feeling it in my chest coming up
to my brain.” Anger was described in terms of the qualities of a powerful and
aggressive force in motion. One participant described how an “unknown
sense of it” was “coming up in my face.” There was a sense of the emotion
rising up. One woman recalled awareness of hurt and how she “felt it
coming up” from her “gut” to her throat, and she was “ready to sob [her] heart
out.” Another woman explained that when she was emotionally “upset,”
she “sort of feels a wave of that coming on. It kind of rushes up.” And one
woman recalled awareness of the increasing intensity of the emotional pain
of aloneness: “It was so explosive. I remember that feeling of it coming . . .
this feeling that was growing in me.”
The sense of an all-encompassing vulnerability in the emotional self
seems pivotal in the process of SIE because it sets the stage for the next
phase of opposition to emotion. So, as clients allow the experience of, or
expression of, the emotion, a sense of vulnerability to harm emerges explicitly
or implicitly. This sense of self as unsafe in the face of emotion promotes
opposition to allowing the feeling, expressing it, or both. The opposition
includes secondary reactive emotions and behaviors that serve to interrupt
the initial emotional experience.
 Blocks to Emotion  •  175

Intensity of feeling across a wide range of emotional experience is the

visceral experience that is associated with a vulnerable sense of self. Some
people’s descriptions also included the quality of a surfacing or fast-moving
sensation that rushed upward in the body. It is this experience of the self as
emotionally vulnerable to dangerous emotions that leads people to protect
themselves. In the context of an experience of self as emotionally vulnerable,
participants described an explicit or implicit need for self-protection that was
met by engagement in three main processes: addressing reactive emotions,
controlling emotional vulnerability, and avoiding emotional vulnerability
(Weston, 2018). The next two sections discuss these three processes.

Reactive Emotions
Secondary reactive emotions, such as fear, serve to protect against the dangers
and sense of threat posed by continuing the initial experience of emotion.
In some cases, the client is aware of this function. As one client explained,
she was aware in the session that her reactive anger protected against her
sadness, and she thought to herself, “This is the protector.” Often, however,
there is a more automatic quality to the onset of reactive emotion. Reactive
emotions interfere with experiencing the initial emotion as shown in the
excerpts that follow.
In this excerpt from Weston (2018), a 28-year-old, African American,
female client presents with anxiety and depression as well as unresolved
trauma:

CLIENT:  It hurts too much. I’m afraid if I go there, I may end up hurting
myself physically.

THERAPIST:  Afraid that somehow if you stay with the hurt . . .

CLIENT:  If I stay with that, physically, I will hurt myself.

In the next example from Weston (2018), another client, a 47-year-old,

European man with work-related interpersonal difficulties, is afraid of and
embarrassed about his anger:

THERAPIST:  You don’t want to express that rage in here.

CLIENT:  No. I think I’m really afraid of it.

THERAPIST:  What’ll happen if you express it?

CLIENT:  I don’t know. Well, oh! I do. I’ll be embarrassed, or I’ll lose
control. . . . Even small angers . . . I don’t feel safe when the
feelings of anger start coming up.
176  •  Changing Emotion With Emotion

In the following excerpt from Weston (2018), a 32-year-old, Caucasian,

female client who suffers from social anxiety describes her fear of allowing
crying because her therapist might judge her:

THERAPIST:  What are you feeling right now?

CLIENT:  (Sniffs) Well, looking at your face, you’re sympathetic, and

you’re encouraging me to let go, and I feel like I’m going to
lose it (cries).
THERAPIST:  Okay, and you’re scared?

CLIENT:  (Blows nose) Yeah. Scared, and I think you’ll think less of me. . . .
I’m almost afraid to look at you [therapist] because it’s going
to bring it (cries) on again.
The four main fears that clients appear to feel are the fear of losing
control, fear of expression of emotion, fear of the unknown, and fear of
dying (Weston, 2018). In the Weston study, participants recalled the visceral
qualities of an extremely intense, deep, or painful (or all three) feeling and
then a sense or feeling of fear that, in some cases, also included catastrophic
beliefs. Participants described specific fears such as losing their sanity, losing
control of an explosive force or strong impulse, or ending up trapped in a
“black hole.” In some instances, participants described a fear of losing their
mind in the face of deep, intense emotion. Some participants described
how fear involved either a visceral sense or “underlying feeling,” whereas
for others, reactive fear involved beliefs and thoughts about the catastrophic
consequences of allowing emotion to flow unabated.
In expressing her fear of emotion, one woman described her awareness
of deep, intense anger in her “belly” followed by a fear that it would be
unleashed in an explosion at the expense of her sanity. Another woman
described a nervous reaction to a “really sad” feeling in her body. She recalled
feeling “really anxious” in her stomach and that she had a “big lump” in
her throat. One man recalled that when he felt anger “coming on,” he felt
“threatened, a lot of apprehension, and a lot of anxiety” in his “solar plexus.”
A third participant described awareness of reactive fear when she focused on
inchoate emotional experience. She reported, “It feels frightening . . . I feel
that kind of fear or threat.”
Some more verbatim accounts of reports of the fear of emotion captured
the intensity of the fear:
It’s so deep, so like a monster. It’s scary . . . I felt it several times. What’s
the use of going on with this and then the fear that “Oh my God, it’s gonna
explode right here in this room, and they’re going to have to take me away in
a white jacket.”
 Blocks to Emotion  •  177

Another participant said,

I’m scared to let it come. . . . I’m really scared to do that. . . . I felt scared right
there. . . . My biggest fear is that if I let all my emotion, I’ll become catatonic.
I won’t be able to face all that is in there. It’ll be just too overwhelming for me.

For other participants, fear was a reaction to the unknown qualities,

meaning, or course of intense and overwhelming emotional experience, or
all of these—essentially a fear of the unknown. One man reported,
It’s an unknown thing that I’m having a hard time dealing with. What is it?
Can’t define it. . . . And for me, it’s sort of a scary thing because I want to know
what it is. This fear, it makes me, yeah, it scares me. I don’t know what “it” is,
so how can I deal with it? “It” is unknown. . . . How can I deal with it if I don’t
know what it is, yet it keeps coming up in my face.

For other participants, existential fear was central. There was a fear of
dying. Here, participants recalled a wordless, visceral sense that should emo-
tional experience be allowed or expressed, they could die. Fear was rooted in
a profound sense of aloneness or abandonment as they grappled with seem-
ingly life-threatening emotional experience. One woman viewed a segment of
the therapy video recording in which she had told the therapist, “I’m fright-
ened” and recalled that she was experiencing a feeling of “preverbal fear”
in response to awareness of a wordless “wave” of “really deep . . . really sad
feeling.” She explained that she had a sense that she could die. She likened
her experience to the fear she has felt when she senses that she is going to
have a seizure, a symptom of her potentially life-threatening seizure disorder,
and no one is going to help her manage it. Another participant described her
reactive fear as a strong sense that allowing an unsafe painful, overwhelming
feeling of aloneness, and expressing it in tears, was “dangerous.” She likened
the experience to an old familiar “feeling of dying.”
Some participants described only one type of fear, whereas others
described more than one type. For example, one man recalled an initial
reaction of fear of losing control that followed awareness of the feeling of
intense, deep, and painful anger. At a later point, he was afraid to express
anger by raising his voice because of its unpredictable, unknown course.

Controlling and Avoidant Behaviors

At this point, when the self feels vulnerable and has possibly reacted with a
secondary feeling, the process of interruption unfolds more actively. Clients’
needs for self-protection now lead to controlling or avoidant behavior
(Weston, 2018). Whereas earlier in the process there was a sense of a
struggle between two opposing parts of self (allow/express emotion vs.
do not allow/express), now the force opposing experience is dominant, and
178  •  Changing Emotion With Emotion

clients engage in behaviors to inhibit emotion by either actively avoiding

their emotional experience or trying to control it. Avoidance is characterized
by flight or escape behaviors that serve to move away and disengage from
the emotion, whereas acts of self-control involve moving toward emotional
experience with the intention of controlling it (Weston, 2018).
Avoidance may take the form of an explicit expression of a general desire to
avoid internal experience as well as specific desires to hide or flee. Avoidant
behavior takes a variety of forms, including an urge to flee the session or
hide, joking, laughter, worry, distraction or dissociation, disconnection from
the perception of emotion, a pushing away of emotional experience, and
expressions of hopelessness or helplessness.
Behaviors of physical control include constricting muscles, posture (e.g.,
hunches over, folds arms), swallowing, breath control (e.g., holds, sighs),
or silence that serves to contain or suppress the visceral experience or
expression of emotion. Acts of cognitive control include invalidation of
emotion and self-criticism (e.g., attacks, questions), as well as negative beliefs
or prohibitions about emotion (e.g., hopelessness, negative consequences
to self, relationships, or both), all of which serve to suppress emotional
experience.
Clients thus consciously and actively engage in behaviors that inhibit
the feeling or expression of an initial emotional experience. The following
(Weston, 2018) is an example of a 45-year-old Middle Eastern woman in
a session who “sucks the emotion in,” which is accompanied by nonverbal
behaviors that serve to oppose continuation of an initial feeling, expression
of the emotion (e.g., physical constriction, sigh, body posture, shaking of
head), or both:

CLIENT:  He abandoned me (sighs), but I can’t tell him that I’m angry.
I can feel my—I’m sucking it all in . . . (slumps over).

THERAPIST:  What does it feel like as you suck it all in?

CLIENT:  Ordinary. I do it all the time . . . (physically constricts her jaw,

shakes her head).

THERAPIST:  What else?

CLIENT:  Ooh! I can feel it’s . . . tingling at the edge of every muscle trying
to get out.

In his interview (Weston, 2018), one man reported that despite his desire
to feel and express emotion, “I completely close off. I have a long history
of blocking my emotional experience with various hurdles . . . barriers . . .
 Blocks to Emotion  •  179

doors.” Clients control through complex protective meanings as shown in

the following statement by another client:
I’m stopping by saying that if I cry about it, even though they aren’t here, I will
be somehow or another allowing them to have some kind of gratification out
of my pain. And by not letting the pain out, I keep them from influencing and
having some kind of control over my life.

Another client expressed awareness that she was “choking down a lot of
anger.” Another gave voice to a choking feeling that controlled the expression
of anger: “I’m the choker, and I’m holding my breath so I can’t speak.”
The following example from Weston’s (2018) study illustrates a process
in which a depressed, 43-year-old Chinese American, female client, an engi-
neer who lost her father when she was 12, is working on how she interrupts
sadness in the session. The therapist has suggested the use of a two-chair
enactment (explained briefly later and in more depth in Chapter 8). In this
segment, the therapist guides the client to enact the suppression of sadness.
Through this enactment, the client becomes aware of how she “squelched”
sadness and that it was related to fear of embarrassment of showing her
feelings to others.

CLIENT:  I was sad.

THERAPIST:  You were sad just before you cut off?

CLIENT:  Just before, yeah . . . I feel nothing until it just escapes, what-
ever it is that’s being squelched, and then I just feel really,
really bad until I pack it down again.

At this point, the therapist guides her into the enactment of squelching
sadness by packing down her cleansing tissues into a box to bring the inter-
ruptive process into an active form of “doing”:

THERAPIST:  Let’s see if we can just pack it in. Can you try? . . . Just pack
it in the way you do. You’re the squelcher. Just pack in those
feelings.

CLIENT:  (Folds the tissue. Can hear sounds of the client “packing” the
tissue.)

THERAPIST:  What’s happening to you now?

CLIENT:  I think I need to keep things all tidy and in their place. I don’t
want to make a mess or something.

THERAPIST:  Mm-hmm. So, what are you doing with the Kleenex now? You’re
packing it in.
180  •  Changing Emotion With Emotion

CLIENT:  (Laughs) I guess I’m almost trying to pack the Kleenex into the
shape of a rectangle.

THERAPIST:  Do you have the sense as you’re doing that of being the
squelcher, the packer-in, to pack in these feelings?

CLIENT:  It kind of feels like trying to keep everything together to prevent

it from spilling out.

THERAPIST:  I see. But if you weren’t there doing that, what might happen?

CLIENT:  Maybe embarrass myself. Maybe let on to other people that

I’m unhappy or that other things that they do bother me.

As the sense of vulnerability in the self is regulated, the behaviors the

client engages in to avoid or control the underlying emotion become the
focus of therapy. The process moves to engagement with how the person
interrupts the emotion and, if possible, helps develop a sense of being an
agent in the interruptive process and of the possibility of not interrupting.
Then, processing of the initial emotional experience can take place. If a client
has had an experience of “surviving” emotion at a visceral level, this new
experience of safety will serve to circumvent the activation of protective
secondary reactive emotion and related avoidant and controlling actions,
and will promote taking the risk of working on fully allowing and processing
emotional experience.

WORKING WITH SELF-INTERRUPTION: THERAPEUTIC CAVEATS

In the case of a client’s difficulty tolerating the sudden awareness of intense,

deep, or painful (or all three) feelings, the therapist can work with the client
to stay focused on bodily based, concrete sensation rather than emotion.
Here, the therapist guides the client to describe the body feeling at a working
distance rather than going into the feeling itself. If, however, arousal is
experienced as unbearably high and threatening, the client can be instructed
to use coping self-soothing methods, such as regulated breathing, calming
imagery, and self-empathy or validation, to promote tolerance and acceptance
of this distressing emotional experience (Greenberg, 2015). The function
of instruction to self-soothe at these junctures is to help people cope with
highly overwhelming feelings and to help them calm down and cope better.
This generally involves regulating secondary reactive feelings. It also funda-
mentally involves psychoeducation to teach the client to deliberately perform
and to practice efforts to down-regulate emotion by soothing self-talk or by
 Blocks to Emotion  •  181

evoking a safe place to get a positive or calming feeling. However, it is also

important at this point to assess if self-soothing has become another means
of interruption because the ultimate goal is for the client to be able to allow
emotion with the reassuring understanding that they have the ability to step
in and out of it rather than be overwhelmed by it.

Recognizing Precursors to Vulnerability

It also is helpful for therapists to early on identify client moments of emotional

vulnerability because they are precursors to subsequent interruptions of the
dreaded experience. Recognition that the client is experiencing emotional
vulnerability thus is an essential first step toward intervening in the inter-
ruptive process to prevent it by heading it off at the pass. Therapists need to
pay close attention to how clients are handling visceral experience; there is
more going on internally than the client may be saying. One client reported
that long before the interruption became apparent, she was aware her
therapist was trying to take her to her feelings, and she was actively trying
to deflect his efforts.
In addition, there is typically a personal history to the client’s difficulty of
allowing and expressing emotion. Historical experience of emotional expe-
rience may include dangerous consequences to allowing or expressing
emotion, such as being physically abused by a caregiver, suffering verbal
attack by another, losing control (e.g., vomiting up feelings, lashing out in
anger resulting in physical or interpersonal injury), or feeling depressed.
Given the historical origins of self-interruption, it may, at some time, be
important to work on these origins. Secondary emotions serve a protective
function as they interrupt and, in some cases, override the initial feeling
and expression of emotion. For example, secondary reactive fear stops the
emotionally vulnerable client from experiencing and expressing sadness,
shame, or anger and related needs. In some instances, the feeling of reactive
sadness may calm and soothe an intense feeling of anger in the vulnerable
self, or anger may protect against sadness.

Addressing Secondary Reactive Emotions

How should the therapist address secondary reactive emotions in response to

vulnerability? Deepening the experience of secondary emotion is inadvisable
given that it interferes with the processing of adaptive emotion that is more
central to well-being (Greenberg & Paivio, 1997; Greenberg & Pascual-Leone,
2006). Instead, therapists need to recognize and validate secondary emotions
182  •  Changing Emotion With Emotion

in the moment but then bypass them by shifting the focus to underlying
feelings and needs.
Secondary reactive fear is the most common reaction to the initial emotion.
Other secondary reactive emotions include secondary reactive shame, which
arises from a feeling that allowing or expressing emotion will have negative
social consequences, or personal values will be violated. Secondary reactive
guilt thwarts the expression of emotion and the associated need. Reactive
sadness occurs in response to experience and expression of intense anger,
whereas secondary anger follows awareness of the experience of sadness and
a weakened sense of self.
Therapists need to validate secondary fear or shame by saying,
So it’s so scary [embarrassing] to acknowledge this emotion. It even feels like
it could destroy you or you’ll never get over it, but you’re saying as much as
“I am terrified and don’t want to feel it. It is there, I do feel sad [angry], and
I really did need comfort [recognition] of what was happening for me.”

It is important for therapists to validate clients’ fear of emotion and to

acknowledge its protective function and its intensity, but at the same time
not allow that fear to prevent focusing on the process of emotion awareness
and ultimately on the self-interruptive process itself. A therapist might say,
“It’s so frightening to go into this painful sadness. I understand you are afraid
of being overwhelmed by it. So, somehow you manage to step away from it to
protect yourself, but it’s still there waiting to be heard.” This is then followed
by an invitation to explore how the client steps away from their sadness.
The therapist needs to adopt a focusing stance toward the secondary
fear. The attitude is one of validating and accepting the fear. The therapist’s
response to the client’s fear of emotion might be:
It’s all right. We will just take it slowly. Don’t force yourself to go where you
don’t want to go. If you’re afraid of that feeling, keep your distance. Let’s stay
right here and see what the fear is. What does this “fear” feel like from here?
If you don’t want to go into it, don’t. But don’t back off either. Just stay right
here and see what is this feeling of not wanting to.

Or the therapist might more simply say, “Scared. Let’s just stay right here
with this ‘scared.’ What is this ‘scared’? What kind of ‘scared’ is it? What is
the whole feel of it?”
During an interpersonal process recall interview (Weston, 2018), one
woman, while watching her self-interruption in the session, was asked by the
interviewer, “How are you feeling right now?” She replied, “Overwhelmed”
and added,
A very deep sense of pain and grief. I remember stopping and crying. She
[therapist] was telling me to keep going. . . . She kept saying, “Let it go and
 Blocks to Emotion  •  183

really cry. It’s okay. Let it go.” . . . And I couldn’t remember what I was crying
about, but I remember stopping it because I had a feeling at that time if I let
this feeling go and I really cry, I will break, I will just break because I might die
because I won’t be able to stand it—the pain. . . . When I explode and all at
once, I have this sinking feeling like I’m dying or just drowning or sinking, and
I have to stop it. . . . This is dangerous.

Her sense of fear about allowing herself to keep crying served to interrupt
the initial experience of emotional pain. However, this secondary reactive
fear of intensely painful feeling was not apparent to the therapist, nor
was the client expressing it overtly. The end result here was that the client
could not “let it go” because she felt overwhelmed and unsafe in the face
of intense, deep feeling. So, she ultimately stopped feeling altogether. It is
important for therapists to not only encourage facing the emotion but also
to validate the fear of the emotion.

Seeing the Self as an Agent of the Shutting-Down Process

Intervention involves both exploring the interruptive process—the inter­

nalized messages, beliefs, fears, physiology and their impact—and accessing
the interrupted experience. Self-interruption involves a conflict between
the feeling part of the self and the part of self that prevents its expression.
One strategy for addressing self-interruption of internal experience is to
use a two-chair enactment, a technique elaborated in the next chapter but
described here briefly because this chapter offers examples of it. In the
two-chair enactment, the interrupting part of the self is often enacted to
make explicit both that it is an active process and how it is done. Clients
become aware of how they interrupt and are guided to enact the ways they
do it, whether verbally by telling themselves to shut up or to not feel; by
frightening themselves that it is too dangerous; by physically squeezing
muscles; or, metaphorically, by, say, trapping or caging themselves. This helps
them experience themselves as an agent in the process of shutting down
and then they can react to and challenge the interrupting part of the self.
Resolution involves expression of the previously blocked experience.

UNDERSTANDING THE EFFECTS OF INTERRUPTION: LIMITED

EMOTIONAL EXPERIENCE

The main effect of interruption, as the Weston (2018) study found, was the
limiting of emotional experience and awareness. The most frequent effect
was a sense of feeling depleted or drained. Many participants described
184  •  Changing Emotion With Emotion

how engagement in protective behavior(s) that served to limit emotional

experience ultimately had a negative effect because interruption of emotion
left them with an encompassing sense of depletion or that they were drained
of energy. Some recalled how physical control over intense, overwhelming,
and dangerous feeling or expression, or both, left them with an internal
sense of emptiness. One woman described how “squashing down” the angry
“monster” that she felt in her body left her feeling “kind of empty . . .
like a void . . . not a good feeling.” Some participants described how the
suppression or avoidance of angry or hurt and painful feelings left them
feeling depressed or sad. One man recalled that the effect of dissociation from
intensely painful feelings of hurt was that he felt numb and “depressed even
more. I wanted to give up.” One woman explained,
Physically, to hold back tears and such pain, it doesn’t hurt . . . and I’m not
tired after I finish, but . . . it takes a lot of strength to hold it back. It’s a lot of
effort and energy . . . to hold this back for the amount of pain that I have . . .
and I’m not tired after this.

Another client reported that, after interrupting, she felt

nothing. To be honest, I walk out of there, and I don’t remember half the things
that went on in there two seconds after I’ve left there. I get in the car and drive
off. Just a depression. Just that total depression . . . nothingness.

Some participants described how avoiding emotional experience by

dissociation from the perception or physical experience of it left them in a
disembodied or alienated self-state. As one woman recalled that after she
reacted to awareness of sadness with shame and anger, “a foggy feeling
[came] in. It’s like I don’t exist. I’m oblivious.” Another woman described the
effect of avoiding an overwhelming feeling of “distressing” inchoate emotion
by withdrawing from contact with the therapist: “Mainly, it’s a feeling of being
disconnected with her.” One man explained, “As you can see, I’m just sort of
saying what I see [inside], but I don’t feel it . . . I kept getting number and
number [increasingly numb] as we went along. Especially in the end there.”
In addition to the uncomfortable effects of protection by avoidance of
emotional experience, some participants described the physically uncomfort-
able outcome of control over it. They recalled how the physical “constriction”
of or “resistance” to feelings of sadness or anger left them feeling like their
body was squeezed in a vise and often with painful consequences. One
woman described how she felt a constriction of sadness that left her with a
sore throat Another participant described the effects of physically controlling
feared anger as
a lot of tension through my whole body . . . I’ve been noticing what I call a
tingling in my extremities, my hands, my arms, usually from my elbow down,
 Blocks to Emotion  •  185

and my leg, usually from my knee to my feet. I think the only part that is free
from it is my head somehow.

In contrast to the negative effect of protection, the positive effect of the

avoidance or control of emotional experience was feeling less vulnerable.
One woman described how she felt safe and protected following avoidance
of the dangerous sense of intense, painful, and overwhelming sadness that
also served to stop her tears:
It’s gone. There’s nothing. It’s like, all of a sudden, it’s like total peace. Like
being wrapped in cotton and totally protected. There is nothing that can
penetrate that. . . . It’s relief. I’m okay now. My whole body is different now.

Other participants recalled how various means of control over emotional

experience left them with a strengthened sense self that was more “in control.”
One woman explained how cognitive control over her emotional experi-
ence of profound sorrow involved a shift from a sense of self as vulnerable,
“a victim,” to more of an active agent “somewhat in control of my emotions.”
Another participant described how he controlled the intense and over-
whelming feeling of emotion that evoked reactive fear by sighing at various
points. In turn, he recalled, “The tightness is gone. The flush is gone from the
face. All the physical stuff is dissipated. [I am] uncomfortable but not emo-
tionally overwrought. The emotions are not in control.” He also explained
that although protection against vulnerability brought relief, he had come
to realize the high long-term cost to his sense of well-being because he
remained depressed. Sometimes the sense of protection that was gained by
control over emotion, however, was transient. One woman described how
reactive anger about sadness left her feeling “in total control.” However, the
feeling of control was fleeting, and she was left in a state of “hopelessness”
that she described as “resignation. It doesn’t really matter. Nothing matters.”
Overall, the effect of self-protection was to limit awareness of threatening
emotion. Participants in the Weston (2018) study described how emotional
experience was diminished, controlled, avoided, or stopped altogether.
More­over, many participants described how, subsequent to various means
of protection that served to limit emotional awareness, they were left with
an overall negative sense of self characterized by numbness, detachment,
alienation, sadness, confusion, physical tension or pain, emptiness, depres-
sion, uncertainty, or an overall bad feeling. In contrast, a smaller number of
participants recalled a more positive effect whereby they felt protected and
less vulnerable. This shift to a less vulnerable state was characterized by a
sense of relief and a feeling that they were now “in control” of emotion as
opposed to an earlier experience of self as emotionally vulnerable. Some
reported that the positive sense of protection was transient.
186  •  Changing Emotion With Emotion

CONCLUSION

From my clinical research on emotion work, I have learned that the client’s
experience of protecting against threatening emotion in a therapy session is
nested within a historical context of the difficulty of allowing or expressing
emotion, or doing both. Phenomenological findings show that the process
of protection begins with awareness of feeling that is initiated in the body
by specific emotion triggers, and a subjective sense of vulnerability soon
follows. The profound sense of self as vulnerable is the catalyst for a related
implicit or explicit need for protection.
In this chapter, I outlined the steps by which self-protection is provided.
In the majority of cases, the activation of an emotion leads to awareness
of an emotionally vulnerable sense of self that is interrupted by secondary
reactive emotions and behaviors of avoidance, or control, or both, that serve
to stop or shut down the initial emotional experience. These reactive emotions
and behaviors serve to protect against the experience of an emotionally
vulnerable sense of self. Reactive emotions include fear, shame, anger, guilt,
or sadness. Four specific classes of fear are fear of losing control, fear of
expression of emotion, fear of the unknown, and fear of dying.
Awareness of vulnerability is also followed by avoidant or controlling
behavior that serves to protect against the experience, the expression of
emotion, or both. The effect of self-protection is either negative for those who
are left with a “bad” or “drained” sense of self or, to a lesser extent, positive
for others who feel less vulnerable and more in control. Overall, the process
of providing protection leaves clients with limited emotional awareness.
In the next chapter, I explore the process of reversing emotional suppres-
sion and how this contributes to a positive therapeutic outcome. As alluded
to in the discussion and examples shared thus far, it begins with helping
clients be aware of their aversion to emotion in the moment.
8 UNBLOCKING EMOTION

A recent study showed that pretreatment suppression of emotion was the

strongest predictor of poor therapeutic outcomes (Scherer et al., 2017),
a finding that supports the importance of unblocking emotion suppression.
In this chapter, and continuing the line of study on the experience of block-
ing of emotion reported in Chapter 7, one of my doctoral students and
I engaged in a task analysis of the self-interruption of emotion (Vrana, 2020).
We looked at the undoing of interruption in a sample of nine clients who
started with markers of self-interruption of emotion and resolved their inter-
ruption. We then compared them with nine clients who started with markers
of self-interruption but did not resolve to see what differed in the in-session
performance between the two samples. In all cases, therapists attempted to
guide the clients to approach a dreaded emotion.
Task analysis is a two-phase method of intensive analysis of therapy
transcripts for identifying change processes in psychotherapy (Greenberg,
2007). The first phase is discovery oriented. To develop an initial model of
task resolution, an intensive qualitative analysis is done of a relatively small
number of pure gold examples (usually three) of a change process. Cases
are added progressively to help refine the model until no new information is

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187
188  •  Changing Emotion With Emotion

added and saturation is achieved. The second phase of a task analysis involves
quantitative validation-oriented studies on a large number of participants to
statistically validate the model (Greenberg, 2007). In this chapter, I discuss
the model built in the discovery-oriented phase. To my knowledge, this is
the first study in the literature of the unblocking of emotion in psychotherapy
and represents the first step in a research program.
The method involves a number of steps:

Step 1. Specify the marker.

Step 2. Explicate the researcher’s cognitive map. The theoretical and clinical
assumptions are spelled out to specify a framework because no observa-
tions are theory free.

Step 3. Specify the task environment. The therapist’s intervention framework

is defined.

Step 4. Construct a rational model. The researcher’s rational understanding

of the resolution performance—informed by clinical experience, case
observation, and a review of the literature on the process under study—is
spelled out. This acts as a type of hypothetical framework to be modified
by what is discovered.

Step 5. Conduct an empirical analysis. Observed client affective/cognitive/

behavioral processes in task resolvers and nonresolvers are analyzed, and
a model of the identified steps to resolution is constructed.

Step 6. Synthesize a rational-empirical model. After the first empirical models

have been established, the rational and empirical models are compared.
The rational models are modified or elaborated based on observations
made during the construction of the empirical models.

Step 7. Conduct a preliminary validation of the model. New sets of clients with
the same marker are studied to further validate the rational-empirical
model until no new discoveries emerge and saturation is achieved.

Step 8. Explain the model: Theoretical analysis. In this last step, the researcher
moves from a descriptive level to a causal level by considering the psycho-
logical processes that allow the client to progress from one component to
another to complete the tasks.

Further step: The validation phase involves constructing measures to evaluate

the degree to which components of the model of resolution are predictive
of in-session resolution and, ultimately, final therapy outcome.
 Unblocking Emotion  •  189

OVERCOMING SELF-INTERRUPTION OF EMOTION:

THE COMPONENTS

In the Vrana (2020) study, the factors that appeared most important in
unblocking the interruption were (a) clients’ experience of the negative
effects resulting from their self-protective acts of interrupting combined with
(b) support and encouragement by the therapist to allow their emotions.
Together, these factors motivated clients to cross the bridge, face their fears
of disintegration, and allow their emotion. It seemed that when clients came
to experience that the harm of the interruptions outweighed the benefit,
they were ready to face the difficult emotion.
Vrana (2020) identified the following components as important in over­
coming interruption of emotion: First, clients had to become aware of their
own aversion to emotion in the moment—that they had experienced a
conflict between having an emotion and blocking it. They then needed to
become aware of how they interrupt their emotion and the purpose of the
interruption. When clients experienced that they were agents of the inter-
ruption and that they were doing it to themselves, it helped them realize
the negative impact of the interruption by feeling the pain it caused. This
realization plus a reduction of fear of emotion helped them develop a desire to,
and the motivation to, allow the emotion. This desire to allow was aided by
the provision of support and encouragement by therapists, which reduced
the threat of allowing the emotion. The clients then allowed the emotion
and integrated opposing sides. They expressed and stayed with the motion,
processing it in productive ways either in the session or sometimes outside
the session in situations in which they had previously blocked the expres-
sion. Many clients along the way revisited a memory that triggered the
emotion that had been interrupted—either a memory of recent interaction
in the context of a current relationship or a memory from the past with a
significant other.
Therapists’ support and encouragement helped clients progress through the
later stages of the model. In these stages, therapists worked to reduce their
clients’ fears of their emotions in a number of ways. They were seen as
validating their clients’ emotional experience and associated needs. They
related to their clients with compassion and encouraged them to face their
feared emotional experience in the same way. Moreover, therapists conveyed
support by reassuring their clients that they were safe, that they were not
alone, and that the therapist was there to guide and help them through the
process of allowing their emotions. In addition, therapists were observed
to explicitly encourage their clients to allow and express the emotion. They
190  •  Changing Emotion With Emotion

directed their clients’ attention toward their internal experience, empha-

sized its importance, and encouraged them to stay with it and symbolize it.
Therapists also used evocative empathy to heighten clients’ experience of
the feared emotion.
A model of the resolution process is shown in Figure 8.1. The components
in the rational-empirical model that were found to facilitate the process
of resolution are represented by the series of light gray boxes in the middle
of the flowchart. In contrast, the components represented by the boxes
with dotted lines—secondary emotions and reluctance to allow the emotion—
signify the states in which unresolved clients tended to become stuck. The
component represented by the darker gray box at the top right highlights
the importance of the therapists’ support and encouragement to clients
as they progress through later stages in the model. Later sections in this
chapter describe the components of resolution in more detail.
The clients’ acknowledgment of the negative impact of the interruption—
an acknowledgment that resulted from their experience of the emotional cost
of interrupting—was important in developing the motivation to overcome
the blocking. In addition, once clients saw the cost and the suffering of
constriction, those who overcame the blocks felt compassion for, and accep-
tance of, the constricted emotional self. All these factors combined led to the
development of the motivation in the client to want to allow the previously
blocked emotion.
Once clients reached a state of wanting to allow their emotions, they
were guided to attend to and symbolize their blocked bodily felt emotional
experience and to symbolize, in words, the emotional impact of past injury,
trauma, or neglect. Direct attention to internal or bodily experience was
important at this point because of possible reentry into past memory/scene
of emotional trauma. Clients expressed the previously blocked emotions,
and resolution involved reduction of opposition to allowing emotion and
processing emotion in a productive way by being able to stay with the expe-
rience of the previously blocked emotion (e.g., pain/hurt/sadness, anger)
rather than deflect from it. At times, there might have been a gradual, small,
step-by-step approach toward experiencing and expressing the previously
blocked emotion to keep it in the clients’ zone of tolerance.
Therapists reduced the barrier to accessing emotion by having clients
attend to and express their fear of experiencing or expressing the blocked
emotion, and by reducing clients’ sense of vulnerability to the emotion. These
two processes were achieved mostly by the therapists’ provision of safety
through empathy and validation, and by encouraging the clients that they
could do it and would not be so overwhelmed that they would not survive
having the feeling. Relational support was an important ingredient of
FIGURE 8.1.  Resolution of Self-Interruption/Aversion to Emotion

Therapist support and

encouragement to allow
emotion

Reduction of
fear of the
emotion
Marker of Awareness of Awareness of Realization of Resolution:
self- the how of the purpose of the negative
interruption/ interrupting interruption impact of Allow the
aversion to interruption emotion/
emotion integrate
Desire to opposing sides
allow the

Unblocking Emotion  •  191

emotion

Secondary Reluctance to
emotions allow the
emotion
192  •  Changing Emotion With Emotion

reducing fear and vulnerability. Therapists provided this support by helping

clients have a sense of control (e.g., “You can come out of this process at any
time”) and by engendering confidence in clients in their ability to deal with
the emotions (e.g., “You will survive”). As this study (Vrana, 2020) showed,
therapists’ support and encouragement are important ingredients in helping
people face their fear of emotion and overcome their blocking of it.

Awareness of the How of Interrupting

Therapists need to help clients become aware of, or enact, how their inter-
rupter holds them back and facilitate clients’ experience that it is they them-
selves who are agents in their self-interruptive process. Clients interrupt or
escape from emotions by intentionally distracting themselves, deflecting,
becoming numb, or losing contact with the emotion. In addition, they physi-
cally (muscularly or physiologically) control, restrict, or constrict the emotion
in various ways. These ways include shutting the emotion down, holding it
back, squeezing it, sucking it back, or making it smaller.
Therapists need to bring these processes to awareness; they also need to
bring to clients awareness of their different means of cognitive control in
the form of self-injunctions against experiencing or expressing the emotion.
Self-injunctions that produce guilt/shame, anxiety, or hopelessness and
clients’ negative evaluations, expectations, or beliefs about allowing the
emotion need to be brought to awareness. Additional types of injunctions
are those that induce anxiety or hopelessness by either scaring the self about
the potential dangers of allowing the emotion or warning of the futility of
allowing the emotion. Furthermore, therapists need to recognize that clients
can stop or prevent the blocked emotion by experiencing and expressing
secondary emotions that are less threatening than the primary emotion. For
instance, a client may express secondary anger toward another person as
a way of avoiding the vulnerability inherent in expressing their primary
sadness and hurt.
Examples from various transcripts illustrate bringing awareness to this
self-interruptive process. In the first example, during a two-chair enactment
of an interruption, the client enacts how she physically holds herself back
(physical control) from experiencing her anger. The enactment brings to
awareness how she does this interrupting:

THERAPIST:  Mm-hmm, and what do you do to her? Do you squish her

down or what?

CLIENT [as interrupter]:  Yeah, that’s exactly what I do—squish her (Thera-

pist: Mm-hmm.) into the wood.
 Unblocking Emotion  •  193

THERAPIST:  With your hands like this (presses hands together)?

CLIENT [as interrupter]:   No, with my feet.

THERAPIST:  With your feet. Can you do it?

CLIENT [as interrupter]:  (Noises of feet pushing down on ground) Push down,

down, down.

Another client describes how she distracts herself and takes a deep
breath [physical control] to stop herself from attending to her sadness. Her
self-injunctions [cognitive control] against allowing the sadness leave her
feeling hopeless:

THERAPIST:  Yeah, but since it’s there and it kind of always—it won’t go—
I mean, it won’t go away, how do you do that? I want you to
do that here: Push it away.

CLIENT [as interrupter]:  Well, I just tell myself to think of something else

and take a deep breath, and (Therapist: Mm-hmm.) then it’s
just gone.

THERAPIST:  Tell her—tell her what she should do.

CLIENT [as interrupter]:  Well, I—I guess you don’t—don’t—don’t think

about it. (Therapist: Mm-hmm.) It makes you feel bad and, um,
you won’t be able to do anything. Might as well just, and not
really . . . you can’t really do anything about it, can’t change
anything, so . . .

THERAPIST:  Mm-hmm . . . So don’t feel—don’t go into it.

CLIENT [as interrupter]:  Right.

Awareness of the Purpose of Interruption: Protection Against Feared Consequences

For this component, therapists help clients become aware of and articulate
their motivation for interrupting the emotion. Clients need to be helped
to realize that the interruption serves to protect them against feared con-
sequences of fully experiencing or expressing the emotion. These feared
consequences are generally either (a) fear of damage to identity, attach-
ment, or both—they fear being embarrassed, humiliated, criticized, judged,
or rejected by others for expressing the emotion or an associated need—or
(b) fear of being overwhelmed by the emotion—they fear that the emotion
will be too intense or unending.
194  •  Changing Emotion With Emotion

It is important for a therapist’s clients to explore the origins of their

feared consequences. These origins often involve clients’ previous experi-
ences with the emotion, including how others in their lives have expressed
the emotion in question (e.g., parents who never argued, a caregiver with
explosive anger), how others responded to them for expressing the emotion
(e.g., punishment, rejection, invalidation), or the internal and external
resources they had at the time to help cope with the emotion (e.g., a child
left to cope with an overwhelming emotion without adequate support from
caregivers). Historical origins also often reflect socially or culturally prescribed
rules and expectations about emotional expression (e.g., “Children should
always respect and obey their parents”).
The client in the following excerpt interrupts her anger during inter­
actions with her husband because she is afraid that he will abandon her if
she expresses herself (i.e., damage to attachment):

THERAPIST:  Wh—what are you afraid? What do you think is going (Client
sniffs.)—going to happen? Can you tell me?

CLIENT:  (Sighs) I’m afraid that if I give him an ultimatum, it might end
up being a separation, and, at this point, I feel like I’ve put in
so much, you know, the last 20 years (Therapist: Um-hum. Client
sniffs.), that maybe what I’m complaining about is too trivial.
(Therapist: Um-hum, um-hum.)

Another client reports fear of losing control and harming his father if he
were to express his anger toward him:

THERAPIST:  What—what do you say—what would happen to you if you

express the anger? What’s your feeling? [inaudible]

CLIENT:  That I’m doing wrong, that’s not the right thing to do. . . . You
don’t put your father down, you don’t—and because I don’t
want to hurt him . . . because when I lash out, I go for the
jugular verbally.

Realization of the Negative Impact of Interruption

Therapists need to help clients realize that their self-interruptions have a

negative impact on them. Negative impacts fall into one of two categories:
(a) physical discomfort and painful emotions experienced by clients during
the session or (b) long-term consequences of continued self-interruption.
Clients need to become aware of how interruption leaves them feeling
tired, resigned, depleted, trapped, tense, squeezed, or experiencing physical
 Unblocking Emotion  •  195

pain, such as a headache. The negative long-term consequences of continued

interruption include maintaining the status quo of feeling depressed and
stuck, being unable to move forward from their unfinished business, or
remaining unable to form close relationships or have their needs met by
others. Although some clients can self-generate these negative long-term
consequences, many clients come to this with explication by their therapists.
In the next excerpt, the therapist explains how the client’s interruption of
her sadness leaves her feeling resigned and unhappy. The client’s responses
indicate that she has internalized this understanding:

THERAPIST:  But it’s also important to be kind to yourself, you know, not just
to sort of push that sadness away, ’cause then I think it leaves you
feeling kind of resigned, you know, not as happy as you can be.

CLIENT:  Yeah, that makes sense.

THERAPIST:  One way is to try to just put [the sadness] aside and say it’s—
you know, I don’t wanna pay attention to it, but somehow it
keeps knocking on your door.

CLIENT:  Yes, it does.

In the following excerpt during a two-chair intervention, another client

describes the physical discomfort she experiences as the result of being con-
trolled and constricted by her interrupter:

THERAPIST: Tell her what it does to you.

CLIENT [Self, speaking to interrupter]:   When you block me, it feels impossi-
ble. . . . It feels painful—my head and my heart. It’s almost like
I can feel. Imagine walls coming up around me.

Reduction of Fear of Emotion

Clients’ fears associated with allowing the emotion are reduced as they inter-
nalize the validity of their feelings and needs as well as experience a sense
of safety in relation to allowing the emotion. They come to see that their
emotions are justified and understandable, or they accept these messages
about their emotions from their therapists. Therapists need to help clients
view themselves as being entitled to their emotions and associated needs
as well as to believe that they can cope with allowing the emotion.
This excerpt illustrates the client’s validation of his sadness:

CLIENT:  Well, I don’t know. Right now, I’m just telling myself that it’s
okay to be sad.
196  •  Changing Emotion With Emotion

THERAPIST:  Yeah, mm-hmm. It’s okay to be sad. You deserve, I mean,

you’re entitled to feel that way given what happened to you.
(Client: Yeah.)

The following client was able to internalize support from her therapist,
which increased her sense of safety:

THERAPIST:  Do you want to sort of stay with the anger and see? What
comes from there and . . .? (Client: Yeah.) But if there’s any
other stuff that comes up, I’ll try to guide you through it, and
you can just tell me if it’s not comfortable.

CLIENT:  Yeah, I think so. I’ll try.

Desire to Allow the Emotion

In this step, clients indicate that they want to allow the emotion or that
they make attempts to approach or stay with the emotion. In the following
excerpt, the client expresses excitement about getting to know the inter-
rupted emotion that he has kept hidden. He refers to the season of spring
as a metaphor to describe a feeling of hope for positive change and growth:

CLIENT:  You know, I don’t know if it’s the fog in my head. You know,
all week, I’ve been feeling like, uh, there’s something inside me,
a feeling that’s waiting to come out, and sometimes I get so
excited, I can hardly even breathe (sighs).

THERAPIST:  So, it’s like something that’s waiting to be born.

CLIENT:  Mm, yeah, probably. I, uh, like someone I’m looking forward to
meeting, too, I would think. Sometimes it’s hard to know why
all the—why all the—yeah, anytime, it’s funny all the things
are happening. It’s—it’s almost like spring—it’s almost like the
garden’s running a bloom, all sorts of little things that seem to
want to grow up all over the place.

UNDERSTANDING THE COMPONENTS OF UNRESOLVED

SELF-INTERRUPTION OF EMOTION

In the unresolved group in the Vrana (2020) study, the clients did not
experience a realization of the negative impact of interruption, the desire
to allow the emotion, or the reduction of fear of the emotion. Unresolved
 Unblocking Emotion  •  197

clients were especially observed to be prone to relying on cognitive control

to interrupt their emotions by inducing anxiety and fear of the potential
dangers of allowing the emotion or in the form of criticism and invalidation.
As a result, they often became stuck in unproductive secondary emotions
of shame or guilt about having the emotion. Cognitive control via hopeless
beliefs and expectations about allowing the emotion was more prominent.
Despite therapists’ efforts to have them see the negative impact of the
interruption, clients in the unresolved group tended to view the protective
benefits of their interruption as greater than the negative impact of their
interruption. They were more likely to minimize, rationalize, or dismiss the
extent of the negative impact of interrupting their emotions compared with
the resolved group. This tendency, along with their aforementioned lack of
agency, further deterred them from developing a desire to allow the emotion.
Unresolved clients, therefore, maintained the view that the potential
negative consequences of allowing the emotion outweighed the negative
consequences of interrupting the emotion as well as the potential positive
benefits of allowing the emotion. In these cases, more therapeutic work is
needed to both validate their fear as a way of supporting them but con-
tinue to work on how they block their emotions to help them realize the
negative impact and cost of this self-protective strategy.

INTERVENING USING TWO-CHAIR ENACTMENTS

A particularly helpful intervention for working with blocks to emotion

is one in which therapists have clients enact the process of interruption
in a dialogue between two sides of the personality (Elliott et al., 2004;
Greenberg, Rice, & Elliott, 1993). In this two-chair enactment, clients are
encouraged to act out how they stop themselves from feeling, verbalize
the particular injunctions used, and exaggerate the muscular constrictions
involved in the interruption (Greenberg, Rice, & Elliott, 1993; Greenberg &
Watson, 2006). Eventually, this intervention provokes a response from the
suppressed aspect—often a rebellion against the suppression—and the inter-
rupted self challenges the injunctions by restraining thoughts or muscular
blocks of the interrupter. Then, the suppressed emotion bursts through the
constrictions, thus undoing the block.
This intervention is meant to turn the passive, automatic process of
interruption into an active one and to heighten clients’ awareness of how
they interrupt themselves. The aim is to help undo these interruptive pro-
cesses so that clients can access and process emotions.
198  •  Changing Emotion With Emotion

Markers
Interruptions often appear during a client’s narrative while they are address-
ing vulnerable experiences from the past or in narratives about the fear of
feeling certain emotions. Self-interruption is essentially giving oneself this
instruction: “Don’t feel. Don’t need.” Self-interruptive splits typically have
a nonverbal, bodily aspect—and are sometimes purely nonverbal, such as
a headache or tightness in the chest—and may be completely automatic.
Nonverbal markers of interruption are abrupt changes or even the disappear­
ance of the emotion that was about to emerge. These markers involve changes
in respiratory rhythm, facial expression, and body tension that are accom-
panied by shifts in emotional processing. All are signs of self-interruption
and may arise in conjunction with other nonverbal markers, such as body
posture that reflects giving up; shy and weak voices; and, in extreme cases,
dissociation.
Interruption involves complex physiological, muscular, emotional, and
cognitive processes that inhibit experience and expression. Resignation and
hopelessness experienced by some clients in the face of their core emotional
needs not being met is another important marker of interruption. Resigna-
tion and deadness often are the result of squashing and suppressing anger or
sadness. “What’s the use” frequently captures this feeling. “I don’t care” often
is an expression of cynical resignation. People express resignation through
their bodies by sighing or shrugging their shoulders and then saying things
like, “What’s the point? Why even bother?”

Intervention
Two-chair enactment is an unusual task involving talking to oneself in an
empty chair; therefore, the therapist needs to provide a lot of structure. To
begin this intervention, the therapist encourages the client to enact how a
part of the self is stopping, blocking, interrupting, or constricting the expres-
sion of the emotion. The therapist invites the client to begin the dialogue in
the chair:

THERAPIST:  So, let’s set up an experiment to explore how this blocking

takes place. In this chair in front of you, you will be the side
that does stop you from expressing your emotion. The chair
where you are sitting now will be your feeling that is blocked.
Can you come and sit in this chair and be the part of you that
stops you from getting angry? Be the part that stops you.
How does this part not let you feel angry? What do you do to
yourself?
 Unblocking Emotion  •  199

Providing some form of psychoeducation before entering the interven-

tion is important, and it’s best to give it at the moment the client blocks,
thus promoting experiential learning. By doing this psychoeducation when
the block occurs, the therapist promotes an experiential as opposed to a
conceptual understanding of how the block is affecting clients. Pointing out
nonverbal behaviors can also bring the experience alive. When, for example,
sadness is blocked, the therapist might draw the client’s attention to how
their breathing changed. When it is anger that is blocked, the therapist might
point out how clients tighten their neck muscles and clutch their hands. The
therapist might then say that it is important to feel sad after a loss, simi-
larly with unexpressed anger, and that, if not processed, these emotions can
lead to depression. The therapist then checks with the client if this all make
sense, saying things like, “It’s as if you were talking to yourself . . . I can’t
be angry. I have to swallow my feelings for the rest of my life? Does that
make sense to you?”
The two-chair enactment task requires three essential steps on the part
of the therapist:

1. Bring the client’s attention to the fact that he or she is interrupting or

suppressing (i.e., by noting that the client looks away whenever mention-
ing certain things, or changes the topic, or smiles).

2. Turn the passive to active and the automatic to deliberate by inquiring

and ascribing personal agency to the client in the interruptive process
(e.g., “How do you stop yourself or interrupt yourself?”). This is an
awareness task that the therapist can use to elaborate conscious expe-
rience and specify what the interrupters are (e.g., “What do you say to
yourself?” “What do you do muscularly?” “How would you do it to me?”).

3. Access what is being suppressed or integrate the two sides of the struggle,
or both.

Therapists need to help clients discover first that they interrupt and then
how they interrupt. They also need to acknowledge the protective function
of the interruption, help clients experience the fear that drives the self-
protective interruption, and ultimately allow what has been interrupted. It is
really important for therapists to validate clients’ fears of the emotion being
interrupted and acknowledge its protective function. Clients, on the other
hand, need to develop a sense of themselves as agents who interrupt as
opposed to being victims of interruption.
Two important aspects of the blocking process need to be attended to
by the therapist. The first is the verbal cognitive aspect, which essentially is
200  •  Changing Emotion With Emotion

what people say to themselves—the words that appear in the client’s narra­
tive. The therapist then asks the client to verbally express the content linked
to the restriction on feeling emotions. The second is the nonverbal aspect of
blocking; with this aspect, the interruption of emotion has a body component.
For example, clients may block themselves by increasing muscle tension and
breathing rate. The therapist assists the client in locating muscular tension
and blocking points, and discovering how they are produced. The therapist
asks the client to enact the experience of blocking emotions, highlighting
how it is that the client has produced the block through their motor activity.
Once clients realize they are the ones producing the block, they are inclined
to choose to stop doing so.
The following clinical example shows how Desh, a 29-year-old, South
Asian man, a computer analyst with generalized anxiety disorder, both
verbally and nonverbally blocks:

THERAPIST [with client already sitting on the “interrupter chair” representing

the interruptive self]:   I want you to block, to stop this side of
you. What do you say to make him stop feeling? What do you
say to this part of you?

CLIENT:  You can’t be angry at your father. You must respect him! How
the hell can you feel that about your own father?

The therapist then advises this client to return to the experiential self. Again,
what matters is that the dialogue is not a logical or rational reflection on
the importance of expressing emotions. The focus is now on how the client
is impacted by the emotional block. The therapist tries to make the client
perceive this impact, articulating it through language and expressing it:

THERAPIST:  (Points to the chair of the experiential self ) Sit here. What
happens inside you when you hear this? Talk to him (points
to the interrupter chair).

CLIENT:  I don’t know . . . I think that’s right . . . I should just let it be.

THERAPIST:  I understand. But what is it like, this experience of feeling

and not being able to express it? Not being able to respond to
your own feelings? How does this affect you in your daily life?

CLIENT:  I don’t know . . .

Once clients have experienced the process of interrupting emotions, the

therapist helps them overcome the blocks and get in touch with the dis-
connected emotions, thus recovering their information and healing power.
 Unblocking Emotion  •  201

This is done by guiding the client to further intensify the self-interruptive

activity so that a self-preservation reaction emerges in the experiential self.
The therapist continues to support and follow the painful experience in the
experiential self until the client achieves some reaction and empowerment
of that self.
The following is an example of work using two chairs for interruption
with a 31-year-old, male, French Canadian client who presented with
depression and anxiety disorders:

CLIENT:  I’m so angry at him [referring to the imagined father in the

empty chair].

THERAPIST:  Tell him.

CLIENT:  I couldn’t do that. I just hold it all in.

THERAPIST:  Come over here and stop him from being angry.

CLIENT:  (Sits in the chair that, up to this point, represented his father)
Who am I here?

THERAPIST:  Be a part of yourself that stops him.

CLIENT:  Well, my father just seems so superior, so powerful. I just retreat.

THERAPIST:  Okay, but as yourself, not your father, make yourself retreat.
How do you do that? What does this voice inside you say?

CLIENT:  It says, “Well, you have no legitimacy. Don’t get angry. I get
scared. It’s not okay; it’s dangerous.”

THERAPIST:  Make him scared. What do you say?

CLIENT:  “Watch out. You won’t be able to speak.”

THERAPIST:  Make him not able to speak.

CLIENT:  “Well, you’re stupid. You don’t have what it takes. Also, you’ll
get too emotional and you’ll cry or you’ll damage the relation-
ship. So just retreat.”

THERAPIST:  Yeah, tell him this again.

CLIENT:  “Retreat, just shrink away, disappear.”

THERAPIST:  Change chairs now. What do you say to that?

CLIENT:  (Sits in the interrupter chair) I feel sort of hopeless, resigned—

like it’s been such a long time always feeling like, weak, never
202  •  Changing Emotion With Emotion

supported. But I do feel like I have a valid point of view. I have

a right to be me. I was never supported. I do deserve it; I didn’t
do anything wrong,

THERAPIST:  What’s that like in your body?

CLIENT:  I just feel so angry that, well, I sort of feel my back straighten,
kind of like feeling taller.

THERAPIST:  (Redirects to the father) Good. Put your father there. Tell him,
“I’m angry at you.”

As shown in this example, after working on a self-interruption of

resignation, once the client gets to the point of feeling more deserving and
says, “I do deserve it; I didn’t do anything wrong,” the therapist then directs
the newly accessed feelings and needs back toward the father.

HELPING CLIENTS ACCESS THEIR ABILITY TO TOLERATE

BLOCKED EMOTIONS

It is essential to ensure that clients have sufficient internal support for

making contact with emotions before the blocks are undone and emotions
are evoked and experienced. Some clients become tense at the prospect of
encountering their feelings. At these times, the therapist has to empathize
with the fear, understand that the block is a protection, and provide more
support. On the one hand, more relational support in the form of validation
and trust building is indicated. On the other hand, the building of internal
support by a slower approach to emotion—in small steps—helps clients
deal with their anxiety. A type of graded exposure or desensitization process
is most useful in helping clients to approach and tolerate their emotions.
The therapist also helps clients mobilize internal support by suggesting,
for example, that clients breathe, put their feet on the ground, and describe
what they are experiencing to increase contact with sensory reality.
The next example illustrates one client’s progression toward symbolizing
her emotion progressing from unsymbolized affect/feeling to the differen-
tiation and expression of her emotional experience. The client, a 52-year-old,
married, Caucasian woman of Slovakian origin, was a highly successful
business executive in her second marriage of 12 years and had three chil-
dren, two from her first marriage. She began the first session by explaining
to the therapist what brought her to therapy: She had been suffering from
depression and a chronic skin problem (hives) that she was told was related
 Unblocking Emotion  •  203

to stress. As she acknowledged a need to “deal with what’s really bothering

me,” she began to cry. She further explained that she cries often and feels
like she has “no control” over it. As illustrated in the following passage, she
worked with her therapist to differentiate her blocked unsymbolized feeling:

CLIENT:  Part of me wants to sort of let it all out . . . but I don’t know
what it is that I’m supposed to let out (cries).

THERAPIST:  Mm-hmm. So, there’s a lot in there, but you’re not quite sure
how to let it out.

CLIENT:  Mm-hmm.

THERAPIST:  Okay. Well, what do you feel like right now? ’Cause I can see
the tears and I can see you trying really hard to push them
back, but . . .

CLIENT:  ’Cause you see right now, I don’t know why I’m crying . . .
I can’t, you know, put my finger on it. Like, what is it about
this? I’m talking about something that’s not that difficult. Why
am I crying (sniffs)?

THERAPIST:  Okay, well instead of wondering about the why, why don’t
we just look at what it is you’re feeling right now. (Client:
Mm-hmm.) Since that seems to be very alive, what’s happening
inside here?

CLIENT:  (Sighs and pauses) I feel like an ache inside all the time, like
I’m not really happy. (Therapist: Mm-hmm. Client pauses.) Um,
I’m very close to my sons, and I miss them a lot ’cause they’re
not here. (Therapist: Mm-hmm.) And I’d like to spend more
time with them, and that’s not, you know, feasible.

THERAPIST:  Mm-hmm. Tell me about the ache that you feel.

CLIENT:  I dunno, it’s almost like a physical, you know (Therapist:

Mm-hmm.) hurting. (Therapist: Mm-hmm.) And it’s almost
always with me.

THERAPIST:  That must be draining to have it always.

CLIENT:  I guess that’s why I’m so tired and exhausted all the time.

In the final stage of overcoming the block, clients feel more empowered,
regaining the adaptive and informative role of emotions. They are able to
contact painful emotions and themes, recognizing unmet emotional needs,
204  •  Changing Emotion With Emotion

and to start to reclaim them. Unblocking allows the accomplishment of

other therapeutic tasks that might present themselves in therapy as well as
the creation of new meaning.
Sometimes interruption is caused by protective anxiety, and unblocking
involves standing up to and reassuring the catastrophizer. For example,
in the following excerpt, the therapist works to help the client, Susan,
a 33-year-old European business executive, stand up to the part that is
silencing her by worrying she will make a mistake. Susan tells the worrying
side that the worrying makes her tense and that she needs to relax. How-
ever, the worrier responds that she is scared and cannot stop worrying in
case she cannot protect her.

CLIENT:  (Speaks to the worrying side) Stop telling me to be careful. I feel

so exhausted trying to ensure I don’t make a mistake.

THERAPIST:  So, from this side, what do you need? Tell her.

CLIENT:  I need you to stop worrying. Stop telling me that “things will go
wrong.” I need you to calm down.

THERAPIST:  Come over here (points to the interrupter chair, where the client
now sits). So how do you respond to her? She [in the self chair]
says, “I need you to calm down. I am so tired and exhausted.”

CLIENT:  (Speaks from interrupter chair) I can’t stop. I’m scared [that]
without me, you might get into trouble—make mistakes, and
you’ll be rejected.

After reprocessing some memories of always being corrected by her mother,

the client from the self chair says the following to the interrupter:

CLIENT:  I am capable. I don’t need you always on my shoulder. And

even if I sometimes make mistakes, I can fix them, and I will
survive. I want you to back off and give me space . . .

THERAPIST:  So, you are reassuring her that you will be able to manage
without her constant monitoring and that you are capable and
can manage.

CLIENT:  (Sighs with tears in her eyes) Oh, that’s it. . . . That’s what I need.
That feels so good.

After this, Susan’s anxiety lifted, and she feels more joyful and less fearful.
Next, we turn to a full example of a two-chair enactment for unblocking.
Interspersed with the transcript are interpretive notes that indicate the dif-
ferent components of the model of change.
 Unblocking Emotion  •  205

EATING THE SADNESS: UNBLOCKING ANGER AND SADNESS

In this example, Jeanne, a 38-year-old Caucasian woman, client came to

therapy suffering from depression and anxiety, and had concerns about an
eating disorder plus her addiction to marijuana. This client, as illustrated in
the following excerpt, is working through her interrupted anger and sadness
after the breakup of a more than 14-year relationship (with John), which
led to an exacerbation of her eating and marijuana problems. In the first
part of the session transcript, she talks about spending the weekend at a
vacation home with a new partner (Yarrow):

THERAPIST:  So, it’s really hard for you to accept these—these feelings, this
emotional part of you?

CLIENT:  I think so (nods). I think so (nods). Because I did notice

that there was a real gap. (Therapist: Uh-huh.) When I was—
particularly when I was talking about feeling angry with John.
And I realized that these—there’s a real gap ’cause I don’t like
to think of myself as a person who just, you know, dislikes or—
I mean throws spears or anything like that. And yet—I am.
(Therapist: You do.) Yeah, and that’s—and that’s—I’m getting
more comfortable with that when I realized that I’m obviously
not very—well even now because I can feel myself struggling
to talk—in—in first person. To talk in the first person. I’m—
I’m, uh . . . [awareness of aversion to anger]

THERAPIST:  It’s really hard for you to kind of express yourself sort of that
one—that other—that passive intellectual, knowing part.

CLIENT:  Well, because there’s an ideal me (giggles) and there’s me, and
I’m finding it—I’ve been very careful building up this ideal me,
and the gaps are troublesome.

THERAPIST:  (Points to the interrupter chair) Would you want to split them
apart? Talk to each other?

CLIENT:  I’m not sure—I’m not quite—I don’t think I’m fighting against
it (holds her throat)—I’m not sure I—I’ll be able to because
I’m sort of watching it. If that makes sense—I’m in a real . . .
I don’t know I can try—who’s supposed to be (giggles) there?

THERAPIST:  Are you more in touch with the ideal self? The kind one who
wants to keep everything cool, collected?
206  •  Changing Emotion With Emotion

CLIENT:  The other in actually—the entire, um, I’m on pure—sort of,

ugh (sighs), for lack of a better term—left brain right now,
I mean it’s very intellectual, I’m very—watching it, I’m, you
know . . .

THERAPIST:  So, this your cerebral, analytical, yeah. (Client nods head; ther-
apist points to the interrupter chair.) This is the cool, collected,
rational side. Okay, stop the emotional side—tell her you
shouldn’t express yourself? How do you stop yourself from
expressing itself, its emotions?

CLIENT:  I’ll try and (covers her eyes and takes a deep breath)—no, because
intellectually, I think I should be expressing those emotions
more clearly. I know I should be expressing those emotions
more clearly—it would just simplify my life.

THERAPIST:  Uh-huh. Stop her from expressing her emotions.

CLIENT:  I don’t know—I do know how I do it, but I do it . . . by pauses

like this. When I can feel myself getting emotional.

THERAPIST:  So . . . what are you doing? (Client: Yeah.) And then what
happens inside—do you go blank?

CLIENT:  No, I—I sigh. I mean that’s where I kind of give myself a
breathing space and, well (sighs), okay, just kind of—um—
it’s—I can only think in metaphors—but I eat the emotion, this
is really what I do. [awareness of self-protective function of
self-interruption]

THERAPIST:  So, you stop yourself by eating your emotions?

CLIENT:  Uh-huh. I don’t know—I think you were for asking how I—
how—why I stop myself?

THERAPIST:  Uh, looking at how you stop yourself—you eat them? (Client:
Uh-huh.) Swallow them back down.

CLIENT:  Uh-huh (nods). (Therapist: Okay.) I save—or I save them for

later.

THERAPIST:  Okay (nods; therapist mimics swallowing something). What does

it feel like—swallowing it down?

CLIENT:  Um, fine. I feel—I mean, in some ways—in some ways, I feel
better. I mean, I could feel sort of tension happening through
 Unblocking Emotion  •  207

my spine and through my shoulders (points to the back of her

neck and shoulders). [awareness of self-protective function of
self-interruption]

THERAPIST:  Is there any indigestion? (Client: But—no. No [laughs].

Therapist laughs.)

CLIENT:  No—I’m kind of very good at it (continues to laugh). Very used

to it. Um . . .

THERAPIST:  Tense in here. Can you speak from your tension? (Client sighs.
Therapist whispers.) What does your tension say?

CLIENT:  Yeah. I—I—I mean, I can feel a sort of lodging in my throat

(points to neck).

THERAPIST:  (Points to own neck) Sitting here?

CLIENT:  I’m swallowing things right now (takes a deep breath and covers
her face). I know I’m getting all tense about going up to the
cottage this weekend—so that’s one of the things I am getting
tense about.

THERAPIST:  What does it feel like?

CLIENT:  Um, I don’t know. I’ve been trying to work that out. And
(sighs), no.

THERAPIST:  Stay with the tension. (Client nods.) Um-hmm. (Therapist

whispers.) Can you focus on the tension? (Client sighs.) Put
words to that tension?

CLIENT:  Now it’s my space is disappearing again. That’s what it

feels like.

THERAPIST:  Somehow, you’re feeling more what? You’re feeling a bit . . . ?

CLIENT:  Um, yeah. Because up there at the cottage, it’s not—I feel
like it’s not my space. And (sighs) yes, so the idea—ugh—and
this is intellectualizing it again, but—I feel like there’s going
to be—I’m going to have to sit in my ideal self a lot more than
trying to find out what my natural self is. I mean, those are
sort of . . .

THERAPIST:  Feel you’re going to have to be what? On your best behavior?

Is that it? Well, not to be you?
208  •  Changing Emotion With Emotion

CLIENT:  Yes, because—not because (sighs) me is particularly bad, but

I think right now—what I’m trying to work or what I’m trying
to find out how I express (sighs) things is—is a lot of negative
emotions. There’s a lot of anger, there’s a lot of, um, frustra-
tion, um, that—that type of emotion.

THERAPIST:  What’s the anger and frustration about? (Client sighs.) Lots
of things all at once. Um, I’ll try and split them up (sighs).
Yarrow [new partner] encroaches upon space, or I feel like he
encroaches upon my space—that I’m trying to—that I’m really
working hard to sort of define—but more than that, I know
that the anger has a lot to do with John [former partner]. I still
haven’t worked out that.

THERAPIST:  So, you’re feeling angry?

CLIENT:  Uh-huh.

THERAPIST:  And frustrated? You’re not quite sure how to express it?

CLIENT:  Uh-huh.

THERAPIST:  You’re still really angry at John?

CLIENT:  I can feel my tone is very (Therapist: Uh-huh.)—but I am—oh,

I’m furious at him! I’m furious at him. And every time—well
I had to call him, too, so that he had to take care of my cats
and my birds for the weekend. And it’s infuriating, it’s—we
get—we got along—we do get along so well on certain levels.
And yet—he complete—I mean he just—he just walked out on
all of that, and I’m furious. There! I’m keeping it nice and cool.
I’m just (sighs) . . .
THERAPIST:  Swallowing now?

CLIENT:  Uh-huh.

THERAPIST:  Swallowing it down?

CLIENT:  Uh-huh. It just doesn’t feel so pleasant. I can just—I can feel it
sort of poisoning—I mean it’s poisoning everything. [realization
of negative impact of interruption]
THERAPIST:  What does it feel like as you swallow? So, it goes inside, and
you, it poisons.
CLIENT:  And it does—it poisons—it does—it poisons my relationship
with Yarrow.
 Unblocking Emotion  •  209

THERAPIST:  It corrodes your insides.

CLIENT:  I mean, I could feel that all the time because when I’m angry,
I confuse their names. I mean it’s awful. I’m always calling
Yarrow “John” when I’m angry with him. So, I’m really sad—
I know that somewhere along the line (lifts her arms up) . . .

THERAPIST:  What’s happening over there? (Therapist points to the client’s

arms moving.)

CLIENT:  (Closes her eyes and shakes her head) Oh, I want just (sigh)—
I am (covers her face with her hands). Oh, I want to scream at
him so badly.

THERAPIST:  Well, why don’t you scream at him (points to the other chair
now representing John, her ex)? Scream at him (brings the chair
closer to the client).

CLIENT:  Oh! He just—oh, I can’t even express that I’m just so furious
with him (covers her eyes, voice trembling, and takes a deep
breath).

THERAPIST:  What do you want to scream at him? (Therapist speaks quietly.)

Try it out. [support and encouragement from the therapist]

CLIENT:  He just (takes deep breath)–—he walked out—I mean he just

walked out on everything, and now it’s (takes a deep breath) . . .

THERAPIST:  It doesn’t sound angry yet.

CLIENT:  I know it doesn’t sound angry. It’s (takes deep breath) . . .

THERAPIST:  (Slaps the chair) “How dare you walk away? How dare you!”
[approach to emotion with support and encouragement from
the therapist]

CLIENT:  And without even—I mean it wasn’t—it didn’t even mean

anything to him. It was just it was going to be . . .

THERAPIST:  “You just abandoned—you just turned your back on us!”

CLIENT:  Completely! (The client covers her face with her hands and takes
a deep breath.)

THERAPIST:  Can you tell him that?

CLIENT:  Ugh, ugh, no! (She puts her face in her hands.) No—that’s the
problem, I can’t tell him. I can feel my—I’m just sucking it all in.
210  •  Changing Emotion With Emotion

THERAPIST:  Okay, then swallow it some more. (Client takes a deep breath.)
More. Take it right in. (Client takes a deep breath.) Don’t want
any of it—take it right in (points to the other chair). How do
you do that?
CLIENT:  I squeeze my stomach. Hold my breath. [articulation/enactment
of self-protective function of self-interruption]
THERAPIST:  Yes, do that. Do it with your hands to the pillow. (Client squeezes
the pillow.) Just tighten up. Hold it in. . . . Come over here.
CLIENT:  (Sits on the self chair and takes a deep breath)

THERAPIST:  What is it like—to take it right in? What does it feel like inside
as you swallow it down? What it is doing to you?
CLIENT:  (Takes a deep breath) Oh it’s—it is—it (covers her eyes)—it—
corroding is the right word. It’s—it’s destroying me. [realization
of negative impact of interruption]
THERAPIST:  Can you speak from it? This feeling—that it’s destroying you?
Eating away like a cancer?
CLIENT:  No. It’s more like I’m fraying around the edges. I’m just break-
ing up.
THERAPIST:  Feel like you’re slowly falling apart, disintegrating?

CLIENT:  (Client nods. Therapist: Uh-huh [sighs].)

THERAPIST:  So, you can’t go there?

CLIENT:  (Shakes her head and takes a deep breath) And every time I talk
to him—oh—I want to—a part of me wants to stay angry long
enough to—[desire to allow]—but every time I talk to him,
I remember why I really wanted everything to work. And, so,
it’s all of that (sighs and covers her eyes).
THERAPIST:  (Points to the self chair)

CLIENT:  (Moves onto the self chair)

THERAPIST:  Tell me what you miss about your relationship? It’s special?

CLIENT:  (Covers her eyes) Oh, how . . .

THERAPIST:  Something special?

CLIENT:  How bright it was and how (sighs), oh, it was (sighs)—it was
so quick and so bright, and we could talk about anything, and,
 Unblocking Emotion  •  211

I mean, the steps between ideas were like infinitesimal, and

it was wonderful, and it was exciting, and, oh, and what’s
worst is that he betrayed all of that even while we were living
together (voice trembles). I did prize that. And at the—I mean
that’s what was so horrible—at the same time, he was under-
mining me at every step (covers her eyes), and I was like—it
was—but, at the same time, he undermined me, but I was
protecting what we had protecting myself. I was afraid to be
angry. [awareness of self-protective function of self-interruption]

THERAPIST:  “I really prized that.” How did he undermine you?

At this point, the client elaborates on how John undermined her intel-
lectually and on her resulting feelings of self-doubt. The transcript picks up
again a few minutes later with the therapist asking the client how she feels
now after she has enacted her ex putting her down:

THERAPIST:  What happens inside when you hear him say, “Ugh, you’re
very bright—but you know, really, these ideas, are just corrupt.
They’re just . . .”

CLIENT:  (Takes a deep breath) Now or then or both? (Therapist: Now.)

Um (sighs), I get so—not angry, I get so sad (Therapist: Uh-huh.)
(Client eyes tear, and she covers them up.) because all I remember
was how I kept trying to run to catch up—so it was sort of—
like, well, okay, this isn’t a good idea, so I’ll do this—and it was
never a good—none of it was ever . . .

THERAPIST:  Can you stay with the sadness? (Client nods.) Can you let it
flow? (Therapist whispers.) So, just let it out.

CLIENT:  Nope (shakes head). I can’t. [awareness of aversion of sadness]

THERAPIST:  Can you suck in the sadness? (Client takes a deep breath.) Suck
it right in.

CLIENT:  (Nods) I’m sucking it in right away (sighs, then takes a deep
breath, then sighs). Yeah, that I’m good at (grabs a tissue and
nods)—I’m sucking it in right away (sighs and takes a deep
breath), then I’m safe. [awareness of self-protective function
of self-interruption]

THERAPIST:  What did it feel like inside? Did you suck it in? (Client sighs
and wipes her face with a tissue.) Can you exaggerate that
“sucking in”? Uhh (makes sucking in sound) . . . (Client mimics
212  •  Changing Emotion With Emotion

the sucking sound.) Uhh . . . Can you exaggerate them some

more? Some more (Client takes a breath.)? What does it feel
like as you suck it all in?

CLIENT:  (Takes a breath) Ordinary. I do it all the time. It stops me from

having to feel it. [awareness of self-protective function of
self-interruption]

THERAPIST:  What does it feel like? It’s familiar? (Client: Uh-huh. It does.)

CLIENT:  (Takes a breath) Oh, I can feel it’s tingling at the edge of every
muscle, trying to get out.

THERAPIST:  Uh-huh. Something struggling to get out?

CLIENT:  (Sighs) And it does—it’s like this dark cloud that I’m sort of
carrying around (sighs). I have images of wanting to take a
knife to him and slash him up because I’m so angry with him.
(Therapist: Uh-huh.) And I don’t really—but I—I know that
I want to slash him and that’s the way I feel—that he’s slashed
me open (tears up and covers her face). [desire to allow]

THERAPIST:  So, you kind of feel slashed open, wounded? (Client nods.)
Uh-huh. (Client: Yup.) You’d like to wound him somehow,
make him feel as painful?

CLIENT:  Yup. And I can’t—I mean, that’s the thing—I can’t get to him
at all (sighs).

THERAPIST:  So, you feel very powerless? (Client: Yes [nods, then sighs and
covers her eyes].) You don’t want—you don’t want do it in
here? . . . You don’t want to express that rage on him?

CLIENT:  No—I think I’m really afraid of it. [awareness of self-protective

function of self-interruption]

THERAPIST:  What would happen if you express it?

CLIENT:  I don’t know. Well—oh, I do. I’ll be embarrassed or I’ll be, you
know, I’ll lose control.

THERAPIST:  It doesn’t feel like it’s safe to be angry here?

CLIENT:  No (shakes her head). It doesn’t feel (sighs)—I don’t think

I ever felt very safe, but that’s the one—this sounds so intel-
lectual, but it’s not—I know that that’s the one thing that he
 Unblocking Emotion  •  213

really managed (sighs) to really reinforce was—I don’t feel

safe at all. And I mean, it’s not . . .

THERAPIST:  You don’t feel safe, anywhere?

CLIENT:  (Shakes her head) No, no, he was always managing to pull the
rug out from under me. I mean, every time I thought I’d cre-
ated little edifices, I was safe—it was, um, it was destroyed. And
I mean, he was never (sighs) . . .

THERAPIST:  So, if you let your guard down in here (Client: Yeah.) and feel
those strong feelings of anger and sadness . . .What? He might
kind of use it again you? (Client sighs.) Would get some power
over you? (Client: Uh-huh.) You scared to argue it out in here?

CLIENT:  Um (sighs), I don’t feel that there are many ways that I can—
I can feel it . . . I mean, it’s not a thought that I have but
I know—I know I must have it because I don’t feel safe, up to
a—ugh, a fairly small limit, and I mean, well, hell—I’m sure
you’ve seen it. . . . Every time I try to express anger, I can’t
do it. I completely close off (Therapist: Uh-huh [sighs].). Even
(swallows)—I mean, it’s like protection (shakes her head and
sighs). [awareness of self-protective function of self-interruption]

THERAPIST:  It just seems to me that it might actually be useful to you—

to express it. [reduction of fear of the emotion through reassur-
ance from self or therapist]

CLIENT:  It would be.

THERAPIST:  If you could, to get some of that anger out because I think it
could provide a shift for you, in so many ways . . .

CLIENT:  Oh, I know. And I mean, I know that’s . . . (sighs)—I know

(takes a deep breath) [desire to allow]. Oh, I don’t know how
to—I don’t know how to do it. I mean, I don’t know how to do
it (voice trembles; sighs).

THERAPIST:  (Whispers) It’s so stuck. (Client nods.) There’s no formula.

CLIENT:  (Shakes her head) No, I mean, I’m (sighs and covers her face,
starts to sniffle) . . . And then, of course, it just starts to get into
feeling badly because it’s not that I don’t trust you, it’s just
that something—I can’t get past it. [awareness of aversion/
interruption]
214  •  Changing Emotion With Emotion

THERAPIST:  Uh-huh. So, it’s not just me personally.

CLIENT:  No. It’s just a terrible sense of—even with you, I don’t feel safe
when I—when the feelings of anger start coming up.

THERAPIST:  What do you think it’ll do? Break a chair? Hurt me?

CLIENT:  No—not hurt you. Um . . .

THERAPIST:  Break a hole through the wall?

CLIENT:  Yeah (sniffles and exhales). Yeah, I’ve had—I’ve had two
(sighs), I mean, I know, I think I know intellectually what’s
happened. I’ve had two models of—of anger. I’ve had my
mother’s model where it’s just—and that’s the one I end up
using—where you don’t (Therapist: Uh-huh.) express, you sort
of—it sort of—yeah. But it ends, oh, yeah, all over the place.
(Therapist: Um.) It ends up all over the place. Or, my father,
who did throw chairs around. (Therapist: Uh-huh.) I mean,
he never—he never touched any of us. He was always very
careful about that, but I mean, there would be these huge,
explosive, destructive . . .

THERAPIST:  So, I think that’s very scary for you, knowing how to express—
you don’t how—how is it kind of, um—you have these two
extremes? And, somehow, it’s hard to kind of trust yourself
to be able to express anger in a way that is—is not as kind
of explosive (Client: Uh-huh.) and out of control as your dad.
(Client: Yeah.) Almost corrosive to you, as your mom. You need
to find a way beyond—express that anger. [therapist support
and encouragement to allow emotion]

CLIENT:  Yeah. And I don’t know how to do it because I’ve just got—
I mean, when I think of expressing anger—I mean, it really is—
it is throwing chairs through windows and—and (sighs) . . .

THERAPIST:  Can you hit the chair? You can do it, and you won’t be
destructive.

CLIENT:  No. No, because I feel embarrassed about it. I mean—there’s

that, too. I just—I’m (sighs).

THERAPIST:  Can you give words to the anger? (Client sighs.) That’s another
way of expressing it. (Whispers) And I’m here to support you.
[safety: reduction of fear through support and encouragement
from therapist]
 Unblocking Emotion  •  215

CLIENT:  (Shakes her head) Oh, it’s so hard. I mean that—I should be able
to do that—but I don’t—well, I know, I don’t have any angry
words. I have all these lovely, passive—you know, “I’m upset,”
“It upsets me.” I mean those—those are—those aren’t angry
words. Those are just ways of avoiding, but I want to be able
to be angry. I deserved better. [desire to allow]

THERAPIST:  Tell him what he did to you.

CLIENT:  (Sighs and covers her eyes) Because I’m not (sniffles)—I go over
and over what he did to me, but what I’m furious about is the
fact that he did it (sniffles) . . .

THERAPIST:  Yes, you have a right to be furious.

CLIENT:  I do [reduction of fear through validation of self]. I am—

I really am furious at him and how he treated me. He’s an
arrogant, selfish person, and I hate him for what he did. I’m also
sad—sad I didn’t stand up for myself and sad I have lost all the
good parts. [allow emotion]

The client and therapist then continue for the next 14 minutes of the
session. In this period, the client stays with the emotion, processing her
feelings in productive ways to differentiate complex aspects of the client’s
relationship with John—both the good and the bad. A new narrative begins
to develop that helps her understand why she, for fear of losing the good
parts, did not stand up to him. She ends with talking about how she now
needs to let go and move on but that she needs time to both grieve the loss
and support herself. In the excerpt, we see how with the therapist’s support
and encouragement, she approaches the feared emotion and articulates the
self-protective function of self-interruption, and by enacting it, comes to
experience its negative impact. This leads to a desire to accept and express
the emotion, which she goes on to do.

CONCLUSION

The perspective offered in this chapter is that, to heal their troubled souls
and minds, clients need to experience the emotions that go with their
stories. It is, however, understandable that clients protect themselves from
feeling their dreaded, painful emotions. They fear that if they allow these
emotions, they will fall apart, disintegrate, and be unable to cope, so they do
all in their power to not feel. However, what they resist persists, so blocking
216  •  Changing Emotion With Emotion

is not an effective solution. Protection or avoidance is not always deliberate

and intentional; it’s just how the mind habitually protects itself from falling
apart. Clients, therefore, often need assistance connecting to their emotions.
In this chapter, I outlined the steps involved in unblocking emotion and
highlighted the importance of the client’s realizing the negative impact of
the blocking. Several examples illustrated how a therapist’s encouragement
helps clients to face the emotion; the therapist reassures clients that they
can undo the protection and will survive. In addition, I discussed how
two-chair enactments that focus on how interruption works are a good inter-
vention for helping clients overcome their blocking; examples demonstrated
what that can look like.
In the next chapters, I turn to the processes and skills needed to facilitate
the leaving of emotions by creating more adaptive emotional responses to
their life circumstances.
PART 

III LEAVING
EMOTION
 
9 WORKING WITH NEEDS

In a therapy focused on emotional change, the aim is to change painful,

maladaptive emotions like fear of abandonment or of annihilation from past
childhood maltreatment. Once these emotions are aroused in the present, as
described in Chapters 5 to 8, they can be transformed by the activation of
more empowering emotions. How do we therapists help clients access more
empowering emotions? My colleagues and I (Greenberg & Malcolm, 2002;
Greenberg & Paivio, 1997; A. Pascual-Leone & Greenberg, 2007) found that
mobilizing the unmet need in the emotion is one of the most helpful ways of
activating an adaptive emotion. For example, maladaptive shame, which is
internalized from the contempt of others, can be transformed by accessing the
need for validation. When the client acknowledges that they need and, in fact,
deserve validation, the accessing of this need activates adaptive emotions,
such as anger at invalidation, grief for all the losses involved, and possibly
self-compassion. What ensues is a sense of pride and self-worth.
Every emotion people experience involves a specific set of needs. When
these needs are met, the cycle of experience flows normally, and the emotion
is fast and fleeting. If we feel shame, but, at the same time, our needs for
validation by someone meaningful are fulfilled, we feel reassured and again

https://doi.org/10.1037/0000248-010
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

219
220  •  Changing Emotion With Emotion

feel comfortable and confident within ourselves and in our interactions with
the outside world. However, if these needs are not met, discomfort, pain, and
suffering persist. In an attempt to deal with this suffering, people form emotion
schematic memories of the unmet need and the emotional pain to act as a
warning system to protect themselves. This system can then be triggered in
different situations, alerting us to danger whenever a situation resembles
the original cause of the pain. The emotion scheme acts as a sort of exagger-
ated warning system. People also may protect themselves from the suffering
with secondary emotions that disguise primary emotions; these secondary
emotions involve a sort of paralysis or imprisonment in bad feelings, such as
hopelessness, anxiety, or reactive anger.
We have found that focusing on reowning previously unmet emotional
needs helps mobilize primary adaptive emotions (Greenberg, 2015; A. Pascual-
Leone & Greenberg, 2007), and that is a powerful driver of change. These
new, adaptive emotions that help modify old, maladaptive emotions are
precisely those the client was never able to experience in the past. And,
focusing on adaptive primary emotions moves people even further toward
having other emotional needs met because these emotions guide us in the
direction of actions and problem-solving to get the needs met. The newly
experienced primary adaptive emotions present new possibilities that people
can now access, thus undoing the existing problematic affective and cognitive
responses. The adaptive sadness of grief helps douse the pangs of lone-
liness and unworthiness; it also helps people let go of the unmet need for
closeness that they never received from a parent. Accessing needs and new
emotions helps people change old beliefs not by disputing them rationally
but by having vivid emotional experience that disconfirms the beliefs. People
cannot believe that they are unlovable while they experience themselves as
deserving of love; likewise, they cannot shrink away in fear while thrusting
forward in assertion.

WHAT ARE NEEDS?

A key way of activating a new emotion is by focusing on what is needed

(Greenberg, 2002, 2015; A. Pascual-Leone & Greenberg, 2007). The essence
of this process is this: When clients access core painful maladaptive emotions
of fear, shame, or sadness, accessed core needs for connection, safety, and
validation embedded within them are mobilized. If clients can be helped to
feel deserving of these previously unmet needs, they are able to generate
more adaptive emotions related to their unmet needs. Thus, when clients
feel that they deserve to be loved or valued, a need is brought to central
 Working With Needs  •  221

awareness. The emotion system then appraises that the need was not met
and automatically generates an emotional reaction, usually healthy anger or
sadness, or compassion for the self’s pain.
Given the crucial role of accessing unmet needs for changing emotion, ther-
apists need to discuss what needs are, where they originate, and whether they
precede or come from emotion. Also, how do we know whether something
is a need? Are people born with certain intrinsic needs, or do our emotions
provide us with a template for the development of our needs? Assumptions
that basic drives or motivations are a fundamental, innate, part of our nature
are so deeply embedded in our theoretical preconceptions that it often takes
a great deal of thought to recognize that life might not necessarily be governed
by predetermined motivational systems. I suggest that psychological needs
are not simply inborn. They are not similar to biologically based drives like
hunger or thirst, or the fundamental motivation to survive and thrive; rather,
they develop from emotions.

Motivation and Needs

Motivation refers to what a person needs, wants, wants to do, desires, or
intends. Derived from the word motivus, it means “to move.” Motivation
is hypothesized to have evolved from many different human imperatives,
including survival needs, attachment, self-actualizing, belonging, mastery,
power, and self-esteem (Bowlby, 1988; Maslow, 1968; Murray, 1938; Rogers,
1959; White, 1959). While not denying the importance of these motivations,
I believe that it is actually emotions that we are born with—emotions are
the “givens”—and that motives, needs, wishes, and desires develop from
basic emotions and the fundamental processes of affect regulation and
meaning creation.
Human psychological needs, then, rather than being givens like instincts or
reflexes, are emergent phenomena constructed in a complex process of devel-
opment. Human needs emerge out of affect, and they represent basic likes
and dislikes, things that the organism desires to preserve a state of well-being.
We desire things because they are good for us and promote survival. These
needs or desires are constructed in interaction with the environment by
the operation of two fundamental inborn processes: affect regulation and
meaning construction. Basically, we come to desire that which helped achieve
the survival aim of the emotion and thereby felt good. Emotions evolved
because they promoted survival, and we come to develop needs for what pro-
motes our survival. The aim in anger, for example, is one of protecting bound-
aries or overcoming hurdles; in fear, the aim is to flee from danger. In both
examples, when the aim is achieved, organisms relax and develop a desire
222  •  Changing Emotion With Emotion

or need to protect or flee because it is good for them. In sadness, the aim is
reaching or crying out for contact or comfort; in disgust, the aim is to dispel
what is noxious and tastes bad. All evolved as action-oriented systems to aid
survival and lead to feeling good when the aim is reached and then wanting
more of this feeling to achieve this aim. Thereafter, organisms develop needs
or desires for boundaries, safety, comfort, and expulsion of noxious substances
because these things are good for them.
In my view, the motive to survive and grow is the only inborn motive
common across species. This innate motivation works in conjunction with two
major inborn operating processes: (a) affect regulation, the effort to physiolog-
ically stabilize the organism to regulate the sympathetic and parasympathetic
nervous systems; affect regulation manifests functionally as trying to have the
feelings we want and not have the feelings we do not want; and (b) meaning
creation, the effort to make sense of emotions and more broadly make sense of
ourselves, our lives, and our world; meaning creation manifests functionally
in narrative construction. These are general purpose operating processes and
not specific content motives.
However, the attempt to identify specific content motives, such as attach-
ment, autonomy, achievement, or power, is so strong in Western thinking that
it is hard for people to see these content motivations as derivatives of emo-
tion. For example, attachment, the need to be connected and protected, has
been postulated to be the master motive. It clearly is an extremely important
and powerful force, especially in infants and toddlers, but to attribute specific
content to it, or any other motive, beyond survival and claim that attachment
is an inborn drive is, I believe, a mistake. Rather than postulating that attach-
ment is an inborn motivation, the question to ask is, What is the mechanism
by which attachment works? We need an explanation of what produces it
rather than postulating a motive as an abstraction. The same applies to other
postulated motives, such as the need for mastery or self-esteem, or the moti-
vation to form a coherent identity.
The problem here is exemplified by the fact that 16th century doctors, in
observing that all human beings—all mammals—slept, postulated a dormi-
tive motivation (in Latin, dormio is to sleep). This is not an explanation of
what produces sleep. To name something a motivation is to create a fictional
phenomenon by confusing explanation and description. Human beings clearly
do attach and do strive for power, status, achievement, and mastery (Bowlby,
1998; White, 1959), but these strivings are better explained by complex
underlying processes rather than postulating inborn motives as an answer.
Love and power are important in understanding human experience (Gilbert,
1992). The need for security and interest or stimulation as well as mastery
also appears to be important (Greenberg & Goldman, 2008). Our ancestors
 Working With Needs  •  223

probably survived if they belonged to a group because the group provided

protection and comfort. Survival also was aided by their curiosity and interest
in novelty because they learned about things ahead of time before the neces-
sities of survival demanded. All of this helped people be safe and master their
situations but not because they had inborn motives to do these things. Rather,
those whose emotion systems oriented them toward attaining attachment and
mastery survived better than those who lacked this emotional makeup. What
was inborn were emotions with differentiated goals to promote survival.
How, then, do people come to develop an attachment motive that is so
strong and leads to needing and seeking comfort and closeness if it is not
inborn? When softness, contact, and comfort have been experienced as regu-
lating infants’ physiology and have thus felt satisfying, the infants develop a
desire for it because it is good for the infant and feels good. The organism’s
feeling of being thus regulated is automatically sought after, and, over time,
as this experience becomes reinforced, it becomes consciously articulated and
is called a need or a desire for whatever was found to be good for one and
thus satisfying. People come to desire and want this particular person; or they
desire and want to listen to opera or rock; or they want to do an activity, such
as skiing or reading. These desires are experienced as psychological needs of
different degrees of intensity. This process of desiring also leads to its oppo-
site, feelings of need deprivation, when the want or need cannot be satisfied,
which can become a source of great psychological distress.

The Role of Affect Regulation and Meaning Creation

In the view I present here, affect regulation and meaning creation are the
important processes that are involved in the development of needs. These two
major human processes act to serve the basic macromotive of survival and
help create needs. Thus, rather than postulate a set of basic motivations, such
as attachment, mastery, or control, I see psychological needs as arising from
a process of construction from an interaction between four elements: basic
inborn biases, preferences and affective values of what is good and bad for us,
lived experience, and affect regulation and meaning creation.
People are born with a motivation to survive, a set of basic evolutionary
developed emotions plus affect regulating and meaning creation systems to
achieve the aim of survival. All psychological needs emerge from these fun-
damentals. Infants, for example, are prewired through the affect system to
favor warmth, familiar smell, softness, smiling faces, high-pitched voices, and
shared gaze. These all produce neurochemical reaction, action tendencies, and
positive affect that support life. Once experienced, these favored experiences
begin to be sought after. Similarly, infants have negative reactions to restraint,
224  •  Changing Emotion With Emotion

loud noises, interoceptive discomfort, and overstimulation, and they move

away from these. Experience leads to the development of emotion schematic
memories with expectancies of what feels good and bad. As cognition develops,
likes and dislikes are further consolidated in awareness and become conscious
needs and desires.
Need or desire is created from the seeking or avoiding of those things that
helped one survive and made one feel good or bad. Need or desire also is
created from the coding of it in memory and in narrative meaning. Feelings
that this is good for us are the rewards or punishments that lead to desiring
more or less of something. We come to desire what we have experienced and
know will help us survive. Being physiologically balanced and maintaining
a sense of coherence is signaled to us by feeling good and by our experience
making sense to us and to our culture. This, then, leads to adaptive action.
In addition, needs are situationally evoked rather than being inner drives.
They are pulled from us rather than pushing us. Witness that even the sexual
drive in primates, for example, in male apes, is aroused by a new female in
heat even if the males have recently engaged in copulation. Human psycho-
logical needs are stimulus activated. A desire for the fresh-baked bread
we smell coming from the kitchen or for the touch of the other when we
see them is evoked by the stimulus rather than by a drive from within. And
these needs or desires are not inborn but developed from having tasted
bread and having been touched.

Neural Circuits
Research in affective neuroscience is beginning to inform our understanding of
needs as physical entities that exist in the brain, namely, neural circuits. As a
result of experience guided by a relatively small set of affectively based biases
and preferences—manifested in early organisms initially as action tendencies
(to move toward or away from) and later experienced as feelings—there is a
selective strengthening and weakening of populations of synapses. This carves
out circuits that become needs (Damasio, 1999); the circuits that are devel-
oped are organized based on lived experience.
Emotions are viewed as being generated psychologically by appraisal of
situations in relation to needs. This view, however, seems to imply, semanti-
cally, that need may preexist emotion. Isn’t there a circularity here? If emotion
is generated by needs being met, then don’t needs have to exist before
emotion can be generated? A type of chicken or egg question arises. Essen-
tially, there is a circular relation between emotion and need but only once
needs have been developed to help satisfy emotional aims. Buck (2014), for
example, suggested that emotions and needs are two sides of a coin, and
 Working With Needs  •  225

offered use of the term emotivation to describe the interdependence of

emotion and motivation. But as I have proposed, once needs are devel-
oped from basic emotions, they become barometers of what the organism
has found aids survival and has felt good in the past, and, thus, guides the
organism’s current strivings. So, as Harlow (1960) found, a need for contact/
comfort developed from the good feeling of the cloth covering the wire
mother because the cloth felt good. A child looks at the mother’s face seeking
to experience the joy that was produced by the smile on the mother’s face.
What was wired in were basic action patterns like rooting, sucking, grasping,
crying, and smiling as well as a system of preference for the pleasant feelings
that come from softness, warmth and smiles. It is only once needs have been
developed that their satisfaction or frustration becomes the activator of emo-
tion. That does not mean they were inborn or preceded emotion, however,
because emotion was initially activated by inborn cues like faces, touch, and
sounds. It is only once needs are developed from basic emotions and lived
experience that they become involved in the generation of emotion.
The organism thus possesses two general purpose systems beyond the
emotion system itself: A presymbolic, affect regulation process of seeking
what feels good for its well-being and avoiding what feels bad, and a later
developed symbolic, narrative construction process that creates meaning.
These are the two systems we work with in therapy. What do you feel, and
what does experience mean? Therapists do not look for motives or needs
as explanatory to produce insight, but we work with reowning disowned
needs. Accessing and reowning those unmet needs for which action tenden-
cies have been disclaimed are vital to psychological health. The reclaimed
needs provide a sense of direction and promote access to new emotions and,
ultimately, to change.
In this view, then, human beings are seen as wired to seek emotions because
how the emotions make them feel aids survival, and they come to desire what
is good for them. This is not a simple hedonistic view in which people seek
pleasure and avoid pain. Rather, people seek to attain and achieve the
survival-related needs, goals, and concerns embedded in their emotions:
goals, such as closeness and proximity, the lack of which is signaled by sad-
ness; safety, the lack of which is signaled by fear; agency, the lack of which
is signaled by shame. Those with feelings like these fare better than those
who do not. I hope this explanation puts to rest the apparent chicken and
egg paradox.
Most important for practice, then, is the knowledge that emotions provide
evaluations of whether needs are being met or not and also help generate
new emotions. Emotions, therefore, are not just emotions. They contain
needs, and it is therapeutically important to access the needs implied in the
226  •  Changing Emotion With Emotion

emotion to provide clients with a sense of direction. Emotion work requires

that therapists work to access previously disowned needs and validate them
as health giving. In addition, when unmet needs are reclaimed and brought
to awareness, the brain automatically generates new emotions based on
its automatic appraisal of whether the need was met or not. This leads to
the generation of new emotions to cope with the situation as it is now
perceived. Thus, for example, a person will feel sad for the loss of closeness
they needed, or angry at the deprivation of what they deserved, or compas-
sionate to themselves for the pain they experienced.

Need Satisfaction and Frustration

I now focus on one last important aspect of the topic of needs: the process of
need satisfaction and frustration, which is essential to the development of the
ability to regulate emotion. Emotion results from appraisals of situations in
relation to need. Emotion dysregulation results from people’s ways of reacting
to need deprivation. So, it is people’s responses, often emotional, to need
frustration and deprivation, not their needs themselves, that are problematic
(Greenberg & Goldman, 2008; Greenberg & Johnson, 1988). Need satisfac-
tion is seen as leading potentially to completion of the need and moving on
to other concerns (Perls et al., 1951). Maslow (1954) argued that once a
need is satisfied, the person moves on to pursuing higher needs based on
his hierarchy. It seems fairly self-evident, for example, that controlling for
other factors, if you are suffering from danger or cold and hunger, then safety,
food, and warmth are a priority. You just do not have the time or energy to
pursue self-esteem needs until other needs are met. On the other hand, Perls
et al. (1951) proposed that, rather than a hierarchy, people had thousands of
psychological needs but that present awareness led to the most urgent need
arising. That action led to need satisfaction, which led to the need fading into
the background and the next need arising and becoming figural in governing
striving. These hypotheses represent the idea that human beings are propelled
into action by psychological needs and goals, and that satisfaction of one set
of needs/goals leads to the pursuit of other needs/goals.
By contrast, a simple learning theory approach, explicitly or implicitly
adopted by many therapists, would suggest that encouraging and responding
to the painful emotion could be viewed as positive reinforcement that would
lead to an increase in frequency of these behaviors. In this view, people are
seen as stimulus-driven organisms governed either by stimulus–response links
or stimulus–organism–response links formed by association or reinforcement.
Learning and reinforcement explanations suggest exposure treatments to
extinguish associations. An affective view of functioning, by contrast, works
 Working With Needs  •  227

with that aspect of human functioning that is purposive and goal driven; the
brain is automatically comparing where they are with where they want to be.
The brain works by predicting and reducing discrepancy between present and
desired states in addition to associative learning. Need satisfaction by reduction
of discrepancy between desired and achieved states is seen as leading to a
reduction in feelings and need. It also leads the experience of a sense of greater
security or confidence rather than a strengthening of the bad feelings of depri-
vation. Moreover, need satisfaction produces a reduction of preoccupation
with getting the need met based on positive expectations of its satisfaction.
Need satisfaction, thus, leads to the abatement of the need. For example,
satisfaction of the need for closeness leads to the person’s moving on to
explore and meet other needs. When the need to achieve is satisfied, the
person relaxes and moves on to meet other needs. This is important for
therapy in which accessing previously unresolved feelings and unmet needs
is seen as necessary in satisfying or changing them. Rather than leading to
a reinforcement of the activated feelings and needs, activation makes them
amenable to new input. If, in therapy, a person is able to access the sadness of
the loss of security suffered in childhood by a distant parent or access the
fear of violence by an abusive parent, that, rather than lead to reinforce-
ment of the sadness or fear, will lead to its reduction. When the sadness and
fear are empathized with and soothed by the therapist’s attunement, and
the unmet needs for security or protection are met in therapy, they are trans-
formed by this corrective emotional experience. In addition, the experience of
resolution and need validation in the present leads to positive expectations
of future need satisfaction and less overall future anxiety or concern about
need satisfaction.

CLIENTS DESERVE TO HAVE NEEDS MET

Therapists work to access feelings, but it is not just acceptance of emotion

and their symbolization in words that is important. All emotions carry within
them needs, met or unmet, and it is these needs that have to be reclaimed
to get the emotion’s message and action tendency. Therapists need to help
clients get to their needs. Psychological suffering and emotional pain are
indicators of unmet needs; thus, considering what needs are unmet is a
crucial part of the therapist’s work. When activated in therapy, previously
disclaimed emotions can be used to reclaim unwanted self-experience,
therefore giving the person information about needs met or not met, one’s
response to situations, and action tendencies to cope with them.
228  •  Changing Emotion With Emotion

The psychological needs most commonly violated or not responded to,

which, thus, bring an experience of emotional suffering, are:

• the need to be connected and understood, the lack of which produces a

sad loneliness and the basic anxiety of insecurity

• the need to be respected, acknowledged as valuable, appreciated, and

validated in what the person does and who they are, the lack of which
produces shame

• the need for safety and security, the lack of which produces fear

Once emotions are accessed, they inform people about their wants or
needs; emotion work involves accessing emotion schemes to get at the needs
inherent in them. An important distinction when working with needs is that
of accessing a heartfelt need versus facilitation of the cognitive articulation of
a need. It is the heartfelt need that helps facilitate transformation. The heart-
felt need is one that comes out of experiencing the painful primary emotion
when emotion schematic processing is activated. It is the activation of the
scheme that gives access to the unmet need. Now, the need is felt as opposed
to merely talking about the need in a more conceptual manner. By analogy,
if someone has a dagger sticking in their side and is asked what they need,
the experienced pain lets them know that they need the dagger removed and
relief from the pain. This is experiential knowing, not conceptual knowing.
The body knows what it needs to survive. This is not existential pondering but
organismic necessity. So, in this discussion of needs, I mean heartfelt needs
that are made obviously clear and accessible by the felt pain of the emotion
schematic activated experience.
In working with emotion to achieve change, we therapists are not trying
to understand and promote understanding of people’s motives by analyzing
the content of their lives and interactions and looking for patterns or expla-
nations of why they do certain things. Rather, we let the emotions reveal
their motivations and action tendencies. We do not see dysfunction as arising
from neurotic needs or their denial, nor do we see dysfunction as occurring
because of interpersonal patterns based on unfulfilled wishes or on inter-
nal working models related to attachment. Rather, therapists see problems
arising from (a) the disclaiming of emotion, (b) the perseveration of certain
past emotional responses in the present, (c) emotion dysregulation, and
(d) narrative construction. Therapeutic work involves keeping our finger on
the emotional pulse of our clients rather than figuring out their conscious or
unconscious motivated patterns or errors in thinking. Emotions are the royal
road to needs.
 Working With Needs  •  229

In therapy, unmet needs often arise in the context of past situations of

abandonment, neglect, and abuse. The learning from those past experiences,
when it was impossible to get the need met, was that it was too painful to feel
and to need, so people shut down to avoid feeling the excruciating loneliness
of isolation, the fear of abuse, and the shame of invalidation. As a result, they
do not need and do not feel, which impacts their current life because they are
unable to, from meaningful relations, connect with others and experience
love or joy. Therapeutic work often involves the client’s letting go of trying
to get the need met by the people who so disappointed them. It requires
separation of the need from the particular other in question. Therapists
promote reowning the need and validating it but also help clients redirect
their efforts at need satisfaction to alternative sources. In doing so, thera-
pists are attempting to mobilize the disowned, unmet needs from the past
but, at the same time, help clients let go of trying to get the need met by the
people who so disappointed them.
After having helped the client process the painful feeling and access the
unmet need, therapists ask, “Who else could meet this need?” Ultimately,
the client must accept that the need is valid and healthy, and that they are
deserving of having it met but that the particular relationship, which origi-
nally never met the need, was inadequate. Therefore, they need to let go of
trying to get the need met by the depriving person.

Evaluating the Worth of One’s Needs

A further important aspect of working with needs is to recognize people’s

ability to evaluate the value of their own desires, feelings, and needs (Taylor,
1990). Thus, in determining the self one wishes to be, people have the
ability either to desire or not desire their first-order feelings and desires. In this
second, higher order, more conscious evaluation, the worth of a desire is eval-
uated against some ideal or aspired-to standard. Being a self involves being
self-evaluatively reflective and developing and acting according to higher
order values or desires. Essentially, this means developing feelings and desires
about feelings and desires. For the emotion system, the evaluation is simply,
“Is it good or bad for me?” whereas in the stronger, self-reflective evaluation,
there is also a judgment of the value of the emotion and its accompanying
desire. People evaluate whether their emotions and desires are good or bad,
courageous or cowardly, useful or destructive. They form subjective judgments
of the worth of their own desired states and courses of action (Taylor, 1990).
Thoughtful reflection on emotional promptings is a key part of emotional
competence. This is where conscious thought plays its crucial role. Thought
230  •  Changing Emotion With Emotion

must be used to judge whether emotional prompting coheres with what

people value as worthwhile for themselves and others. This is not just a
matter of “get in touch with your feelings and follow them” but involves
both evaluating the desirability of the feelings one gets in touch with and
changing them when they are no longer aiding adaptation.
Therapists, thus, help people feel entitled to their need, but this entitle-
ment should be to their need’s being legitimate and not to the legitimacy of
having the other person meet their need, which is an unproductive form of
entitlement. Healthy entitlement is supported by clients’ expressions being
made through “I” statements, which help in the taking of responsibility. So,
“I deserved more” is better and emphasizes agency more than “Why did you
not give this to me?” which is more of a complaint. Once the person experi-
ences “I deserve,” the person is empowered, and the question “What do you
need to do to get what you need?” is viable. Although the need often is inter-
personal at times, it can also be from the self, so therapists can ask, “What do
you need from the other or from yourself?”

Mobilizing Agency

Therapists need to work toward emotion and need activation. They see
development as occurring by way of transformation of emotion rather than by
learning through conditioning, skill training, or rational restructuring to change
behavior. Emotion-oriented therapists also do not focus on understanding
motivation; rather, they try to access emotions. Instead of analyzing clients’
interactions to find patterns of behavior or explanations for actions, therapists
access emotions and make sense of the motivations and action tendencies
within them. Problems are seen as arising from disclaiming of emotional expe-
rience and from the perseveration of certain past emotional responses in the
present as well as from lack of emotion awareness, emotion dysregulation, and
faulty meaning creation.
The need and action tendency in an emotion provide direction; in adaptive
emotion, they provide meaning and orientation. In maladaptive emotions, the
sense of having deserved to have the unmet need met and the therapist’s
validation of this sense facilitate access to the adaptive emotions of asser-
tive anger, the sadness of grief, or compassion for the self for not having
had the need met. As a result, a sense of agency is mobilized in the person.
Approach action tendencies (often in anger and sadness) are then able to
undo the withdrawal action tendencies in the maladaptive feelings (often
of shame and fear).
 Working With Needs  •  231

SESSION EXAMPLES

The following transcripts show therapists working to access the heartfelt

needs within aroused emotions. Some of the examples illustrate how this
work leads to new adaptive emotions.
The first excerpt is from the very beginning of therapy. The therapist
is creating an alliance with Mary, a 49-year-old, depressed, White woman,
of English descent, who has suffered a trauma and is scared to be assertive
with her husband to express what she feels and needs. The woman has been
lied to by her husband about his illegal financial dealings, and she now has
to cope with the fear and humiliation of his potential incarceration. Before
clients go on the path of facing their pain, it is helpful for them to have
some sort of rationale as to how this may help. Telling them that getting
to their need will help guide them is a good way of gaining agreement on
a therapeutic goal and thereby creating a good alliance. In this excerpt,
the therapist offers the rationale that by exploring together her emotions
and her needs within the emotions, this exploration will help clarify what
direction she wants to take, which will help her feel better. The therapist
frames the therapeutic work in terms of facing her fear and identifying
her need.

“I’m Game to Go Ahead”

THERAPIST: Well, I still think that, you know, it looks like something that
needs to be explored, you know, that part of yourself that is most
of the time contained—actually giving it a voice in the safety of
this room, um, [to] actually clarify what you need to say to your
husband about what that’s all about (Client: Mm-hmm.) inside.
And you know that’s the first step: to unlock the feeling and
unlock the emotions, and from that, we will see how it’s going
to come out. But typically, what happens is people get a better
sense of what they are experiencing, and from that, you get a
better sense of what you need (Client: Mm-hmm.) in the situa-
tion, um, and through that, it provides a sense of clarity (Client:
Mm-hmm.)—well, more clarity in terms of what you need to
do next (Client: Mm-hmm.). Yeah, so. [providing a rationale to
work on emotions and need]

CLIENT:  I’ve, um, well, that’s why I’m here.

232  •  Changing Emotion With Emotion

THERAPIST: What—what are you feeling, or what’s your gut reaction when
I say that, or . . .
CLIENT:  Well, I think, um, I think that is the direction that we have to
take because, um, I don’t see any other, any avenues rather than
a status quo, which obviously hasn’t been working and, over
time, is—is not getting any better. (Therapist: Mm-hmm.) Um,
so I certainly, at the end of last session, felt more, uh, I guess you
might say, game to (Therapist: Mm-hmm.)—to go ahead and
not worry so much about (Therapist: Mm-hmm.) what the end
result would be. I mean, it’s certainly some concern. (Therapist:
Mm-hmm, sure.) I’m not just sort of (Therapist: Sure.) blowing
all kinds of caution to the wind (Therapist: Mm-hmm.), but, you
know, I need to not, um (Therapist: Mm-hmm.), fear change.
[agreeing]
THERAPIST: And, certainly, you have control in this process, too, it’s (Client:
Mm-hmm, mm-hmm.)—and you have ultimate control in what
you decide to do. That’s not something that I would be telling
you what to do. (Client: Mm-hmm, mm-hmm.) It’s—this process
evolves from within yourself. Yeah, I sense that you are kinda
feeling like, okay, um, maybe really let go a bit of this fear and
just take a chance? And see what happens? Is that kinda what
you are feeling? [providing safety of control]
CLIENT:  Yes, I need to do this.
THERAPIST: Mm-hmm. What do you—what do you need from him, what
would you like to tell him what you need from him? [getting at
need conceptually]
CLIENT:  Well, I need his trust. I think that this has eroded our, um—
I needed him to let me know the bad parts as well as the good
parts, even if, maybe, he doesn’t think well of himself. I know
he thinks I’m critical of him, and I am. There are a lot of things
that definitely offend me, and he doesn’t want to hear that. He
thinks by hiding, um, enough of the stuff that’s going on, maybe
I won’t notice all the things that will back up my feelings that
he’s not a good person.
THERAPIST: So, you are saying, “I need you to basically let me hear about
parts of yourself and what’s going on. I need to hear that.”
CLIENT:  My husband always has this great fear that, um, he would
be in court or somewhere, and if I am called to testify—and
 Working With Needs  •  233

I wasn’t—testify against him or let things out that work against

him (Therapist: Mm-hmm.), and some of it comes from the fact
that he knows that I can’t lie very well. (Therapist: Mm-hmm.)
And I think some of it comes from the fact that he thinks, in
his own mind, “She thinks I’m wrong,” and under that kind of
pressure, it’s going to come out that “she thinks I’m wrong.”
(Therapist: Mm.) Um, there it will be in front of everyone (Ther-
apist: Mm-hmm.), um, it would be on public record, it would
be (Therapist: Mm-hmm.) used against me by my, um, accusers
(Therapist: Mm-hmm.), and there will be, uh, nowhere to hide
(Therapist: Mm-hmm.), no way to save myself, and . . .
THERAPIST: What’s happening to you, what’s happening to you now, what
are you experiencing?
CLIENT:  Well, it’s a very sad thing. It’s a very, um, destructive thing.
THERAPIST: Very painful, isn’t it, to . . .

CLIENT:  Yeah, to a certain extent, I think, um (cries) . . . [activated emo-

tion schematic processing]
THERAPIST: Can you stay with that, just the feeling, hold that feeling?

CLIENT:  I feel so untrusted, so left out (cries).

THERAPIST: What do you need from him? [heartfelt need]

CLIENT:  I needed him to respect me enough to trust me, to keep me in

the loop. I—I didn’t know what to expect. I feel myself get-
ting more and more angry with him. (Therapist: Mm-hmm.)
(Client now speaks as if to her husband.) “Why did you let things
come to this stage where I had to be in here defending myself,
defending you without the tools to be able to do it?” (Therapist:
Mm-hmm.) I was just so angry.
THERAPIST: Mm-hmm. “I feel betrayed almost . . .”

CLIENT:  “I felt (Therapist: Yeah, it’s not fair.) very much betrayed, very
much set up (Therapist: Mm-hmm.) so that I had no—no way to
defend myself (Therapist: Mm-hmm. “I was left out.”), very little
knowledge about how to help you [husband]. I need you to
trust me.” [heartfelt need]
THERAPIST: “Just so betrayed. So, painfully sad, too.”

CLIENT:  “I feel so sad (cries) that this is what it’s come to, such a loss.
Married for 26 years, and you didn’t trust me, and now I can’t
234  •  Changing Emotion With Emotion

help you. In fact, I hurt you by what I’ve said in those inter-
views, and we have lost all we had. It’s like our history is being
shattered, and you will in some way die to me even though you
will be alive. (Sobs) Just such a loss, and now I have to carry on
without you. I needed you to trust me more, and now I’m now
all alone. Just so sad . . .”

After stating her need, the client begins to access her anger and then her
sadness. She works through her sense of betrayal to get to her loss and
begins a grieving process.
In the next excerpt involving a different client, the therapist guides the
client to regress to an earlier adolescent time to get to the emotion and
the unmet need. After accessing her sad, lonely feeling, the client gets to
her unmet need for contact/comfort and to be liked, which leads to a sense
of deserving anger. Her fear is touched on but not worked through in this
segment, but she accesses the unmet need for protection and safety—which
most often is the organismic need—in the face of violence. This need, over
time, would be followed and may lead to boundary-setting anger, the healthy
sadness of grief, and compassion to the self.

“I Need You to Like Me”

In this excerpt, the client, Chloe, a 33-year-old, Black, Jamaican woman
who is employed as a nurse, is working on her childhood abuse and neglect.
She presented with difficulties in interpersonal relations and in adjusting to
a new job.

THERAPIST: Let’s go back and be 13 years old, and speak to your father. As a
13-year-old, tell him what you told me: “I’m really trying to . . .”

CLIENT:  “I’m really trying to get your attention to get your love, to show
you: Look how good I am in school. Look at all the awards I’ve
gotten. Look at all the awards I’ve gotten.”

THERAPIST: As a 13-year-old, what’s it like? Tell them [both parents], “I’m

really . . .” [focus on internal experience]

CLIENT:  (Speaks as if to her parents) “You know, I’m really turning to

my friends because there’s nothing at home for me—there’s
nothing here. The only thing I get at home is discipline and work.
And when I’m done with my homework, it’s clean the house or
do this or go down to the basement, you know, like go play in the
cold basement. It was never, ‘Let’s go out together,’ ‘Let’s do this
together,’ or ‘How was school today?’ It felt cold and lonely.”
 Working With Needs  •  235

THERAPIST: What did you feel? [focus on internal experience]

CLIENT:  Just unloved (cries). Sad, lonely, and empty. [focus on internal
experience]

THERAPIST: Yes, so unloved, unwanted. Tell him what you needed, what you
missed: “I needed . . .” [heartfelt need]

CLIENT:  (Speaks as if to her father) “You know, I needed to have some

type of contact, conversation with you to find out how my life is
going, to find out how your life was going, you know, there was
nothing there. You’re just people that I feared. I didn’t—going
home was not a nice experience. I didn’t like being at home,
particularly all the fighting.”

THERAPIST: Go back. Be the 13-year-old and tell them what it’s like. It’s hard
to go back there, but you were there at one time. Do you feel
any of the fear? [age regression]

CLIENT:  If I was 2 minutes late, I was terrified ’cause I knew I was going
to get hit.

THERAPIST: Tell them about this fear . . . as the 13-year-old. [focus on under-
lying fear]

CLIENT:  “Yes, I’m afraid. I’m terrified. I just want you to like me. I’m
really trying to be good. I’m really trying to be good so you’ll like
me. So, you know, you’ll like me and see that I’m a good kid, and
you’ll want to do things with me.” [fear and need]

THERAPIST: Tell them, “I need you to like me.” [heartfelt need]

CLIENT:  “Yeah, well, yeah, I need you to like me.”

THERAPIST: What do you feel now as you say this? [focus on emerging new
feeling]

CLIENT:  I feel so deprived. I’m angry. I deserve to have parents who like
me. Goddammit, you were my parents. I deserved to be loved.
I was just a kid trying so hard. [deserving of assertive anger,
which is self-affirming]

The preceding sequence demonstrates that the need is pivotal. When the
client expresses her need and feels deserving, a new adaptive emotion of
anger is generated. She now feels more deserving and is more of an agent
who is stronger and less of a passive recipient of the mistreatment. Allowing
and acceptance her initial feelings of sadness, fear, and loneliness are
236  •  Changing Emotion With Emotion

necessary and important yet insufficient for change. What is central is that
once an unmet need is accessed, a new emotion, in this case, anger, mobi-
lizes the person to get what she needs to promote her own survival and
growth. Her newly felt adaptive anger provides a sense of direction and
an action tendency to achieve this.

“I Needed a Mother”

In the next example, Walter is a 47-year-old, White man suffering from

depression. In a previous session, he had just become his 6-year-old self and
was experiencing his fear. He had expressed his fear by saying, “Very scared.
Feel like I will be hurt by her [mother] at any time,” and the therapist had
responded, “Very unsafe.” Here, the therapist facilitates the heartfelt need
now that the client’s emotion schematic fear has been activated and differ-
entiated. This heartfelt need comes out of the sense of what he needed to
make the painful feelings go away. Note how accessing the need leads to
accessing newly experienced anger at not having had the need met and,
ultimately, leads to beginning to grieve for what was missed.

CLIENT:  Right, right.

THERAPIST: When you feel so scared, so panicked and unsafe, what do you
need? [heartfelt need]

CLIENT:  What do I need?

THERAPIST: Hmm. What did you need from your mother at that moment?

CLIENT:  I needed a mother. . . . I needed her to make things clear. . . .

Don’t scare me so much. Don’t threaten me like this.

THERAPIST: (Points to the empty chair) Tell her: “I need you . . .” [amplify the
need]

CLIENT:  (Faces the empty chair and speaks as if to his mother) “I need
you . . . [to] be patient to make things clear . . . make clear
what’s going on and why you are so angry. . . . I don’t know
the consequences and impact of what I do. . . . I need you to be
patient and tell me that it’s wrong and why it’s wrong (cries).
I need you to be clear. . . . Then, if I understand, I won’t do it
again next time.” [heartfelt need]

THERAPIST: So, I need you to make it clear, what’s going on, not to scare me.
What do you feel right now? [focus on emerging feeling]
 Working With Needs  •  237

CLIENT:  I feel angry inside now. [assertive protective anger]

THERAPIST: Hmm. What is the anger like?

CLIENT:  I want to attack her back.

THERAPIST: What do you want to say or do?

CLIENT:  I would like to beat her back.

THERAPIST: Do it.

CLIENT:  He hits a pillow with his hand. [symbolically aggressive anger]

THERAPIST: What is the anger like if it is expressed in words? If the anger

can speak, what will it say? . . . You can feel your anger . . . You
say you feel angry.

CLIENT:  The anger is here (points to his stomach). There’s a fire which
wants to come out from here. It wants to attack, to destroy, to
say . . . [differentiating]

THERAPIST: Hmm. Feel the fire which wants to come out. If the fire could
speak, what would it say?

CLIENT:  Now I want to swear. “You’re a bitch. A fucking bitch. You were
cruel and mean, and you just used me. You never loved me.”

THERAPIST: Tell what you are most angry at her for? What makes you most
angry? [differentiating]

CLIENT:  I feel she is unreasonable . . . totally unreasonable. She only can

use violence to attack others. [differentiating]

THERAPIST: Tell her.

CLIENT:  “I’m furious. I’m so angry.”

THERAPIST: Yes, some more, tell her. [intensification]

CLIENT:  “I’m angry at you. . . . I’m angry at you for that you seem like a
mad person. I feel you’re really sick.”

THERAPIST: Only in violent ways.

CLIENT:  “Just a mad person. You can only be mad. . . . You’re the one
who has no brain in the family. . . . Feel like you don’t treat me
as a family member, just like we are your enemies. I feel like you
treat me as your enemy. If I do something wrong—even little
238  •  Changing Emotion With Emotion

things at home—not just me, including my father, you will go

crazy like a mad person.”

THERAPIST: What do you need from your mother? [heartfelt need]

CLIENT:  I need my mother to speak well . . . to think clearly . . . to

think clearly whether I am your family or your enemy. I need my
mother to have a certain attitude—to treat us as your family.

THERAPIST: Yes, tell her what it was like to not get this. Tell her what you
missed. [shift to sadness]

CLIENT:  I need her to have a consistent attitude. I missed the safety of

knowing what was coming, of what would happen next. It was
scary, and it’s sad that I lived so long in fear. I missed a lot of my
childhood.

At this point, the client begins to focus more on the grief of what he had
missed, but he continues to oscillate between anger and sadness.

“It Wasn’t My Fault”: Confronting the Internal Critic

In this next example, the client, Jina, a 32-year-old, White, European woman
who had been sexually abused as a child, is confronting her own internal
critic, who blames her for her abuse and pushes and criticizes her. She begins
in the self chair, speaking to the critic. This later evolves into a dialogue with
a mother who ignored the daughter’s sexual abuse. At this point in the tran-
script, the client is telling her critic to stop abusing her. Essentially, the critical
voice is blaming her for making mistakes based on her blaming herself for
the abuse when she was a child. This excerpt again illustrates that when the
unmet need for love and acceptance from the self and the need for protection
from the mother is accessed by going into and allowing the painful feelings
of being unprotected, it leads to the emergence of more healthy adaptive
emotions:

CLIENT:  (Talks to the critic) “It’s not needed” (sniffs).

THERAPIST: Yeah, tell her, “I don’t want that abuse anymore.”

CLIENT:  “I don’t want you to abuse me anymore. I don’t want it.”

THERAPIST: “Yeah, and I’m really angry.”

CLIENT:  “I’m angry at you for making me feel so pressured, and I act out
of guilt, and I do stupid things, and then I feel worse, and it’s
 Working With Needs  •  239

just a vicious cycle [access emotion scheme] (blows nose), and

then I second guess myself, and it just (cries, sniffs) interferes
with everything.”

THERAPIST: “Yeah, you interfere with my whole life.”

CLIENT:  “And I don’t want you to interfere anymore.”

THERAPIST: Yeah . . . What do you want? [heartfelt need]

CLIENT:  I want her to be able to forgive me and let it go (cries) (Thera-

pist: Yeah.)—let me make mistakes if I need to (cries).

THERAPIST: “Let me be human.”

CLIENT:  (Cries) That feeling I had when I was 5. [scheme activation]

THERAPIST: What is it?

CLIENT:  (Cries) “That’s when you told me it was my fault that I was
sexually abused, and I hate that feeling. I feel so guilty and
worthless (Therapist: Yeah.), and I think that’s the connection
I have.”

THERAPIST: Yeah. Tell her—take a step.

CLIENT:  “It wasn’t my fault. I was just a little girl.”

THERAPIST: Yeah, “I was a little girl.”

CLIENT:  I felt pressured. I should have said no, but I didn’t, but it was
because I was pressured, and any little kid would have done it.

THERAPIST: Yeah.

CLIENT:  I’m not abnormal.

THERAPIST: “I was young and scared and nobody was there.”

CLIENT:  (Blows nose) Nobody was there to keep me safe.

THERAPIST: Yeah, yeah, that’s right. “I was in danger, and I just did what I
could, what I had to, to survive. It wasn’t my fault.”

CLIENT:  “It wasn’t my fault (cries) (Therapist: Yeah.), and it wasn’t my

fault. Stop telling me it’s my fault. (Therapist: Yeah, yeah.) It
wasn’t my fault (cries).” [assertive anger]

THERAPIST: Yeah, yeah, it’s really heavy to hold that.

240  •  Changing Emotion With Emotion

CLIENT:  “It’s been like a rope around my neck just waiting to be tight
enough to choke my life out, and I have a life worth living, and
I don’t need to die.”

THERAPIST: Yeah.

CLIENT:  “I can be productive.”

THERAPIST: Yeah, yeah.

CLIENT:  “And I can stay productive if I can just get you to work with me
instead of against me [referring to her critic].”

THERAPIST: And how could she work with you? What do you need from her?

CLIENT:  “I need you to forgive me, to realize that it wasn’t my fault,

(Therapist: Yeah.) to love me.” Because she hates me for being
so stupid to let that happen, and I could have had control, but
I didn’t . . .

THERAPIST: So, you want her to realize that the truth is that little children
can’t stop . . .

CLIENT:  Abuse.

THERAPIST: And it’s not their fault—yeah, so you need forgiveness and you
need comfort.

CLIENT:  I need love (Therapist: Yeah.) I need to be loved for who I am.
[heartfelt need]

THERAPIST: Yeah: “Love and accept me for whatever way I am, yeah, all of
me.”

CLIENT:  And to let that go because that destroys everything.

At this point, the dialogue shifts to the mother who ignored her abuse.

CLIENT:  (Speaks to her mother in an empty chair) “I resent you for not
loving me, even when I changed and was . . .”

THERAPIST: So, “I resent you for not seeing my pain (Client: Yeah.) all those
years”?

CLIENT:  “And I bottled it so much to the point where it was just explod-
ing, and you didn’t see any of it, you didn’t recognize it. (Thera-
pist: Yeah) I needed you to help me feel better about myself, for
it happening, I was just so afraid of you (blows nose), and I was
 Working With Needs  •  241

afraid that if you ever found out, you would hate me and throw
me out of the house.” [heartfelt need]

THERAPIST: Uh-huh, uh-huh, so you needed to feel that I could tell you to
feel safe.

CLIENT:  “I didn’t feel that I could approach you and say this happened
(Therapist: Yeah.), and that makes me angry. Why couldn’t I
tell you? (Therapist: Yeah.) I was just a little kid.” [emerging
assertive anger]

CLIENT:  “I was just a little kid.”

THERAPIST: “So I’m angry at you for silencing me.”

CLIENT:  “For not listening to me when I did talk, and . . .”

THERAPIST: Yeah, yeah, so kind of like she didn’t create an environment

where you felt . . .

CLIENT:  Safe at all.

Again, it is not only accepting the painful feelings but also that sense of
agency that is provided by access to the need that gives the whole process a
sense of direction. The process can be described as a deepening downward
and inward movement to arrive at the painful underlying feeling, followed
by an emergence—an upward and outward leaving and moving toward new
possibilities.

CONCLUSION

Getting at heartfelt needs, which are embedded in underlying painful emo-

tions, helps people access more adaptive emotions. This chapter looked at
what needs are, how they are developed, and how to activate them to promote
change. In addition to activating clients’ recognition of their own needs, it
is important that therapists help people feel that they deserve to have their
needs met, especially in situations of past deprivation. Doing so provides
clients with a sense of worth and helps them move from a passive position
toward a more active, assertive position in which they feel deserving of having
had their needs met.
Accessing a feeling of deserving to have a previously unmet adaptive
need met is a central part of the change process of undoing old feelings with
new ones. It is best achieved by dealing with unfinished business from the
past, so the next chapter looks at reexperiencing the past in the present.
10 REEXPERIENCING THE
PAST IN THE PRESENT

As demonstrated in Chapter 9, identifying the unmet needs in a painful

emotion can often involve a journey into the client’s past. In this chapter, I go
into greater depth to share several methods of reexperiencing past emotional
events to access and transform maladaptive emotions. I discuss different
memory processes—episodic, autobiographical, and semantic memory as well
as declarative and procedural memory—and their implications for practice
with a focus on exploration of the role of memory reconsolidation in pro-
moting therapeutic change. I then describe various ways of accessing memo-
ries to make them accessible to change and outline, in particular, age regression
interventions. In these interventions, clients are invited to go back, become the
child, and speak as the child as well as talk to themselves as a child in imag-
ination or in a chair dialogue. These evocative interventions can be disorga-
nizing for some highly fragile, severe personality-disordered clients. Clinical
judgment based on degree of client fragility and the strength of the therapeutic
relationship need to be used in the decision to engage in going back into child-
hood memories (Bateman & Fonagy, 2004; Yeomans et al., 2015).

https://doi.org/10.1037/0000248-011
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

243
244  •  Changing Emotion With Emotion

EPISODIC, AUTOBIOGRAPHICAL, AND SEMANTIC MEMORY

Emotion and memory are highly interrelated. Emotion schematic memories

of painful experiences that need therapeutic work are most accessible by acti-
vating episodic memories. An episodic memory is a memory of a past personal
experience that occurred at a particular time and place. It is the unique, sub-
jective memory of a specific event so always will be different from someone
else’s recollection of the same experience. Episodic memories are of events
that can be explicitly stated, such as one’s spending the first day at a new job,
attending a relative’s 100th birthday party, or a bride’s recalling her wedding
day. These memories are not just memories of the bare facts of the event itself;
rather, in these memories, people see themselves as actors in the events, and
the emotional charge and the entire context surrounding the event are part of
the memory. Episodic memories give the best access to emotional experience.
A good way to access episodic memories is through age regression, a type of
intervention in which clients are invited to go back and become their child.
This intervention activates memories of experiences and specific events
to help unfold the sequence of the actual events that took place at any given
point in a person’s life so that it can be reconstructed.
“Episodic memory” is sometimes confused with “autobiographical memory.”
The two are related, but different. Autobiographical memory is a memory
system consisting of a number of recollected experiences from an individual’s
life based on a combination of episodic memories plus semantic memories
(general knowledge and facts about the world). Autobiographical memory
thus contains the information one has about themselves that builds across
episodes. This memory process includes several domains of which self-
description—the source of a large part of a person’s sense of identity—is an
important one and contains information, such as one’s occupation, favorite
color, and ice cream flavor preference.
Autobiographical memories are also important in therapy. Autobiograph-
ical memory narratives disclosed by clients are often related in the land-
scape of action in terms of what happened and generally are initially told
in a more external than internal manner. They provide the client with
the chance to engage in storytelling to create a visually rich, detailed picture
describing what happened. Whereas autobiographical memory may involve
episodic memory, it also relies on semantic memory, which has to do with
the knowledge and rules governing behavior that have been acquired
through a lifetime of experiences. Semantic memory is factual and typically
devoid of emotion or reference to the self or to specific times and places. In
semantic memory, for example, one knows the city they were born in and
 Reexperiencing the Past in the Present  •  245

the date, although they do not have specific memories of being born there.
Autobiographical recollection, on the other hand, involves thinking about
past events in a personal way, is emotionally meaningful, and has great
relevance to people’s sense of self and the meaning of their lives. Although
semantic knowledge conveys meanings, it is rarely the kind of personal
meaning embodied in autobiographical and episodic memories. Semantic
memories, therefore, are far less relevant in a therapy focused on emotion
because they usually are recounted with little or no emotional arousal.
The critical distinction between semantic and especially episodic memory
is not so much the type of information being processed but the depth of
experience involved in each. Episodic memory is highly experiential and pro-
vides the person remembering with the lived experience of remembering. It
is the most powerful memory process for accessing affect because it makes
possible a type of mental time travel through subjective time—from the
present to the past—thus allowing one to reexperience previous experi-
ences. This simply does not occur when recalling factual knowledge through
the semantic memory system.
Here is an example of memory processes in which the client shares both
autobiographical and episodic memories:

CLIENT:  The memories I have preceding age 4—they are always like in
regards to pleasing people and making them feel good. . . .
My mom was working during the day, but in the mornings, and
she always would bring in this baby bottle for me, and I remem-
ber one morning, she brought it, and I took it, and I started
sucking. . . . Ooh, God, ugh! I hate this taste, but, somehow,
I knew it is important for her, you know, like part of her daily
routine and also like the contact between me and her and the
preparations and everything. . . . I couldn’t say anything, and
this is what I do all the time . . .

THERAPIST: So, it’s pretty amazing at 2½, you were already so attuned that
this would hurt her, that I’m going to drink this anyway and not
ruin it for her, like, “I sacrifice myself.”

Here, the client relates an autobiographical memory demonstrating her

inability to assert her needs, and the story includes an episodic memory in
which she actually almost tastes the bottle and feels the disgust. This sensory
detail makes the experience accessible now to reprocess at the experiential
level. If the client had relayed information about this time of her life as a
more general semantic memory (e.g., “Mom worked during the day, but she
always brought me a bottle to drink every morning when I was little”), she
246  •  Changing Emotion With Emotion

could reprocess the experience at a conceptual level of insight. Insight can

be helpful for understanding that her mother cared for her, but reprocessing
the experience means changing the feeling of it so she no longer feels lonely
abandonment in her body.

DECLARATIVE VERSUS PROCEDURAL MEMORY

Episodic, autobiographical, and semantic memory together are known as

declarative memory, which refers to memories that can be articulated as
opposed to another type of memory, procedural memory, which is responsible
for knowing how to do things but not knowing what it is that one knows
in one’s body. Procedural memory stores information on how to perform
certain procedures, such as walking, talking, and riding a bike at a level below
conscious awareness or, as in the preceding example, the experience of the
daughter’s subsuming her own needs to please the mother despite the disgust.
Semantic memory, then, is a more structured recorded memory of what hap-
pened; it can be articulated in language, whereas procedural memory cannot.
Procedural memory is important because it carries scripts, the unconscious,
automatic sequences of experience and action that constitute a lot of people’s
psychological lived experience. A lot of emotional schematic reactions are
operating at the procedural rather than the declarative level. They are trig-
gered by cues without deliberate intention. For example, when the boss raises
their voice, it automatically activates fear and an action tendency to withdraw.
Or, when a spouse frowns, the partner does not consciously know that their
spouse’s expression of disappointment is actually covering their anger, which,
if expressed, would activate guilt, which would lead the spouse to block their
expression of anger. None of this is conscious, but it is a script stored in
memory at the procedural level and requires activation in therapy to trans-
form this sequence.
Personally-relevant events appear to be stored in memory at their “emotion
addresses” through the emotion schematic processing system. One memory
of sadness is connected to other memories of sadness. When people feel
angry, anger memories are activated. This form of mood-dependent memory
means that a current disappointment links to other disappointments, a feeling
of shame to other diminishments. Present emotional experiences, thus, are
always multilayered, evoking with them prior instances of the same or
similar emotional experiences. Therapists need to access memories in therapy
to transform much of people’s maladaptive emotional experience. We first
have to arrive at painful emotions from the past, predominantly by activating
episodic memories, and only then can we help people leave them through
transformation by having new lived experience in psychotherapy sessions.
 Reexperiencing the Past in the Present  •  247

Boritz et al. (2008, 2011) directly investigated the relationship of expressed

emotional arousal and autobiographical memory in the context of early,
middle, and late phase sessions of the treatment for depression. They found a
significant increase in autobiographical memory specificity from early to late
phase therapy sessions. Treatment outcomes were predicted by a combination
of high narrative specificity plus expressed arousal in late phase sessions. So,
as opposed to providing generic memories like, “My father was never there,”
remembering a specific time when he was absent was therapeutically more
productive. In addition, the combination of expressed emotional arousal
and narrative specificity was associated with complete recovery at treatment
termination. Recovered clients were significantly more able to emotionally
express their feelings in the context of telling specific autobiographical
memory narratives than clients who remained depressed at treatment termi-
nation. Interestingly, some cognitive experimental research findings (Williams
et al., 2007) have consistently identified difficulty retrieving specific personal
memories as a consistent marker of clinical depression. Accordingly, thera-
pists need to shift clients to be more specific by asking the client to give a
detailed concrete example or life event to exemplify a general concern or
issue and by facilitating a reexperiencing of episodic memories as opposed to
a global retelling of past memories and significant events.
The following excerpt drawn from a therapy session with a 47-year-old,
married, Caucasian client with complex trauma demonstrates the therapist
empathically supporting the narrative retelling of a trauma event involving
the episodic memory embedded in an autobiographical narrative memory.
The focus of the exploration, whether it was an internal experience or external
description, is noted in brackets:

CLIENT:  I said that to my sister yesterday, that night is so clear to me.

THERAPIST: The night she died.

CLIENT:  The night she killed herself. It’s so clear, I can remember
everything.

THERAPIST: Can you tell me?

CLIENT:  Just like it happened yesterday, and I remember, and it sort of

came into clear focus for me as a kid, and I hate it, I mean,
I hate it. I remember the night that my mother died, that’s what
it was like. [emergence of episodic memory narrative of suicide
scene] I was walking home to my brother and sister, my sister
was supposed to be babysitting my brother in the house, and,
um, it was quiet, and I thought they were waiting to jump out
and go, “Boo!” you know? Kids’ stuff. [external track describing
248  •  Changing Emotion With Emotion

what happened] (Therapist: Mm-hmm.) So, I tiptoe—tiptoe up

the sidewalk and open the front door very carefully and listen,
still nothing, just the sound in my eardrums. [shift to internal]

THERAPIST: This deafening silence. [therapist evocative reflection of internal

experience]

CLIENT:  So quiet, and I’m thinking this is really berserk, really crazy,
because usually by now, they’ve jumped out and scared the living
daylights out of me, and we’ve all laughed (Therapist: Mm.) and
punched each other, or whatever kids do. And I remember
walking in and still nothing, and thinking this is really funny, and
I took my boots off, and I went creeping down into the kitchen,
and I saw my mother’s foot first, and—I was in absolute shock
and not knowing what to do. [shift to internal experience]

THERAPIST: And your heart almost stopped. [evocative elaboration of inter-

nal experiencing]

CLIENT:  And I started shouting because I thought my sister was supposed

to be there, and I started screaming for my sister, and then I
noticed that on the table there was a note saying that she was
over at my aunt’s and uncle’s at a New Year’s party, and they had
put my little brother to bed there [shift to external], and that
was really because of all the turmoil as a child, too. I was fright-
ened to call anybody because you know your own business stays
within the four walls of your house, so (Therapist: Sure, sure.)
it felt like 10 hours, I’m sure it was a minute, but it seemed like
10 hours.

THERAPIST: So, then you walked in and saw what had actually happened.
[Therapist invites a return to the scene and shift to external.]

CLIENT:  I tried waking her up. I thought she might just have, you know.

THERAPIST: Who knows as a child?

CLIENT:  And I’m just shaking her and shaking her and trying to wake her
up, and thinking, you know, oh, God, what do I do, who do I call,
what do I do (Therapist: Mm.). So, the first thing I did, I called
my aunt, she came over with my sister because, of course,
I said,—I don’t know what I said, I have no idea—and, of course,
when she came in, my heart also goes out to her because I can’t
imagine an adult, myself now walking in on a situation like
that—with your family.
 Reexperiencing the Past in the Present  •  249

In this segment, the client and therapist work together in a detailed unfolding
of a trauma scene. The client presents a clear, episodic memory along with
her internal experience.
In the next example with a client, the therapist probes for the disclosure
of a specific autobiographical memory narrative:

THERAPIST: Uh-huh. So, see if any specific memory comes up of any—of a

time when you really felt (Client: Uh—oh, yes.)—uh-huh. [focus
on episodic memory]

CLIENT:  I took—I remember the time when I called home. I called . . . I

called my mother’s home just to hear whoever’s voice answered.
I did it four or five times, and then I would just hang up (Thera-
pist: Hmm.) just to hear [her family name], just to get in touch
with that house that seemed so far away and gone and lost.

Here, the client responds to the therapist’s request for a memory with a
narrative that conveys the sense of the client’s poignant longing for the
family that she had to leave behind. She felt “lost” when she chose to leave
home as a teenager to live with the father of her newborn baby. It is clear
in the preceding two examples that the therapist is actively encouraging the
clients to shift to the recollection of emotionally significant personal memo-
ries and to describe their internal experience.
Therapists need to invite clients to shift from external processing of what
happened or from reflexive processing of what it meant to internal pro-
cessing of what it felt like to facilitate deeper emotional experience. Lewin
(2001) found that in good outcome, experiential therapies shift from exter-
nal or reflexive to internal processing, comprising almost a third (30%) of
all process shifts undertaken by therapists. In contrast, in poor outcome,
therapists initiated significantly fewer shifts to internal processing (16.75%)
than their good outcome counterparts. In essence, it appears as if the ther-
apist’s specific focus on emotional experience in the context of the client’s
reflections on their lives helps the client to enter more fully into a sustained
elaboration of their own internal world of felt emotions.

MEMORY RECONSOLIDATION

Emotionally distressing events result in emotional reactions. The emotions

of this experience fade unless they are “burned” into memory. The more
highly aroused the emotion, the more the evoking situation and the emotion
will be remembered (McGaugh, 2002). Then, the emotions are connected
250  •  Changing Emotion With Emotion

to memories of the self in the situation, and episodic and emotion schematic
autobiographical memories are formed. As a result, the emotional response
can be recreated again and again long after the event. For example, a memory
of a betrayal or something that reminds one of it stimulates an emotional
response of anger and hurt. Given that maladaptive emotion schematic
memories result in such painful emotions as fear, shame, and sadness, which
are at the center of many disorders, the possibility of disrupting previously
acquired emotion schematic memory by adding new input has important
clinical implications.
As discussed in Chapter 4, memory reconsolidation provides a way of
understanding how distressing emotional memories can be both strengthened
over time and also altered through the corrective experience. Consider, for
example, an emotionally distressing event, such as a betrayal or abandon-
ment. The emotional reaction is an integral component of the memory
connected via the spatial and temporal context to the event and bound to the
self, thus forming an autobiographical memory. The more highly arousing the
emotional reaction, the more likely an episodic memory will be formed and
the evoking situation will be vividly remembered later on. When a memory is
recalled, the emotional response is reengaged, and the sympathetic nervous
system is reactivated via the amygdala. According to reconsolidation theory,
the recollected event and its newly experienced emotional response are
reencoded into a new and expanded memory trace. Thus, memory for the
original traumatic incident is strengthened, making it (and the now intensi-
fied emotional response) even more likely to be accessed in the future.
This theory also provides a mechanism for understanding how this same
emotional memory might be revised. During therapy, patients are commonly
asked to recall and reexperience a painful past event, often eliciting a strong
emotional reaction. If the psychotherapy process leads to a new, more adap-
tive emotional response, this plus the feeling of being in the context of the
safe, therapeutic, relational environment can then be incorporated into the
old memory through reconsolidation. In this view, change in psychotherapy
is not simply the result of a new memory trace being created or new semantic
structures being developed. Instead, reconsolidation leads to the transfor-
mation of the components of the memory structure itself. It is conceivable
that once this transformation has taken place, the original memory, including
the associated emotional response, will no longer be retrieved in its previous
form. By this view, psychotherapy is a process that not only provides new
experiences but also changes our understanding and experience of past
experience in fundamental ways through the transformation of memory.
It is important to reiterate that, in this process, transformation is not
simply the result of a new memory trace being formed; the original event
 Reexperiencing the Past in the Present  •  251

memory itself is transformed in fundamental ways. Psychotherapy, then, is a

process that not only provides new experiences and different ways to evaluate
new experiences but also changes emotion schematic memories of past
experiences in fundamental ways through the reconsolidation of memory.
Accessing a new emotion in response to the same situation is one of the
best ways to change the experience of an old emotion memory. Once a pre-
viously inaccessible emotion memory is evoked, the new emotional experi-
ence is integrated into it, and when the memory reconsolidates it, the new
emotion fuses with the old memory and transforms it. Thus, for example,
feeling adaptive anger to overcome shame leads to changing the memory of
the experience and thereby the narrative. As pointed out in Chapter 4, two
things are essential in this process: The old memory needs to be activated
so it is being currently experienced; then, novelty should be introduced only
after at least a 10-minute delay. New experience too soon or not in conjunc-
tion with memory activation, like in a subsequent session, will not produce
incorporation of new experience in the reconsolidation phase.
For example, consider the client mentioned earlier who recounted her
episodic memory of her mother’s suicide scene. Whenever she thought of her
mother, she had horrifying memories of her mother lying in a pool of blood on
the kitchen floor. Whenever this image came to mind, it left her feeling cold
and clammy with awful feelings of fear and emptiness. After working through
her anger, shame, and sadness, and after finally letting go and forgiving
her mother, the client talked about how this awful memory had changed by
remembering previous happy memories of her mother. These memories, in
contrast, left her feeling all warm and cozy. These new feelings toward her
mother changed the old cold, clammy feelings. They fused with the old feel-
ings to form a more integrated picture of her mother. This client reported later
at follow-up that when she thought of her mother, she no longer imagined
her lying in a pool of blood but, rather, remembered her alive mother and felt
warm and loving feelings. Ultimately, a full transformation of her emotion
memory occurred, and she thought of her mother as the loving mother she
had known before the suicide, and she had good warm, feelings remembering
having felt loved by her mother.
Evoking the emotion schematic memory, reducing the intensity of previous
emotions by putting words on them, processing them further in terms of the
needs embedded in them and their impacts on the person’s experience, and
then introducing new emotions allow the memories to be reconsolidated in a
new way. Thus, in relation to, say, a betrayal, if the offending other is eventu-
ally seen with more compassion than anger, and the situation is experienced
with sadness at loss rather than shame of humiliation, the experience of
the memory changes. With new feelings, the emotion schematic memory is
252  •  Changing Emotion With Emotion

changed, and now the amygdala is no longer activated by memories of the

offending incident. To achieve this change, it is necessary to activate the pain-
ful memory and then to experience the memory of the betrayal without the
attendant pain and fear and, instead, with some new feeling, such as anger
or compassion. We need to see that what leads to change is the emotional
mechanism of changing emotion with emotion rather than a process of reason
triumphing over emotion.
New emotion memories, however formed, also help change autobiograph-
ical memories and ultimately personal narratives. Narrative and emotion
are intricately interwoven. No important story is significant without emotion,
and no emotions take place outside of the context of a story (Angus &
Greenberg, 2011; Greenberg & Angus, 2004). The stories people tell to
make sense of their experience and to construct their identities depend, to
a significant degree, on the variety of emotion memories that are available
to them. By changing their memories and by accessing different memories,
people change the stories of their lives and their identities. Thus, for the
client discussed earlier who thought about her mother’s suicide scene, her
access to positive memories of her mother and a new lived experience in the
session supported a view in which she saw her mother as loving and caring
rather than as recklessly abandoning, as she had previously seen her.
In discussing memory reconsolidation, it is important to distinguish it from
the behavioral phenomenon of extinction. In animal studies of both recon-
solidation and extinction, an element of the learning situation, the context
(a conditioned stimulus), is presented without its previous consequence (the
unconditioned stimulus). In most of the experiments with rats, the uncon-
ditioned stimulus is a shock administered through the grid floor. Because
of this similarity, there has been some question about how to separate the
two—and this has considerable importance in the present context because
reconsolidation is assumed to actually change components of the reactivated
memory, whereas extinction is assumed to merely create a new memory that
overrides the previously trained response. Thus, an “extinguished” response
is not really gone because it can spontaneously recover over time or be
reinstated if the organism is exposed to a relevant cue in a new context.
Recent work has shown that the cellular/molecular cascades in these two
cases are different and that whether reconsolidation or extinction is initiated
depends on the temporal dynamics of the test procedure and how recently
the memory in question was formed or reactivated, or both (de la Fuente
et al., 2011; Inda et al., 2011; Maren, 2011). At this time, it is clear that
reconsolidation and extinction represent distinct reactions to reactivating a
memory (Lane et al., 2015).
 Reexperiencing the Past in the Present  •  253

WOUNDED CHILD WORK

A central part of an emotion-oriented therapy involves processing unresolved

painful emotional experiences from the past, predominantly from childhood.
Children have less capacity than adults to adequately process their emotions,
and this can result in the development of core maladaptive schemes. These
past painful experiences generally lead to maladaptive ways of responding in
the present to others and themselves. When children are ignored, rejected, or
physically or emotionally hurt, they will tend to respond to others in similar
ways to show they coped with earlier difficulties.
All too commonly, perhaps resulting from direct physical threats, shame,
or a lack of available confidants, painful experiences are never discussed with
anyone or processed. When a parent is the instigator of abuse, it is often a
double whammy, first because of the violation or harm and, second, because
the parent is not available to assist the victim in dealing with it. The lack
of an available caregiver to provide comfort and support may be a critical
ingredient in what makes the experience(s) overwhelming or traumatic. What
this means emotionally is that the implicit emotional responses were never
brought to the conscious level of discrete feeling through symbolization in
language. As a result, the traumatized individual knew the circumstances of
the trauma but did not know how it affected them emotionally. This lack of
awareness contributes to the tendency to experience traumatic threats in
circumstances in an overly generalized manner that reflects the inability to
distinguish circumstances that are safe from those that are not. It is often
only in therapy when the experiences are put into words that the emotional
responses are formulated for the first time.
Putting these feelings into words present opportunities for work with the
wounded child, a metaphor for a vulnerable wounded part of the self. This
metaphor helps people reown their feelings by talking about and symbolizing
them in language, identify where these feelings originated, and, most impor-
tantly, facilitate transforming these feelings. Ultimately, in this work, the goal
is to help people regain strength and access nurturing feelings toward their
own pain and hurt. The wounded child metaphor is important because it is
easier for an adult to allow, and to experience, their vulnerable feelings when
they imagine themselves as a child. They can more easily connect with how
they feel now as an adult when they take a child position in imagination.
Identifying with their younger self helps get past the adult protective coping
measures developed over a lifetime. It is easier for a 50-year-old adult man,
for example, to experience his fear of being alone when imagining himself as
his 6-year-old self—taking the position of being afraid of being alone at night
254  •  Changing Emotion With Emotion

in his bedroom that is far away from the safety of his parents’ bedroom—than
it is to feel his fear of being alone as a 50-year-old. As an adult, he is supposed
to have all kinds of adult resources, both internal and external, to slough off
his lonely fears as childish and not befitting his current situation in life. All
people develop these coping methods or what Winnicott (1965) called a false
self that protects the more vulnerable parts of self. Usually, the more wounded
a person was, the more they build these false self-protective walls.
Every adult has vulnerabilities and feelings of weakness that are well rep-
resented by the image of a vulnerable or wounded child. This, however, is not
suggesting that the person is fixated at an early stage of development but,
rather, is a way of describing an adult feeling: At some time, all adults feel
vulnerable, afraid, alone, and insecure. These are adult feelings too often dis-
allowed as childish. Society tends to put weakness into the hospital as though
it were sick rather than accept it as a healthy adult need for comfort, nurture,
and safety. I am not talking about a child self, stuck at some early stage of
development, but an adult feeling of weakness. The vulnerable feelings may
retain the remnants of childhood feelings that have developed from these,
but they are most definitely adult feelings. So, therapists are working with
an actual present, adult emotion, and the notion of it being a wounded child
is symbolic, not real.
Representing adult experience as a wounded child within is an interven-
tion method that helps people access the feeling and the full range of memo-
ries of this feeling had their origins in childhood (Bradshaw, 1988; Webster,
2019). It provides the context for reexperiencing feelings that were felt but
never were adequately processed and have remained in memory and rep-
resent themselves in the present. The wounded child metaphor therefore
facilitates access to feelings and provides a lead into age regression interven-
tions. I use this term “regression” not in the way that Freud did to denote a
defense mechanism leading to the temporary or long-term reversion of the
ego to an earlier stage of development (Freud, 1917/1976) but as the name
for an intervention to help access feelings of adult vulnerability or weakness.
The aims of working with the wounded child with age regression are to help
arrive at the painful emotion memories and, ultimately, to leave them by
transforming them with new emotional experiences.
The aim of all emotion work is to access the dreaded core maladaptive
emotions, which are so painful that people do whatever they can in life to
not feel them or even to not feel any emotion at all. The therapeutic skill to
help clients approach dreaded feelings is to ask the client to stay with the
emotion and to talk from it. This is both a general skill of emotion-focused
work and a specific skill needed to help clients approach their pain in the
context of wounded child work. The therapist, thus, invites the client to stay
 Reexperiencing the Past in the Present  •  255

with the feeling, make space for it, and become the wounded child to give
a voice to the painful experience as the child. The therapist then helps the
client differentiate the experience and validates how painful it was. The process
generally ends with self-soothing by which the therapist helps the adult self
respond to the woundedness in the child with compassion and support.

The Process of Wounded Child Work

Clients come to therapy because they are feeling bad, and therapy gener-
ally starts with the therapist helping client unfold their narrative and begin
exploring their concerns. Generally, the clients talk in the landscape of action
about “what happened.” Sometimes, they move into the landscape of meaning
and talk about what “what happened” meant, but they spend little time in
the landscape of feeling. The therapist’s task, initially, is to empathize and
combine that with a gentle, consistent pressure toward the internal, toward
the client’s core affect. However, when clients talk about their feelings, these
often are secondary feeling reactions, such as saying, “I’m frustrated or angry”
when talking about situations in which their needs have not been met and
they primarily feel hurt, or they may be crying in helplessness or hopeless-
ness when they are primarily angry. Sometimes, however, right from the start,
clients may present experiencing primary, painful, maladaptive feelings like
feeling “lonely” or “worthless,” but then they often are talking about these
painful feelings in a helpless or protesting manner rather than experiencing
them in a productive manner. The therapeutic task is to help clients process
these core feelings productively.
After the first few sessions focused on listening to the narrative and devel-
oping an alliance, the therapist works to coconstructively develop a focus on
the client’s core painful, maladaptive emotions. In our research (Greenberg &
Goldman, 2019), we have found that the core painful feelings that most often
appear are fear, sadness, or shame. These emotions are identified by the
therapist, who, in addition to listening to the content of the narrative, is
emotionally attuned to what is most painful in the client’s narratives. The
origins of these painful emotions are explored and related to the client’s
attachment and identity histories. By exploring their histories, clients access
disowned emotions—emotions that are too dangerous or frightening to feel,
so they block them, treat them as “not me,” and disclaim the feelings and
action tendencies. When their needs for security and validation are not met
and their painful feelings are not soothed, people protect themselves by
cutting off their feelings and needs. They, however, now also anticipate and
come to expect negative treatment from others, and they react to minor cues
of abandonment or criticism using their survival strategies. These strategies
256  •  Changing Emotion With Emotion

that were designed to protect them have now become an important part of
the problem. Driven by the desire to survive, they disclaim their painful feel-
ings and needs in an attempt to best cope with the situation. It is important
in working with emotion to always see people as doing the best they can, in
their context, in their efforts to thrive and survive.
After agreeing on goals and tasks, and establishing a safe, trusting bond,
the focus shifts collaboratively to working with the client’s memories,
emotional reactions, and survival behaviors from their past. A key way of
working is to have the client reexperience childhood situations and feelings
by means of age regression to childhood. The client is invited to enter
episodic memories as a way of accessing the dreaded painful feelings to
rework them in the present. Here, they deal with past traumas, experiences
of abandonment, invalidation, neglect, and unprocessed hurt and grief. A
helpful approach is to imagine going back progressively or, more appropri-
ately, regressively, in imaginary small steps to help the client get into the
experience of being a younger self. The therapist can use a metaphor of going
down in an elevator or being on a journey by saying, “Now you are moving
down from 30 years old to 20, to 15, to 12, and now you have arrived. You
are 8 or 6 years old.” Alternately, before immediately becoming the 6-year-
old, the therapist might also ask the client to imagine their 6-year-olds sitting in
front of them in a chair, or on their knee, and have the adult client describe
how they see their child self. This helps evoke memories of being the child.
Ultimately, therapists want to help people identify with and speak as the
wounded child self.
The most usual process in wounded child work is that in which the thera-
pist guides the client to move from a discussion of current feelings or events to
memories related to the feeling or event. For example, in discussing unresolved
feelings toward parents, the therapist might say, “So, you have this feeling of
never being seen by them. Let’s go back to when you remember feeling this as
a child.” Or, the person may be talking about how much of a bully the father
was to her and to her mother, so the therapist invites her to go back by saying,
“So, if you are willing, let’s go back when you were 8 years old and get at
what it felt like for you as a child growing up in that environment.” Some-
times, clients of their own accord might reenter and reexperience a childhood
scene—not as a flashback, but they may suddenly feel themselves, when they
are talking about an adult experience, reexperiencing a childhood scene. They
spontaneously go back to an experience and reexperience it in the present.
A client, for example, may talk about having been humiliated by a coworker
and suddenly go back to having been shamed in class at school by a teacher
and remember the other kids making fun of her. Clients need to feel sufficiently
safe within themselves and with their therapists to do this reexperiencing.
 Reexperiencing the Past in the Present  •  257

Compassion and Self-Soothing

The expression of anguish or emotional suffering has been identified

(Greenberg, 2015) as a marker for self-soothing work in which a more adult
part of the self soothes the wounded child. Typically, the anguish occurs in
the face of powerful interpersonal needs (e.g., for love or validation) that
were not met by others. Intervention involves some soothing agent that
provides soothing where none was available before. This can be done in
a chair dialogue: Clients are asked if they, as an adult, could soothe their
wounded child. The goal is to evoke compassion for the self. Therapists can
use chair work to try to evoke compassion, but one does not have to use
chair work because accessing and soothing the wounded child can be done
as part of a more dialogical intervention.
In this type of imaginary transformation, the therapist might say,
Try closing your eyes and remember your experience in this situation. Get a
concrete image if you can. Go into it. Be your child in this scene. Please tell me
what is happening. What do you see, smell, hear in the situation? What do you
feel in your body, and what is going through your mind?

After a while, the therapist can ask the client to shift perspective by saying,
Now, I would like you to view the scene as an adult. What do you see, feel, and
think? Do you see the look on the child’s face? What do you want to do? Can
you do it? How can you intervene? Can you try it now in your imagination?

Changing perspectives again, the therapist can ask the client to become the
child and ask the following questions:
What do you as the child feel and think? What do you need from the adult?
Can you ask for what you need or wish? What does the adult do? What else do
you need? Ask for it. Is there someone else you would like to come in to help?
Can you receive the care and protection offered?

This intervention concludes with the therapist asking,

Check how you feel inside right now. What does all this mean to you, about
you, and about what you needed? Can you come back to the present, to your-
self as an adult now here with me? How do you feel? Can you say goodbye to
the child for now?

A helpful intervention to help evoke compassion is to ask clients to give

examples of times when they have been empathic to another person or to an
animal. It is the client’s capacity to be empathic and caring of another in need
or pain that therapists try to build on to help the client become more aware of
their compassion so that they can access it in the service of soothing themselves.
However, when the self-soothing dialogue is introduced to clients who
are not sufficiently differentiated from the hostile negative caretaker and
258  •  Changing Emotion With Emotion

they are asked to start with their own child, the contempt or destructive reac-
tion of the other may be evoked. It is precisely this type of negative reaction that
needs to be transformed over the course of treatment. In such cases, it can be
initially difficult for the client to feel compassionate about their own wounded
child state; instead, they invalidate their own vulnerability. At these times, it is
better not to ask the person to see themselves as a child in the other chair
or to imagine the part of the self that needs soothing, which may evoke
negative feelings or condemnation of the child or the vulnerable self. It may
be more helpful to symbolize the anguish as being that of a universal child
or a close friend who has experienced the same things that the client has
experienced and that are the source of their anguish. Even though people
understand the implication of what they are being asked to do by being
compassionate to a universal child in similar circumstances, they may be able
to soothe a universal child more easily than their own child, who auto-
matically evokes self-contempt. Once compassion has occurred in relation to
a child in need, it is easier to transfer this feeling to the self.

Strength to Protect the Self

Sometimes the adult self may feel overwhelmed by seeing a hurt, damaged
child because they do not yet have a sense that they can protect themselves
effectively, or they may fear that they will disintegrate and drown in their
pain. At these times, therapists can become surrogate protectors. For example,
when a client is overwhelmed or frightened by the pain they see in themselves
as a young child, the therapist and the child can work together to confront
the abusive or neglectful other. The client can feel safer in their therapist’s
presence, drawing strength from the therapist. The client can be encouraged
to imagine the therapist right behind them or even in front, telling the abusive
other to stop. In empty-chair dialogues, the therapist can help the client put
their need into words.
At times, the client may be unable to offer solace and comfort to the
distressed self for a number of reasons. A client’s feelings of vulnerability
and fear may not have been validated sufficiently, or the feelings are still too
entangled and confusing, and the client has not yet begun to differentiate
out from an unresponsive parent. Or the client may still be distraught about
their own behavior and feel too ashamed, or, for whatever reason, cannot
access their resilience. Sometimes clients may feel angry and betrayed by
significant others who did not provide for them, and this can also hinder
their desire to assume any responsibility for self-care. However, slowly, as
therapy progresses, and with a continued and repeated discussion of the
importance of self-compassion, clients, over time, are helped to accept that
 Reexperiencing the Past in the Present  •  259

if they are to heal and thrive, they need to be compassionate to themselves

for their own protection and well-being.
What follows is an example from a session with a 28-year-old woman from
mainland China who is working in therapy, speaking in English. The session
addresses the client’s core wounded feelings of fear and shame from child-
hood maltreatment by both her mother and father. The cross-cultural appli-
cability of this type of work with core emotion is important because there is
the misapprehension that it may be more difficult to work with emotion in
Asian and more collectivist cultures in which concern for the other supersedes
concern for the self in individualist culture. The situation of this client is that,
as an adult, she has difficulty in intimate relationship and relates this to her
treatment by her parents. In this ninth session, she is dealing with a memory
related to being slapped by her father and how this relates to her current
marriage.

Clinical Example: Hatred Toward Father

CLIENT:  Ya. It’s just that . . . my father would never hit me or my mother.
There was, however, an instance when he picked up a chopper
[an ax] and attempted to hurt my mom. I was shocked. And
when my husband put his fist up to my face . . . it reminds me of
my father waving the chopper at my mom.

THERAPIST: I can only imagine how it affected you. How did you feel as a
child?

CLIENT:  I have some hatred towards my father.

THERAPIST: Hatred. This seems like the root.

CLIENT:  Same—same pattern with my partner.

THERAPIST: It haunts you. It will be good to address it? Let’s try and go back
to that time in your life to that experience feeling scared and of
hating. [age regression]

CLIENT:  Okay, what do you mean?

THERAPIST: Imagine you are going back to when you were young. Go back.
You’re now 20, 15, 12, you’re 7 years old. Be your 7-year-old
and speak as her. What was it like for you?

CLIENT:  (Nods) When I was much younger, he used to buy things for
me. I have some gratitude towards him, but as I was growing
up and until he passed on, I have a lot of hatred towards him.
260  •  Changing Emotion With Emotion

Especially the way he treated my mom . . . the way he remarried

and cheated on my mom.

THERAPIST: He’s someone you feel gratitude towards but also a lot of hatred.
Be the 7-year-old and tell me what you feel. [Speak as the child.]

CLIENT:  He doesn’t give me an allowance—he always takes from my

mom. Since I was young, he doted on me. He had never hit me.
I just recall one thing that one moment. . . . In the beginning,
I loved him as a daughter should. I make sure he took care of
his health and take his medications.

THERAPIST: There’s love and hate.

CLIENT:  Hate—there was this once because of my mother and how he

treated her, and . . . regarding my stepmother, and he slapped
me across my face!

THERAPIST: Slapped you . . .

CLIENT:  Yes, at the dining room table. Slapped me.

THERAPIST: Such a shock? Go back to that. How old were you? What do you
feel? Speak as the little girl.

CLIENT:  I was 10 years old. I remember, at that moment, when he

slapped, I felt pain . . . I have felt it. In my whole life, he had
never beaten me . . .

THERAPIST: He hit you. What’s it like for you, you feel so much pain?
Describe what it was like, the pain. [episodic memory]

CLIENT:  The pain is like . . . a lot of stones crashing down on me—my

heart is broken. The fatherly love was all spilled on the floor.
I wanted to gradually forgive him, but I couldn’t . . .

THERAPIST: After that moment, it was impossible to forgive as your heart has
broken. That slap caused the pain in your heart.

CLIENT:  (Nods) Since that moment, my brother also realized that he has
changed. He has totally changed. I felt that since that moment,
he changed. No longer my dad. He changed to become . . .
became a stranger. Someone I don’t know him anymore.

THERAPIST: As a child what would you want to say to him if he were here?
Tell him how you feel about his treatment towards you, your
mother . . .
 Reexperiencing the Past in the Present  •  261

CLIENT:  I’m 10 years old that year—I’m in Primary 3; my parents are

divorced already for 1½ years, I help out with household
chores—cook, clean. As a 10-year-old, it’s too much. I want to
play like my friends.

THERAPIST: A lot of responsibility. So burdened and alone.

CLIENT:  Yeah, I feel so alone and afraid. I need a father who takes care
of me. Protect me, not scare me. It’s not supposed to be my
problem or responsibility to look after everyone and every-
thing. I have no parents. I need my parents. [emotion sche-
matic memories and needs]

Coconstruction of What an Experience Was Like

Therapists, as shown in the preceding case, need to repeatedly guide toward
the focus, toward the core painful maladaptive emotion—in that excerpt, to the
feeling of being alone and afraid. The work needs to always move toward the
focus but without losing the more nondirective following aspect. The thera-
pist is not imposing their view of what it felt like but, rather, is helping
coconstruct how it was for the client. Coconstruction is an art that involves
being able to empathize and validate as well as simultaneously refocus on core
issues, deepen experience, and evoke emotion.
For example, a 29-year-old client who comes into the 12th session express-
ing sadness and anger about her bad relationship with her parents says
she is sad that they have not reached out to her despite her telling them that
she does not want to talk to them. She says, “It’s so painful that even my dis-
tancing from them feels like nothing to them.” She is distressed about what
is happening now with her parents. However, it is important in these situa-
tions of current interpersonal difficulties for the therapist to guide toward the
unfinished business of her childhood because of a history of neglect and aban-
donment as well as core feelings of sad loneliness and insecurity rather than for
the therapist to stay on the current interpersonal conflict. The client’s current
distress with what is going on with the parents needs to be treated as a door-
way into her past relationship with her parents that was filled with neglect
and invalidation. It left her with a big hole inside from her feelings of empti-
ness and unsureness. The client wants to vent about how bad her parents are,
but the therapist, after validating the client’s present anger by affirming—“It’s
so infuriating to get no response, not even a nod in your direction”—guides
toward her core emotional pain by saying, “So much hurt, so much anger. All
your life, you’ve felt you’ve never been considered, never been seen. Let’s go
back to those early days that have left you feeling so invalidated.”
262  •  Changing Emotion With Emotion

GUIDELINES FOR AGE REGRESSION WORK

This section discusses a set of steps that act as a therapist’s guide to age regres-
sion work (but Webster, 2019). First, when an experience of concern related
to childhood abandonment, neglect, or trauma emerges, this is a marker for
age regression and possible work on imaginal transformation. For example,
a client may say, “My parents just always left me to myself. They were too
involved in their own stuff to even know what I was doing, never mind feeling
almost like I didn’t exist for them.” The therapist empathizes and guides the
client to pay attention to what is being felt in the body in the present: “Just left
so alone, feeling I’m not important? Just stay with that feeling. What do you
feel in your body right now?” The therapist then guides the client to go back
to an earlier time when they felt this before:
If it’s okay with you, let’s go back to an earlier age. Do you remember a specific
age or time when you were aware of feeling that? Take your time. . . . Let’s go
back: You are 30, you’re 20, 15, 10, now you are 6 years old. Okay, so you are
6 years old. What’s happening and what are you feeling?

At this point, the therapist follows five steps to focus the client on the
feelings in the event as a child:

1. Guide the client to be the child and talk as the child in the present. Say,
“As your 6-year-old, what are you feeling in your body? There you are; your
mother is talking to her friend. What’s it like for you? What do you feel?
Be the 6-year-old and tell your mother.” Guide the client to reexperience
the feelings in the present. Help the client stay with and accept the painful
feeling: “Just stay with those feelings and welcome them.” Validate the child
experience: “Yeah, it was so painful and must have been so lonely.”

2. Once the feeling is felt deeply and is validated, focus on the unmet need.
Ask, “What did you need?”

3. Validate the need and promote a feeling of having deserved to have the
need met: “Of course you needed attention and support. You deserve it.
Tell them again: ‘I deserved some of your attention.’ ” Transformation now
occurs by accessing a new feeling that arises in response to the need having
not been met (usually, assertive anger or grief at the loss or compassion).
“What comes up in you now as you say that?” is a good question to assess
new feelings. Sometimes a new feeling comes without an explicit state-
ment of the need but asking for the need often helps access a new feeling.

4. Once the pain and the need have been felt, one of the new feelings that
may emerge is compassion. The therapist encourages the experience
and expression of compassion by asking the client to be the adult self
 Reexperiencing the Past in the Present  •  263

and speak to wounded child self: “If you, as your adult, looks at your
wounded child here feeling so alone and unimportant, feeling all this,
what would you want to say to them or do?”

5. The therapist generally finishes the session by bringing the client back to
the present and debriefing the client’s experience of the work: “How are
you feeling now? What do make of this? Are you ready to go back into
the world? Anything you need right now?”

When the therapist invites the client to be compassionate to the wounded

child, it is ideal to have the client enact this compassion. The therapist can
ask the client to see the child sitting in a chair in front of them or in their
imagination and then talk to the imagined child and express care, support,
compassion, and love. Enacting compassion embodies the experience more
deeply than just having the therapist and client talk about it.

Using Imaginal Reentry and Imaginal Transformation

Another variant of regression work is imaginal reentry into a past scene in
which the child felt unprotected or abandoned. Here, the therapist asks the
client to go back to the scene but to bring in a person to protect or nurture
the child self. The aim is not self-soothing but imaginal transformation.
The therapist says, “Imagine yourself as a child in a scene related to the
painful memory. Imagine yourself now as an adult or a protective other entering
the scene and intervening to assist.” The therapist guides the client to imagine a
protective other to support and protect the vulnerable wounded self. The other
may be a police officer who protects against an abusive father; or perhaps it
is the therapist, who set limits or educates; or it might be a mythical figure to
take the child to a safer place. The therapist asks the protective other, “Is there
anything that you want to say to the child or to anyone on the child’s behalf?”
and makes sure that the child feels safe and protected by the support of the
adult. The therapist initially and along the way, at appropriate moments, asks
the child questions related to the child’s sensations, emotions, thoughts, and
behaviors. So, in guiding the client to enter the scene and during the process,
the therapist might ask, “What do you see, hear, smell, sense in your body?
What do you feel? What is going through your mind? What do you want to do?
What is happening?”

Speaking as the Child or to the Child

In age regression, the client can take two major positions: speaking as the
child or speaking to the child. When clients are being the child, it is good
for them to speak as much as possible in the present tense, such as saying,
264  •  Changing Emotion With Emotion

“I feel afraid” as opposed to “I felt afraid.” When speaking from the adult
position, the client could be both an observer and an actor who does things
like support and express love and caring to the wounded child self. Different
self–other combinations can be used. The most classical form as previously
described involves saying, “Imagine yourself being the wounded child and
speak from that position” and then asking the client to speak from the adult
position. The adult then can be asked what the child needed or what the adult
could say to the child that would help the child—or even if the adult could
take the child away and protect them.
However, in some self-annihilating clients, being the wounded child or
speaking to the wounded child brings up too many feelings of contempt for
the child. In such cases, a different form is best. For example, when invited to
speak to her wounded child, one middle-aged woman who had been sexually
abused by her neighbor immediately chastised her 8-year-old for knowingly
going to the neighbor’s house because he had a big TV. But when asked to
imagine another child, in this case, her daughter, in the same situation, the
client was able to access feelings of care and protectiveness rather than blame.
She was then able to feel more compassion toward her own child self. To
sidestep the negative feelings clients might have about themselves as a child,
the therapist can ask what they would feel and want to say to a universal
child who has suffered the same things as the client had as a child: “Imagine a
child who was abandoned this way by their parents. What do you feel or want
to say to this wounded child?”
A variant intervention, as mentioned earlier, involves asking the client to
imagine a very close friend: “So similar that they have had the same experi-
ences as you and are feeling the exact same way as you. What do you want or
wish for them? What would help them? What can you give them to help this?”
The therapist asks the client to imagine an ideal parent or significant other
in the other chair—not as they were but as the client needed them to be—and
then has the client ask that other for what they need. Next, the therapist has
the parent speak to the wounded child as a good parent.

Developing Capacity to Care for the Self

In the resolution process, clients typically move from anguish, through the
main steps of accessing painful primary maladaptive emotions, and toward
a statement of unmet needs and the sadness of grief at not having had those
needs met (Goldman & Fox-Zurawic, 2012; Ito et al., 2010). At times, how-
ever, there is fear and interruption of emotion, and also protest about having
to soothe oneself rather than having received soothing from others. These
difficulties have to be worked through before the client can access the primary
 Reexperiencing the Past in the Present  •  265

painful emotions. It appears that it is not simply enacting compassion for the
self that leads to resolution but also access to the unmet need and grieving
its loss that are important in accessing compassion for the pain of the loss
and the provision of the missing compassion that is so healing. As clients go
through this process with a supportive and empathic therapist, they develop
feelings of compassion for themselves and for what was lost. Over time,
doing this in conjunction with receiving empathic soothing and acceptance
from therapists, who are emotionally attuned, clients eventually develop the
capacity to soothe themselves and transform their painful emotions.
It is important to reiterate that therapists are not assuming that there is a
child within. It is just that an earlier self-state of vulnerability or wounded-
ness experienced as a child is evoked in the session, which, in turn, activates
the emotions they experienced at the time of the injury. It can be highly
poignant to clients to have the hurt they experienced as a child soothed and
comforted by their adult self to provide the affective attunement that was
never received.
The timing of this intervention, particularly for the questions regarding
how the client feels toward the younger self who was wounded, is important.
It must not occur too soon in therapy because that can lead the client to
feel invalidated or overburdened once again. When clients have been over­
burdened and responsible for caring for themselves, they need a period
during which they can lay down the burden and relax. They want someone
else to provide the care and support that was missing before they, once again,
assume the mantle of self-care. Of course, when they take it up again, it is in
a different way—one that acknowledges their feelings and needs as well as
supports them to find better ways to meet their needs in the present.

Clinical Example: Viewing the Child Self Through Grandmother’s Eyes

The following example shows a process of a client entering her wounded

child position and transforming her core emotion schematic memories of
worthlessness. The client is a 30-year-old Korean woman who has suffered
from depression most of her life. She struggled as an adolescent with her
very strict parents; as a teenager, she had self-harmed. The excerpt begins
with the therapist guiding toward memories and helping the client stay with
and focus on her core feeling of worthlessness until she accesses resilience
and her need for validation of what she does have to offer. She then accesses
compassion for herself through her grandmother’s eyes:

THERAPIST: So, partly it’s about things you have observed in your family,
sort of, right? With the people around you, right? With your
266  •  Changing Emotion With Emotion

brother, in particular. Expectations. But there’s also memories,

I mean emotional memories, not just scenes but also experiences
of being shut out, receiving hurtful remarks, in different ways
being told that you don’t fit in or something like that, you’re not
allowed to join in.

CLIENT:  Yes, I repeatedly felt I didn’t fit in, I was failing.

THERAPIST: You say they linger in you. So, that means they’re there now,
right? (Client: Mm.). So, that means they are with you; they do
something to you now.

CLIENT:  Unfortunately, they do.

THERAPIST: So, let’s stay with that feeling Yes, so, that’s an important—
important thing. There is a threat there, like, “I have to meet
their expectations.”

CLIENT:  (Sobs) Yes, yes.

THERAPIST: So, what do you feel now? Just hold on to it, it’s important.

CLIENT:  I don’t want to give these people the power.

THERAPIST: I understand that very well. It’s like there’s some injustice in . . .
not only have they done this, but in addition, it affects you
even now.

CLIENT:  Yes, many years later.

THERAPIST: I understand that . . . there’s an inner protest inside of you

against it. But if you look up inside of it, it’s like you carry with
you many different forms of experiences of, “If I don’t . . . If
I’m not performing or don’t master it all, then the truth is that
I’m nothing. Then I’m worthless.” (Client: Yes, mm.) And these
memories, these different events, are triggered almost daily.
(Client: Yes.) It’s not that you necessarily remember what
happened . . . (Client: No.). But the threat that you are not good
enough is triggered almost daily.

CLIENT:  It does, and I’m very anxious that people don’t actually like
me—that they are just nice towards me (laughs).

THERAPIST: Like it’s a secret that is kept from you or something like that.
(Client: Yes, yes.) That, in reality, they dislike you or think you’re
no good.
 Reexperiencing the Past in the Present  •  267

CLIENT:  Yes, I’m afraid of that because during my entire education, apart
from the 2 years spent at university, there have been people let-
ting me know that they don’t think I’m any good. And I don’t
understand why because I can’t remember ever doing anything
towards anyone. On the contrary, I’ve been taking care of
people, and I’ve tried to make sure nobody felt left out. So if
anyone in class or at handball—there was one girl in particular
that was a lot by herself and was bothered, so me and a friend of
mine took care of her. I can’t understand what I have done that
makes people annoyed with me, and it’s not the same person.
There were some people at elementary and middle school, not
so much at high school, there wasn’t, so, there I was actually
doing all right.

THERAPIST: It’s like you’re under constant . . . I mean your inside has been
under constant threat of being told that you’re not . . . (Client:
Yes.) don’t like you, sort of, right? (Client: Yes.) But deep inside,
there’s a truth that threatens you, right? That you’re not like-
able . . . (Client: Yes.) or that people can turn against you at any
time. (Client: Yes.) If I may direct you a little bit inwards, sort of,
right? So, to listen to this feeling . . . it’s actually a quite deep . . .
If we peel off all the attempts of trying to cope with it, sort of.
There’s actually a deep feeling of not being good enough. Not
being adequate. Not being enough, right? What is it that this
part would have needed to hear? [preliminary attempt at need]

CLIENT:  I don’t know because I don’t know whether I’ll be able to say
that.

THERAPIST: No, it’s hard to say it. Right. So, if we just keep focusing on
that, when we sort of direct the flashlight in there (points toward
their own stomach). (Client: Mm.) It’s just like something arises:
“I don’t even want to say it because it’s so . . . hurtful?” . . . or . . . ?
(Client: It is . . .) Yes, so, if we go there anyway . . . (Client: Yes,
um . . .). It’s vulnerable, right? (Client: Yes.) Just like opening
something that no one is supposed to see or no one is supposed
to know about. [validate the fear and guide toward the core
emotion]

CLIENT:  (Cries) It’s so hard.

THERAPIST: I understand. I can see it hurts, right? But it’s almost like it’s
also . . .
268  •  Changing Emotion With Emotion

CLIENT:  Yes, I think so. I need to give myself a chance. Rome wasn’t built
in 1 day.

THERAPIST: So, if we try even more (points toward stomach), I understand

this happens because it’s vulnerable, it’s a little bit like you need
to give yourself the time or something like that, but it sounds
like deep inside, there’s an experience of being worthless, sort
of, right?

CLIENT:  (cries) Yes. Worthless. [The client has hit rock bottom and feels
anguish core maladaptive pain.]

THERAPIST: Mm, and it feels that way when I say it. Just like that part sort
of . . . boils down to the feeling of not having anything to offer
anyone or something like that, right? (Client: Yes.) So, just stay
with it, it’s really important. (Client: Mm.) This is what gives us
the chance to make a change, to go there. (Client: Yes.) Yes. What
is it deep inside this wounded part of you . . . that feeling worth-
less part of you would have needed to hear? [heartfelt need]

CLIENT:  It’s . . . You also have a lot to give. That . . . there’s someone that
needs you, too. [With the help of the therapist focusing on her
organismic need, the client begins to mobilize and bounce back.]

THERAPIST: So, that you are significant, is that it? (Client: Yes.) You need to
hear that you’re significant. (Client: Yes.) Can you feel it when
you say it? Yes . . . Right, just like, I don’t know . . . you have
said something about your grandmother, a picture of her eyes.
(Client cries.) Yes . . . Yeah . . . Mm . . . So, just welcome it. It’s
just like this is what that part needs deep inside. Those eyes.
That warmth. The deep acceptance, sort of. (Client: Yes.) Yes,
mm. [Therapist evokes a soothing other.]

CLIENT:  (Drops her tissue) Oops. Um, she was very unique (mumbles).
She could make anyone feel . . .

THERAPIST: So, what would she have told this part of you? (Client: Um . . .).
What is it that her eyes and her warmth communicated? And
what does she see?

CLIENT:  She sees her grandchild . . .

THERAPIST: What does she see when she sees you? What does she see in
you? Her eyes. If you keep her eyes lifted up, the warmth, the
voice . . .
 Reexperiencing the Past in the Present  •  269

CLIENT:  Um . . . That I primarily . . . I think for her, it was most

important that I’m kind and good, caring, and take good care
of the people around me.

THERAPIST: So, that’s the actions, but deep inside, what she tells you. It’s
sort of the things she likes about you, so that’s really important,
so it’s like you can imagine something even more fundamental,
sort of, when she sees you, she tells you . . . ?

CLIENT:  That . . . she loved me no matter what and is proud of me . . .

and . . . thought I had a lot going for me.

THERAPIST: What does that do to . . . (points toward stomach) If we sort of

bring back that part of you that feels useless, sort of . . .

CLIENT:  Mm . . . (laughs) . . . Yes, I—it makes me feel good to see myself

from her . . . or with her eyes. Things like that. Thinking that she
did see me.

THERAPIST: So, it means that it feels a little bit like what? A little bit
alleviating?

CLIENT:  Yes, that I can. . . . My chest tightens when I think about me

being useless, and it’s’ almost like I can breathe a little easier
when I think about her.

THERAPIST: (Gesticulates with own hands) It’s just like there’s two very
different . . . things, right? One is what was stored in you,
right? The bullies, the different people signaling that “We don’t
want you” or “We don’t like you,” or something like that. (Client:
Yes, mm.) The hurtful, really bad feeling of not being anything,
not being valuable, right? (Client: Mm.). And then it’s just like
the picture of those warm, loving eyes, and the love, sort of,
which came through words and action, and in every possible
way. (Client: Mm, yes.) It’s just like there’s something important
in letting the one catch up with the other. To bring the first into
the latter. [changing emotion with emotion by synthesizing two
feelings]

CLIENT:  I never tried to prove anything to my grandmother (Therapist:

Yes.) We were . . . good enough the way we were.

THERAPIST: So, the safety in that . . . the safety in that no matter what
happens, no matter what shows up, that love will remain. It’s
absolute, sort of, it’s not conditioned by anything, or . . .
270  •  Changing Emotion With Emotion

CLIENT:  (Cries) No, mm, that’s right.

THERAPIST: What do you feel now?

CLIENT:  (Exhales) That I . . . right now, I feel like I miss my grand-

mother (cries).

THERAPIST: Yes, right. There was so much . . . like we talked about. You got
so much from her, sort of, right? Yeah. (Client: Yes.) It’s just like
allowing her warm eyes and love affect you . . . and especially
let it affect that inner, deep, hurtful feeling, sort of, right?

CLIENT:  (Eyes tear) Yes. It feels warm and comforting. She accepted me,
and it makes me feel worthwhile.

BRIDGES TO THE PAST

As stressed, the first phase of emotion-focused work involves arriving at

emotions by attending to and becoming aware of them mainly through the
therapist’s empathic attunement to affect and attention to bodily sensations
and feelings. Initially, the client might be expressing secondary feelings of
anger in reaction to some primary feeling to a situation that evokes fear
of abandonment. By empathizing with these feelings but then putting the
focus on the more primary feeling of, say, the abandonment anxiety under-
lying the anger, the client can be helped to track back to the deeper feelings
of fear of abandonment.
This work begins by paying attention to what is occurring in the present,
what feelings the client is expressing, or what is occurring in the client’s body
while they are talking. The therapist can then guide the client to go back
in time by means of questions such as; “Have you felt this feeling before in
your life?” or “When did you first have this feeling?” If, for example, a client
is saying they are feeling so frightened at work or so lonely and that even
though they are married, they feel this loneliness, the therapist might ask,
“When did you first have these feelings?” or “Have you felt this feeling of
loneliness before in your life?” The current feeling state of aloneness is used
as a launching pad to explore its origins.
Similarly, therapists can build a bridge to the past by moving from present
body sensations and experience to the origins of these experiences. They do
this by asking clients to stay with a body experience and to arouse memo-
ries: “Just stay with those sensations in your chest. Do they remind you of
anything?” or “Just follow that body experience back to where it started.” For
 Reexperiencing the Past in the Present  •  271

example, if people, as they are talking, feel shaky or queasy, therapists can
ask them to stay with their body experience by saying, “Just stay with those
sensations in your stomach. Can you let words come from the sensations?”
followed shortly thereafter by, “Do these sensations and feelings remind
you of anything from an earlier time?” or “Just follow your body experience
back to where it takes you.” In addition, if clients present with symptoms,
the therapist can focus on the bodily experience associated with the symp-
toms. For example, if a client talks about obsessive rituals like checking under
the bed repeatedly before sleeping, the therapist might explore what bodily
sensations are occurring in the sequence leading up to these behaviors. Once
the client becomes aware of some bodily experience triggering the symptom,
the therapist can help the client track backward to earlier times when those
sensations played a role in the client’s life.
After a feeling or body experience has been identified and located in the
body, the therapist guides the client to put into words and speak from it, a
method that can help access the wounded child. For example, in a session,
a man says that even though he is an accomplished professional, he still
feels anxiety making presentations. As he talks about this, the therapist
asks what he is feeling in his body, and he says he has butterflies in his
stomach. The therapist asks him to pay attention to the sensation in his
stomach and just follow it. The client slows down, focuses on his bodily
felt sense, and connects it to his experience of his father giving him tasks
as a child but with an attitude of “I know you will mess this up,” and how
this left him with this great performance anxiety to not screw it up. The
aim, of course, is not insight but to go back into the experience, access
the unmet need, validate the deservingness of the need, and transform it
with new experience.
In general, it is helpful to ask clients when they felt certain sensations
before and to then guide them to go back to the earlier experiences and the
memories associated with the sensations. This going back should be done by
traveling on the wave of the feeling, not by logical deduction. The therapist
does not ask, “When have you felt this before?” which is a request for infor-
mation and more likely to get a cognitive response, but, rather, “Follow that
feeling back to when you have had it before. What was it like?”

Clinical Example: “Like the Walking Dead”

The following example involves another client from mainland China. She
is a single 27-year-old suffering from childhood trauma and social anxiety.
272  •  Changing Emotion With Emotion

I mention the client’s nationality as in the previous example as a way of

demonstrating the cross-cultural application of emotion-focused work. In my
experience in Asian cultures, metaphors are often used to express emotions.
Moreover, descriptions of body sensations are more common because word
labels for emotion are not as familiar or common, but emotions are definitely
available and can be worked with. The discussion following illustrates how
important emotion work is.
The client in this session talks about when her girlfriend ignores her and
how that evokes the feeling of being ignored by her mother. The session
moves to wounded child work. Note the client’s reference early on to body
sensations and the use of the metaphor “like the walking dead” in response
to an exploratory question from the therapist about what she felt. Also note
how following her sensations acts as a bridge to past memories:

THERAPIST: Wow, yeah, that sounds really sad, really feels like . . . Does it
feel like that feeling is being triggered again? “When I was little,
with my mother . . .”

CLIENT:  I guess what I was feeling was that I hadn’t been connected to
my girlfriend lately, a feeling I’m having right now.

THERAPIST: It’s like feeling . . . ?

CLIENT:  Right. I just feel like if she doesn’t talk to me (Therapist: Yes.),
my hands and feet are gonna be cold and I’m gonna panic. It’s
like this walking dead feeling I have. [body sensation]

THERAPIST: Wah, cold hands and feet, and panicking inside your heart. That
feeling is so deep in memory, and also terrible, because I am not
like a normal person, almost like a walking dead. Mm-hmm. Do
you feel it that way now? Does it remind you of how Mom made
you feel when you were a kid? [bridging to past]

CLIENT:  Yes. I feel it now like I used to feel.

THERAPIST: Can you remember how old were you the first time you felt
this way?

CLIENT:  (Furrows eyebrows) I can’t remember, but, in my memory, when

I was a baby, I wasn’t connected to my mother. I felt like I was
there alone. It was hard. I felt like I was the only one in the
world. (Therapist: Yes.) I couldn’t do anything, and I felt like if
Mom didn’t show up, I would be screwed.
 Reexperiencing the Past in the Present  •  273

THERAPIST: “Yes, I was so young, I needed someone to take care of me, but if
my mother didn’t come, my hands and feet would be cold, and
I would be disconnected with the world.”

CLIENT:  Also, once I was in the factory with my mom, and she went to
the bathroom and left me outside, and then an uncle told me,
“Your mom doesn’t want you anymore.”

THERAPIST: Wow. Oh, my God. What would you like to tell Mom? Be the
child: “What I felt is . . .” [childhood regression]

CLIENT:  Because Mom likes boys more than girls, I’m afraid of being
abandoned because I’m a girl.

THERAPIST: Uh-huh. “Mom doesn’t want me, she doesn’t want me, and then
she can give birth to another boy.”

CLIENT:  Actually, those feelings resemble my feelings now.

THERAPIST: Yeah, so it’s rooted in Mom.

CLIENT:  I mean, it’s like Mom doesn’t want me anymore. It’s over.
(Therapist: Hmm.) And then I . . . I couldn’t live alone.

THERAPIST: Yeah, helpless. Yeah.

CLIENT:  I’m an orphan. (Therapist: Well, yes, yes.) I can’t live any longer.

THERAPIST: “Yes, I’m going to die.”

CLIENT:  And then, trapped in a terrible panic.

THERAPIST: Yes, let’s slow down now. Can you stay in the feeling of panic?
If you can, look at the panic, put the panic in here, as if it were
between me and Mother, with me by your side. Look at the panic,
now . . . feel it here. You’re afraid, but I’m here with you now. Can
you be that frightened child, maybe 5 or 6 years old, and talk
from that fear? “I’m afraid I’ll be alone.” [age regression]

CLIENT:  Yes, I’m afraid I’ll be abandoned alone and how will I survive.
I’m really afraid who will look after me. It’s like, please don’t
get rid of me. [core emotions scheme of fear of abandonment]

Having entered the child state, they then work on the client’s fear of aban-
donment as a child and on providing a feeling of safety to help transform the
fear. She ends up both asserting her right to have a parent who loved her or at
274  •  Changing Emotion With Emotion

least took care of her, and validating her worth as a girl and a daughter who
did not deserve to be so neglected because she was a girl.

Clinical Example: “I Am So Scared”

In this example, the therapist guides a 32-year-old, single, male client suf-
fering from depression and interpersonal difficulties back in an age regres-
sion to be his 5- or 6-year-old. The client did not feel safe in his relationship
with his parents that included a mother who was very harsh and a father
who could not protect him. When he was young, his mother always scolded
him, which made him feel that his mother did not love him:

CLIENT:  When I was a child, I was so eager for a good mother. When she
showed in front of me that she was burdened, I was willing to
take care of her and tried to understand her feelings . . . because
I believed that she loved me or liked me (eyes tear). (Therapist:
Hmm. Hmm.) . . . And I also loved you, liked you (moves into
direct contact with the mother, imaging her in front of him). But
when I gradually feel maybe you cheated me, you used me, I am
very angry, very sad (cries).

THERAPIST: Hmm. Really heartbroken.

CLIENT:  Right (wipes tears with a tissue).

THERAPIST: Yeah, so what are your tears saying?

CLIENT:  Tears say, “I have endured so much pain to take care of your
feelings, but this is meaningless. It was all being used by you.”

THERAPIST: Thinking of that, you must feel such heartache.

CLIENT:  Right. I feel heartache for myself.

THERAPIST: Are you thinking of yourself when you were a child?

CLIENT:  Right.

THERAPIST: How little?

CLIENT:  Heartache for my whole childhood. Heartache because I was

a good child when I was little and took too much care of your
[mother’s] feelings.

THERAPIST: When did this feeling begin? How old were you? When you
started to feel this heartache.
 Reexperiencing the Past in the Present  •  275

CLIENT:  How old? Five to 6, or 6 to 7. At that time, I thought my mother

was very fierce and not tender.

THERAPIST: Hmm. When you think of your time in 5 or 6 just now? Do you
have any picture coming up in your mind? [evoking image of
child self]

CLIENT:  It’s just like that I did something wrong. I recall when I was
young, one day at home, I played with the meat that my mother
bought and made it bad. Then when she came back, she became
furious and punished me fiercely.

THERAPIST: You are the 5- or 6-year-old you. You hear your mother say that
she is so furious, scolding and humiliating you, and then beat
you. What do you feel? [age regression]

CLIENT:  I am so scared.

THERAPIST: Hmm. Very scared.

CLIENT:  I am scared, I am scared, I am stunned. I look at her and listen

to her. All I have in my heart is scared feeling. [core fear]

THERAPIST: As you sit there and now you talk about this fear, do you get the
sense of that scared feeling? Right now in your body?

CLIENT:  Yes.

THERAPIST: What is your scared feeling like?

CLIENT:  Scared that she will hurt me. I just feel she will really hurt me.

THERAPIST: Feels like you’ll be hurt. So scared, so afraid and unprotected,

just wanting to run away or be protected.

CLIENT:  Right, right. Feels like she is going to do something to me at any

time. [fear of danger]

THERAPIST: Hmm. So scared. When you come here, you are like this (portrays
the client’s gesture of curling up).

CLIENT:  Right.

THERAPIST: It looks like you want to shrink. Disappear. Yes, good.

CLIENT:  The whole me wants to shrink, very scared.

THERAPIST: Just hold this position. Feel the scared feeling. [action tendency]
276  •  Changing Emotion With Emotion

CLIENT:  Hmm (continues to do the action of curling up).

THERAPIST: You can say more about that scared feeling.

CLIENT:  Tell her?

THERAPIST: Yes, tell her.

CLIENT:  “I feel that I don’t know what happened . . . just all of a sudden . . .
why all of a sudden . . . suddenly so furious and suddenly feels
like you want to beat me. Right. What happened? This meat . . .
this meat . . . is this meat so important? To knock over the
meat . . . to make it bad . . . is it such a serious thing? . . .”

THERAPIST: Feel what you feel there (points to the part of body curling up).

CLIENT:  Feel it’s horrible. Really want to hide myself.

THERAPIST: Hmm. Really want to hide. So scared.

CLIENT:  Hmm. Very scared. . . . Feel like I will be hurt by her at any time.

THERAPIST: Very unsafe. What do you need?

CLIENT:  I need to feel safe. I need some protection, someone—something

to hide behind.

In this excerpt, the client arrives at his core fear of danger, and this makes
it accessible to new input by accessing new feeling. He takes the first step
of leaving the painful maladaptive state by accessing his need, which, with
his therapist’s help, validates that he will begin to feel deserving of having a
mother who did not terrify him or having protection against her rage. Once
his brain appraises that his need for safety was not met, it will automatically
feel both angry at having been robbed of and sad at having missed a safe
childhood.

CONCLUSION

A central part of an emotion-oriented therapy involves processing unresolved

painful emotional experiences from the past, predominantly from child-
hood. In this chapter, I discussed different methods of reexperiencing past
emotional events in the present and highlighted the importance of episodic
and autobiographical memories. Memory reconsolidation was offered as a
 Reexperiencing the Past in the Present  •  277

key change process. In addition, the chapter presented guidelines for age
regression work and demonstrated wounded child work and bridging to the
past through body sensations.
For some clients, a potential difficulty on this path is when intensely
painful emotions become too overwhelming. Therefore, Chapter 11 looks at
emotion dysregulation and methods to enhance regulation. In that chapter,
I also examine ways of soothing core anguish to transform it through self-
compassion.
11 EMOTION REGULATION

The inability to regulate emotion is rapidly being seen as a core form of

psychological dysfunction (Barnow, 2012; Bradley et al., 2011). That inability
can result in being overwhelmed by strong, painful emotions (increased
sympathetic nervous system arousal) or, alternatively, becoming numb and
distant from emotions (increased parasympathetic arousal). Good emotion
regulation, on the other hand, is having the desired emotions at adaptive
levels, at the right time, and in the right way. Clients who come to therapy
frequently are experiencing conditions related to underregulation of emo-
tion, such as depression, anxiety, substance abuse, and eating disorders. In
addition, emotional dysregulation is the problem that leads to dysfunctional
behaviors in disorders involving self-harm, trauma, and borderline func-
tioning (Warwar et al., 2008). These are often dysfunctional attempts by
clients to regulate underlying painful emotions (Linehan, 1993). Emotion
regulation, therefore, is a topic of central interest in psychotherapy and is
becoming a transtheoretical factor in understanding a variety of symptoms
and maladaptive behaviors. It is being proposed as a possible unifying trans-
diagnostic emotional change process.

https://doi.org/10.1037/0000248-012
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

279
280  •  Changing Emotion With Emotion

Whether in everyday life or in a therapy session, when emotions are over­

activated, can no longer be connected to cognition, and are outside the client’s
zone of tolerance, some form of regulation of emotion is helpful. However,
there is some ambiguity about what process is being referred to talking
about “emotion regulation.” The term emotion regulation has predominantly
come to be used to mean a second-level, deliberate management or control
of emotion (Gross, 1999). This type of regulation occurs after the emotion
has been activated or to prevent its activation, and it involves reducing
and reining in emotion. It is used in this way chiefly in cognitive behavior,
modification-oriented therapies and involves the teaching of skills, such as a
change in the situation, distraction, cognitive reappraisal, or calming.
On the other hand, another term, affect regulation, is used mainly by
more affect-focused, intrapsychically oriented therapies to mean the implicit
modulation of emotion or the relational coregulation of affect. This clinically
and neuroscientifically based view focuses on automatic processes involved
in the generation of emotion as an aspect of regulation. In addition to delib-
erate emotion regulation skills, automatic regulation processes are involved
in managing negative affect. An affective neuroscience perspective supports
a one-factor view of emotion regulation in which regulation is seen as being
automatically integrated with emotion generation (Campos et al., 2004;
Cozolino, 2002). This view differs from a two-factor, conscious control view
of deliberate emotion regulation in which emotion is first generated and
then managed. Emotion regulation in which the client can deliberately reg-
ulate emotion is necessary, but a second-level, deliberate process acts after
the emotion is generated and needs to be combined with the development
of automatic affect generation capacities.
Automatic regulation of emotion is achieved implicitly at the point of gen-
eration. This automatic regulation is developed by internalizing the empathic
soothing of the other so that the self feels more secure and is less intensely
activated, or by transforming emotion at its point of generation so that when
it arises, it is already regulated. Therefore, affect regulation occurs much
more implicitly by coregulating affect or by changing emotion with emotion
such that the emotion that needed regulation is no longer being activated.
With affect regulation comes an automatic soothing or transforming of emo-
tion so that the experienced emotion is already regulated or is modulated
(Jurist, 2019).
Deliberate emotion regulation involves some form of conscious strategy
that helps reduce arousal (e.g., breathing and soothing techniques) to enable
calm and meaning-creation in sessions, and skills to be used outside the
session to help people cope. In general, the dysregulated emotion is either
 Emotion Regulation  •  281

a secondary, symptomatic emotion, such as anxiety, anger, helplessness, or

hopelessness, or a maladaptive primary emotion, such as traumatic fear of
danger, overwhelming sadness of lonely abandonment, or the debilitating
shame of self-loathing. Clients enter therapy to rid themselves of these pain-
ful emotions so they can cope better in their lives.

BUILDING CAPACITY FOR SELF-SOOTHING

Automatic affect regulation occurs more implicitly by coregulating affect via

internalization of safety and the therapist’s empathic soothing. Experiencing
an aroused emotion being soothed by the therapist, often nonverbally, is a
right hemispheric process and is one of the best ways to build the implicit
capacity for self-soothing. Being able to self-soothe develops initially by
internalizing the soothing functions of the protective other (Stern, 1985).
For example, I have had clients who say they hear my voice in their head
during the week. Having a constant reminder of empathy from someone
else is helpful; empathy from the other is internalized as empathy for the
self (Bohart & Greenberg, 1997).
Other affect regulation processes involve the transformation of emotion
intrapersonally at the level of generation. For example, transformational sooth­
ing is focused on internally bringing soothing and compassion to painful
emotions from the past by the adult self or by evoking a soothing figure
from the past to help resolve the past threat, as demonstrated in Chapter 10.
This strengthens the self by changing emotion with emotion and developing
automatic soothing so that the emotion that is experienced is already regu-
lated when it emerges.

Deliberate Coping Regulation

Deliberate emotion regulation skills have been studied as a general factor in

coping. A large body of research has implicated difficulties in emotion reg-
ulation as central to the development and maintenance of psychopathology.
Recently, a systematic review identified 67 studies that measured changes
in both emotion regulation and symptoms of psychopathology following a
treatment for anxiety, depression, substance use, eating pathology, or border­
line personality disorder (BPD; Sloan et al., 2017). Results showed that
regardless of the intervention or disorder, use of both a maladaptive emotion
regulation strategy and overall emotional dysregulation was found to sig-
nificantly decrease following treatment. Symptoms of anxiety, depression,
282  •  Changing Emotion With Emotion

substance use, eating pathology, and BPD were also reduced. The findings
of this review provide evidence supporting the notion that emotion regula-
tion is a transdiagnostic construct and is for treatments that target emotion
regulation for individuals presenting with multiple disorders.
A number of meta-analyses have shown mixed results about which delib-
erate strategies appear to be the most effective. Aldao et al. (2010) exam-
ined the relationships between four symptoms—anxiety, depression, eating,
and substance-related disorders—and the following six emotion regulation
strategies:

• reappraisal—reinterpreting the meaning of an event to change its emo-

tional impact
• acceptance—remaining in contact with feelings, thoughts, and sensations
• problem solving—making a conscious attempt to change a situation or
its consequences
• avoidance—behaviorally avoiding situations to have an emotional impact
as well as experientially avoiding internal experiences
• rumination—focusing passively and repetitively on distress or negative
mood
• suppression—pushing away thoughts, emotional expression, or both

They found a large effect size for the maladaptive effects of rumination,
medium-to-large maladaptive effects for avoidance as well as medium-to-
large adaptive effects for problem-solving and suppression, and small-to-
medium adaptive effects for reappraisal and acceptance. These results are
surprising given the prominence of reappraisal and acceptance in cognitive
behavior and acceptance-based treatment models. The authors also found
that internalizing disorders were more consistently associated with regula-
tory strategies than externalizing disorders.
Another meta-analysis by Webb et al. (2012) revealed that attentional
deployment had no effect on emotional outcomes, whereas response modu-
lation had a small effect, and cognitive change had a small-to-medium effect.
Although attentional deployment and concentration were not effective, dis-
traction was found to be an effective way to regulate emotions. Suppressing
the expression of emotion also proved effective, but suppressing the experi-
ence of emotion or suppressing thoughts of the emotion-eliciting event did
not. Reappraising the emotional response proved less effective than reap-
praising the emotional stimulus or using perspective taking.
Daros and Williams (2019), in another meta-analysis and review, ascer-
tained the relative endorsement of six of the most commonly studied emotion
regulation strategies. They compared strategies in individuals with elevated
symptoms of BPD to strategies used by individuals with low symptoms of
 Emotion Regulation  •  283

BPD and healthy controls as well as to individuals with other mental dis-
orders. Results indicated that symptoms of BPD were associated with less
frequent use of cognitive reappraisal, problem-solving, and acceptance, and
more frequent use of maladaptive strategies of suppression, rumination, and
avoidance. When compared with individuals with other mental disorders,
people with BPD endorsed higher rates of rumination and avoidance and
lower rates of problem solving and acceptance.
These aforementioned studies show that deliberate regulation skills help
with symptom alleviation; however, which skills to use when and by whom
remains to be understood. The studies produced mixed results of what was
most effective, but of interest is that cognitive reappraisal and acceptance—
the most strongly advocated cognitive behavior therapy strategies—may not
be as effective as either distraction or suppression of expression in helping
people regulate. It was found, though, that BPD clients used less cognitive
reappraisal, problem-solving, and acceptance than non-BPD clients, thus
lending some support to these strategies as correlates of healthier functioning.

Self-Soothing: Learned Through Direct Instruction

In the emotion-focused approach I present here, I recommend that explicit

regulation strategies be taught as a first step—as coping strategies to deal
with down-regulating emotion in people whose emotions are so dysregulated
as to impair their coping. This work, in general, needs to precede working on
processing of underlying emotions, but it may, at times, be done in conjunc-
tion with it. However, when there is sufficient capacity to regulate emotion,
I recommend focusing on accessing and transforming the emotion schematic
processes that underlie the presenting dysregulation.
A two-stage treatment framework, thus, is potentially useful for highly dys-
regulated clients. It begins with the teaching of deliberate down-regulation
skills followed by work on automatic regulation by targeting underlying pri-
mary emotion generation processes. The notion of stages here, though, is
not meant to suggest a hard-and-fast sequence rule. Rather, it is applied in
a marker-guided fashion to fit the current state of the client in the session
and in how they are coping with life outside the session. If a client at a
particular juncture is so overwhelmed by emotion in the session or in life,
then down-regulation and use of skills are needed to help cope. When the
emotion is sufficiently regulated and the client can bring cognition to bear
on emotion to make sense of it, the therapeutic process can profitably shift
to access the underlying generating processes that, in the first place, led to
the emotion that needs to be down-regulated.
284  •  Changing Emotion With Emotion

Thus, if a client is panicking in an out-of-control fashion or is so filled with

despair to want to harm self or others, then skills of distraction, calming,
and distancing from emotion are needed. If, however, they are able to talk
about these emotions and their triggers in a more modulated fashion—and
not be swamped by them—then it is time to explore the underlying emo-
tions to which these dysregulated emotions are a reaction: for example, the
underlying attachment insecurity, shame, or sadness that leads to the panic
or self-hatred. In these situations, down-regulation is a second-level process
in which emotions that have been generated are acted on to control and
manage them to help people cope. Thus, when a person gets to unmanage-
able levels of anxiety, coping self soothing is helpful to manage the intensity
of the feelings.

Transformational Self-Soothing: Learned Through Experience and Internalization

A different type of self-soothing is more transformational in nature. As dis-

cussed in Chapter 10, it involves ways of being with the self to moderate
and transform core pain. It is rooted in a client’s ability—based on inner
resources, probably derived from the internalization of compassion received
from others—to soothe their own core painful, primary maladaptive emo-
tions. This enables them to achieve lasting change by transforming their
pain. The brain functioning involved in affect is inherently complex; the
primary level of emotion regulation is best understood as involving a rapid
cascade of effects moving up and down different subcortical and cortical
areas. People do not have deliberate cognitive control of this type of pri-
mary regulation of affect. Rather, lots of implicit processes involve massive
feedback loops and syntheses of different levels of processing in which dif-
ferent parts of the brain interact with each other, leading to synchronization,
which results in the self-organization of the entire brain.
The development of automatic transformational self-soothing, then, is
different from the development of deliberate coping self-soothing. Trans-
formational self-soothing involves the activation of unresolved emotional
suffering to enhance its regulation at its point of generation rather than to
control it once it has been generated. Thus, it is the painful emotions that
never received the needed soothing in the past or the present experienced
threat of abandonment or disintegration that can be changed by feeling
compassion toward the self, grieving the loss, and soothing the anguish
of the self. Once a painful emotion schematic memory has been evoked,
soothing can be provided both by the individual themselves or by the thera­
pist. Coping self-soothing is a deliberate skill used to address symptomatic
 Emotion Regulation  •  285

dysregulation that one needs to overcome, whereas transformational self-

soothing focuses on bringing soothing to unresolved painful emotions from
the past. This helps transform past threat and strengthen the self by the
development of automatic soothing so that emotion now is experienced in
a regulated way.
Deliberate forms of regulation by cognitive and behavioral means are
more of a left hemispheric process and are useful for people as coping skills
when they feel out of control. However, emotional dysregulation problems
that occur in more fragile personalities and arise more from deficits in the
more implicit forms of regulation possibly are more right hemispheric and,
therefore, cannot be modified by direct procedures. It is the building of
implicit or automatic emotion regulation capacities over time that is import-
ant for these highly fragile personality disordered clients. Implicit forms of
regulation often cannot be trained or learned as a volitional skill.

ADDRESSING EMOTIONAL DYSREGULATION

The term emotional dysregulation refers to the inability to regulate unwanted

emotional states. As mentioned earlier, emotional dysregulation is an aspect
and possible cause of many psychological disorders, such as personality dis-
orders, bipolar disorders, anxiety disorders, depression, addictions, and post-
traumatic stress disorder. Emotional dysregulation is the person’s inability
to control or regulate their emotional responses to evocative situations. It
can also be thought of as having high emotional reactivity: The person often
reacts in an emotionally exaggerated manner to such things as criticism, per-
ceived abandonment, or relational conflict. Environmental and interpersonal
challenges such as these lead to overreacting, crying, blaming, having angry
outbursts, engaging in passive–aggressive behaviors, or causing conflict.
Emotional dysregulation often involves avoiding abandonment and rejection
or having difficulty maintaining stable relationships. Emotional dysregula-
tion is frequently relational and is triggered in intimate relationships or in
relationships with people who have power or control over one.
Dysregulation can be arranged on a continuum ranging from an over­
regulated style to an underregulated, overactivated, hyperaroused regula-
tory style. An important characteristic of dysregulation and disorganized
affective responses is unpredictability involving oscillating between excessive
or diminished affective responsiveness A central characteristic is difficulty
with both soothing oneself and returning to a baseline of emotional expe-
rience. There may also be difficulties being stimulated and feeling a sense
286  •  Changing Emotion With Emotion

of liveliness. Either style, under- or overregulation, can lead individ­uals to

engage in external regulation in the form of self-harm, eating dis­orders, sub-
stance abuse, sex addiction, or some form of excessive risk-taking. These
behaviors often are central in personality disorders and posttraumatic stress
disorder.
Emotional dysregulation probably develops from an interaction between
the temperament of the child and the early experiences of abandonment,
deprivation, or frustration of the child’s attachment and identity needs. Emo-
tional dysregulation may derive from early interpersonal traumas in child-
hood or latter traumas in life. Early traumatic events create a hyper­active
central nervous system that is sensitized to cues related to early stressful
events. Traumatic events and emotional neglect lead to the development of
maladaptive emotion schemes.

When to Regulate and When to Activate

An important issue in any treatment is to consider when emotions should

be regulated and when they should be activated. In addition, one needs to
consider what types of emotion are to be regulated and how this is to be
done. Emotions that require down-regulation generally are either secondary
emotions, such as anxiety, anger, despair, and hopelessness, or primary mal-
adaptive emotions, such as the anxiety of basic insecurity, fear of danger,
and the shame of being worthless as well as any emotions that currently
are not able to be connected to adaptive cognition because they are so over-
whelming. Maladaptive emotions of shaky vulnerability, overwhelming
sadness, or feelings of core shame all benefit from down-regulation to create
a working distance from these feelings rather than become overwhelmed
by them. Suppressing feelings, however, can lead to a rebound effect, also
known as a bottle-up, blow-up effect. Total distancing from emotion in
many situations, then, is not helpful. In some cases, however, people can
effectively distance themselves from their emotions, and this disengagement
can facilitate learning and memory. Likewise, too much emotion at too high
an intensity can, at times, be countertherapeutic. A crucial clinical judgment
is when to down-regulate, distract, and modulate and when to facilitate
approach and intensification.
There are a variety of indications for when to down-regulate emotions.
First, it is important to promote regulation when the therapeutic relation-
ship cannot yet provide the safety needed for emotion activation or deeper
work. A clear indicator for emotion regulation is when a client feels over-
whelmed by emotion or when emotion does not inform or promote adaptive
 Emotion Regulation  •  287

action. When a person is in a crisis, then down-regulation and crisis manage-

ment are needed. A previous history of violence or uncontrolled anger, or,
alternately, prior experiences of disintegrating and being unable to cope are
strong indicators for promoting either anger regulation or anxiety manage-
ment. If clients engage in destructive coping, using substances to self-medicate,
if they binge eat, or if they engage in self-harm to deal with distress, then
coping skills are needed (Linehan, 1993). If the problem is a skills deficit,
then training in the development of emotion regulation or problem-solving
skills is called for.

Which Emotions to Target and How

The therapist needs to make a judgment about which emotions need regu-
lation and which type of regulation is necessary. They need to distinguish
among primary, secondary, and instrumental emotions, and between adap-
tive and maladaptive primary emotions—and help clients to do the same.
It is generally secondary emotions of global distress that need down-regulation,
except for trauma related experiences for which it is primary maladaptive
emotions that need down-regulation. Let’s look at anger regulation as a case
example.
Therapists should distinguish among primary adaptive anger, which needs
to be supported; secondary anger, which masks hurt; or primary maladaptive
anger, which is an immediate and overly general response to perceived
threat, and frequently is associated with posttraumatic stress reactions. For
instance, a rape survivor might, for years after the assault, react consistently
with rage at being touched by a person of the same gender as their rapist.
This anger probably needs both deliberate skills to initially help cope but
also, in the long run, deeper work to transform the underlying fear memo-
ries. Secondary reactive anger, however, is often defensive anger that masks
more vulnerable core emotion, such as sadness, fear, or shame. Here, it is
better to work on the underlying vulnerable feelings than on skills to regu-
late the anger. Instrumental anger is anger one uses consciously or uncon-
sciously to manipulate or control others; one’s use of it is not a candidate for
regulation, but the person needs work on personality problems and to learn
to express that anger in more direct ways. Each of these distinct anger prob-
lems requires different intervention strategies. Skills are then needed for
improved coping related to maladaptive and secondary anger, but adaptive
anger at unfairness needs facilitation rather than regulation.
Also, the same individual can experience and express a variety of types of
anger, so each situation needs to be treated differently. For example, therapy
288  •  Changing Emotion With Emotion

for a client who was abused by his father and sexually molested by a male
relative involved several ways of addressing his anger:

• His secondary defensive anger covering shame when he felt slighted by

his wife needed to be bypassed rather than regulated to get to his under-
lying shame.

• Blowing up at perceived signs of disrespect from his children, however,

needed deliberate regulation skills. His use of instrumental anger and
aggression to control others needed learning of new, more direct ways of
expressing himself.

• The difficulty he had acknowledging feelings of healthy anger about his

father’s abuse because he feared doing so would jeopardize the current
relationship he had with him needed discussion and problem-solving.
Resolution of the past trauma needed acknowledgment of his appropriate
anger at the abuse but for him to let go of it and not react to things with
his father in the present in terms of the past.

Therapists themselves, thus, need to distinguish and help clients distinguish

among different types of emotions so they know when to regulate and when
to express, when to modulate, or when to bypass their anger and attend to
a more core vulnerable experience.
There are a variety of forms of treatment for emotional dysregulation.
Medication, when appropriate, combined with effective psychotherapy can
improve sleep and stress management. Plus, psychoeducation sometimes
can significantly improve the quality of life of people with emotional dys-
regulation. Teaching clients skills to regulate has been proved useful as have
relational processes of validation; development of a secure attachment rela-
tionship with the therapist; and development of mentalization, the ability
to reflect on the contents of one’s own and others’ mental processes. What
is clear is that emotion needs to be the target of treatment, so methods
of working on changing how emotions are both generated and managed
once generated are central. Next, I discuss deliberate skills, which are use-
ful coping skills for people who are highly dysregulated—but are not a full
treatment. Then, I discuss an emotion-focused approach to changing the
emotions underlying dysregulation.

DEVELOPING EMOTION REGULATION SKILLS

Distraction and distress tolerance skills are useful for regulating emotions
(Linehan, 1993). They involve identifying triggers, learning to avoid trig-
gers, establishing a working distance from emotion, allowing and tolerating
 Emotion Regulation  •  289

emotions, increasing positive emotions, engaging in self-soothing, doing

diaphragmatic breathing, and relaxing. Tolerating distress includes mindful
breathing and awareness of emotion. Regulating breathing and observing
one’s own emotions—letting them come and go—are crucial processes that
help regulate emotional distress. It is the development of these skills that is
the focus of this section.
At first glance, many activities may seem like they help people keep their
emotional balance, but on further consideration, they reveal themselves to
be unhealthy: They help in the moment, but, in the long run, they actu-
ally hurt. These include such things as abusing alcohol or other substances,
engaging in compulsive sex, inflicting self-injury, avoiding or withdrawing
from difficult situations, engaging in physical or verbal aggression, or exces-
sively using social media. These activities tend to help people feel good in
the moment, but they usually function to delay the inevitable: that people
have to face the emotion.
Overt dysregulation of emotion like yelling or overwhelming weeping
plus acting out behaviors can benefit from learning skills to manage emo-
tions more effectively. The first step in the practice of self-regulation skills
is for people to recognize that they have the choice in how to react to situ-
ations and to deliberately choose to use the skill. Using the power of choice
is a primary self-regulation skill that empowers people to work with the
disruptions and challenges that they face. People also have to accept that
they never have complete control over how they feel.

Choice, but Not Control

Developing the motivation to choose is an important aspect of therapy.
A quote attributed to Viktor Frankl (1959) states that “between stimulus
and response there is a space. In that space lies our freedom to choose our
response.” The ability to stop and take a breath is a crucial skill because it
allows one to take an observer’s perspective in relation to internal experi-
ence to observe one’s sensations, feelings, and thoughts; where one’s focus
of attention is; and to what one is reacting. This skill helps develop a work-
ing distance from emotions rather than being overwhelmed by them. Learn-
ing how to pause in between an intense emotional reaction and ensuing
actions is one of the most valuable skills a person can have.
Having chosen to regulate and having managed to take an observer’s
perspective, one of the most powerful tools in emotion regulation is simply
to identify and name the emotion one is feeling. Here, it is good to know
about the difference between primary and secondary emotions, and how
to address each in the most helpful way. Therapists can provide this infor-
mation as part of their psychoeducation for clients and their orientation to
290  •  Changing Emotion With Emotion

what therapy will be like or in an ongoing fashion as part of the process.

In addition, receiving support and understanding is helpful in regulating
emotions, and therapists should certainly discuss with clients how they will
provide support and understanding during sessions. If appropriate, they can
also discuss available family and community supports.
Caring for body, mind, and spirit aids being emotionally regulated and is
an important responsibility. Engaging in physical activity, eating well, and
getting lots of sleep are critical to having resilience and balanced emotion
regulation. A healthy body is also an important step on a path to a healthy
mind. Eliminating physical issues, such as feeling, tired, hungry, or sick, will
make it easier to maintain emotional balance. Negative emotions should not
be ignored, but leaving room for the positive as well and increasing positive
emotions is almost always good. Focusing on the positive helps put worries
and insecurities aside.
A mind-set of living life in the present instead of being stuck in the past
or the future, first advocated in Western psychotherapy by Gestalt therapy,
has now been adopted by a variety of approaches, as have specific mind-
fulness practices. Facilitating a present-living mindset often means helping
people become more aware of emotions, thoughts, and body sensations.
Mindfulness practices can help increase the ability to regulate emotions and
decrease stress, anxiety, and depression. It also can help to focus attention as
well as to observe thoughts and feelings without judgment. The more inte-
grated the practice of mindful awareness becomes in life, the more emotions
become regulated.

Acceptance
Allowing oneself to be vulnerable takes strength and courage. Acceptance
of suffering—no longer running away from difficult emotions but facing
them instead—is an attitude more than a skill but is of great help in regulat-
ing emotions. Accepting vulnerability is crucial to explore emotions and ask
questions to get in touch with how one is feeling in a given moment. Learn-
ing to let go of emotion and move on can be difficult but is perhaps one of
the most important emotion regulation skills. People often become stuck
when attempting to process negative emotions. Negative emotions seem to
stick in the brain. Instead of simply letting them go and moving forward,
people often hold on, obsessing over every little bit of emotional experience
and bemoaning, “Why did this happen to me?” It seems paradoxical, but
accepting that one is feeling emotions that one would rather not feel can
be the key to letting go of those emotions. When people accept that they
are suffering, they stop running from the difficult emotions and turn to face
 Emotion Regulation  •  291

them, and when they find they do survive feeling them, they experience that
it was more manageable than the beast they had imagined.
Allowing and accepting an emotion involves observing it, welcoming it,
acknowledging that it exists, and accepting it. Then, one needs to stand back
from it and experience it as a wave—let it wash over them and then move
past and away. It is helpful to concentrate on some part of the emotion,
like how one’s body is feeling or some image about it. The person needs to
observe the emotion coursing through their body to symbolize the experi-
ence of it in words (Lieberman et al., 2007). For example, they can create
a safe distance from an overwhelming emotion by adopting an observer’s
stance so they then are able to describe the fear as, say, a black ball located
in one’s stomach.
It is helpful to recognize that a person is not their emotion and that emo-
tion is a part, but not all, of the person. People are more than what they feel;
they do not necessarily have to act on the emotion, but they may just need
to sit with the emotion. Often, acting can intensify and prolong the emotion.
Paradoxically, becoming aware of an emotion is one of the most effective
ways of helping to contain an emotion. Accepting an emotion helps clients
become aware of it, express it, and decide what to do about it as soon as it
arises. Suppressing emotions and not doing anything tend to generate more
unwanted emotions and thoughts, making them more unmanageable and
more distressing. When people become aware of what they feel, they are
able to reconnect to their needs and are motivated to meet them.
People need to practice welcoming, accepting, and validating emotions.
This can be a difficult concept. They need to learn to accept their emotions
just the way they can learn to accept things about themselves or their experi-
ence that they cannot change: their age, height, allergies, and so on. Accept-
ing what one cannot change and approving or liking it are two different
things. One does not have to like their allergies or acne, but those things are
there and can be managed. They are not easy to change; however, if a per-
son just accepts or, in some instances, comes to appreciate them, they feel
a lot better than if they keep fighting the idea that those things are there.

A Safe Place
Therapists also can help by explicitly guiding their clients to self-soothe in
the moment. Promoting clients’ abilities to regulate and achieve a working
distance from their emerging painful emotional experience is an important
skill that helps them tolerate their emotions and self-soothe. A central strat-
egy to promote self-soothing is to suggest to clients when they are in high
distress and before they become overwhelmed that they imagine a place
292  •  Changing Emotion With Emotion

where they feel safe and to access that place in their imagination. Once
they have an image of that safe place, they are asked to feel what they
experience there (Elliott et al., 2004; Watson, 2002). Therapists can say, for
example, “Imagine taking yourself somewhere safe, where you feel secure
and comforted. Where do you take yourself? Can you describe what it’s like?
What do you feel there?” In this exercise, clients go to a safe place in their
imagination where they can list their concerns and set them out in front of
them or imagine placing each concern in a separate container. In this way,
clients are encouraged to relieve the tension of their concerns and anxiety
in the moment. It gives them a sense that they can create some distance
from their anxiety to feel more relaxed and calmer. Alternatively, therapists
can encourage their clients to “clear a space” (Elliott et al., 2004), that is,
ask clients to create a space in their mind by acknowledging their troubling
concerns one at a time but then push them to the side of their mind to create
an internal space of calm emptiness.
These imagery exercises help clients soothe high secondary distress in
the session and are also given as homework to cope with high distress expe-
riences outside the sessions. Therapists use these exercises to teach clients
that they are capable of imagining and providing a safe place for them-
selves. Having the ability to access a safe place when they are in a distressed
state helps clients to shift into a more soothing stance and achieve a calm
state—a deliberate skill that helps clients handle immediate feelings of anx-
iety in specific situations and cope better by building the capacity to calm
and reassure themselves.
Other ways of teaching clients self-soothing to down-regulate intense
feelings is to direct their attention to experiences that feel comforting. When
clients do not find it easy to call up a safe place, therapists need to provide
compassion and help clients identify their need for safety or comfort. Once
that has been done, therapists can then ask clients to identify experiences
they do find comforting—perhaps having a cup of tea or coffee, taking a
warm bath, curling up with a good book, listening to certain pieces of music,
or watching TV. When clients feel overwhelmed or emotionally flooded in
the session, therapists guide them to engage in self-soothing strategies to
regulate their emotions. Attending to their breathing is central. Therapists
need to guide clients to breathe more regularly, put their feet on the ground
and become aware of what is happening around them, name what they see
around them, feel themselves sitting in their chair, or look at their thera-
pist and describe what they see. Relaxation exercises and relaxation audio
recordings can be useful to teach clients relaxation skills. It also is important
to explore with clients ways that they personally find comforting and sooth-
ing. Some clients have difficulty knowing what is comforting because they
 Emotion Regulation  •  293

have never been able to comfort themselves. It is important to encourage

these clients to pay attention to times in their day-to-day lives that provide
them comfort. Doing so helps them to begin to build up strategies and ways
of caring for themselves when feeling distressed and alone.

Emotion Awareness Exercises

Two emotion awareness exercises can be used to help people identify their
emotions as the first step in emotion labeling. The first is a training sheet
(see Exhibit 11.1), which therapists can provide to clients as a handout for
them to fill in either during therapy or in between sessions. It is helpful to
go through each step during therapy first, possibly over multiple sessions,
to allow time for defining key terms (e.g., “action tendency”) and to do the
deeper work, such as matching needs to emotions. The second exercise is a
therapist-guided imagery sequence to help clients identify how they respond
to their own emotions (see Exhibit 11.2).

REGULATING EMOTION AT THE LEVEL OF AUTOMATIC

GENERATION

The ability to regulate emotions comes, in part, from early attachment expe-
riences with parents and caregivers (Schore, 1994; Sroufe, 1996). If our
parents were good “emotion coaches,” they would recognize our emotions
as opportunities for intimacy, validate and empathize with our emotions,
and help guide us toward socially appropriate expression and action. The
optimal method of emotion work to help clients become emotionally regu-
lated is approaching and accessing previously avoided emotions and being
able to tolerate, accept, validate, and understand them.

Providing a Corrective Relationship and Environment

Emotional dysregulation has been attributed to failures in dyadic regulation
of affect early in the life cycle (Schore, 2003; Stern, 1985). Early attach-
ment trauma and affect dysregulation result from early misattunements
between mother and infant (Schore, 2003; Sroufe, 1996; Stern, 1985), and
any approach to therapeutic treatment of these clients must involve repair
of these early and implicit relational experiences. Repeated experience of
emotional stress reduction through affective soothing in therapy is vital for
developing regulation. The relationship with the therapist can provide a
powerful buffer or psychobiological coregulation for a client.
EXHIBIT 11.1.  Emotion Episodes Awareness Training Sheet
Step 1: Step 2: Step 3: Step 4: Step 5:
What is your What is the What are the What is the Establish your
emotion situation to thoughts need/goal/ primary
or action which you accompanying concern emotion.
tendency? are reacting? the emotion? being met/ Is your emotion
Is it best not being in Step 1
• An event?
described by met: primary?
an emotion • An internal
experience? • In the If not, is it
or feeling secondary or
word, or by • Another emotion?
person? • In the instrumental?
an action
tendency? situation? Your primary
emotion is
the one that
fits with your
unmet need.
For example,
if your need
is to be close,
then sad
would be
primary, not
angry. If your
need is for
nonviolation,
then anger
would be
primary, not
sad. If your
need is for
security,
then fear is
your primary
emotion, not
anger.

Adapted from Emotion-Focused Therapy: Coaching Clients to Work Through Their Feelings,
Second Edition (p. 363), by L. S. Greenberg, 2015, American Psychological Association (https://
doi.org/10.1037/14692-000). Copyright 2015 by the American Psychological Association.

EXHIBIT 11.2.  Guided Imagery Sequence

1. Invite the client to close their eyes and remember a time when they struggled with
a difficult emotion, a feeling of being criticized, or an argument with a partner.
Ask them to picture the situation and enter into it to relive it now. Ask: “Where are
you? Who is there with you?”

2. Encourage the client to identify the strongest emotion they feel in this situation,
feel what it’s like in their body, and label it (e.g., legs shaking, heart speeding up,
a huge foam ball in the throat).

3. Help the client identify how they responded to their emotion. Ask: “What do you
feel like doing now?” It is important to make clear that it’s how they react now—not
how they reacted at the time.
 Emotion Regulation  •  295

The first step in helping clients develop automatic emotion regulation is

the provision of a safe, validating, empathic environment. How the therapist
joins with clients and connects emotionally with them is the first experi-
ence in therapy that influences emotion regulation. Therapists’ empathic
attunement to affect, acceptance, and validation is, as discussed in Chap-
ter 5, emotionally soothing. Being able to soothe the self develops initially
by internalization of the soothing of the protective other (Sroufe, 1996;
Stern, 1985). This internalization helps clients develop implicit self-soothing
and the ability to regulate their own feelings automatically.
Internal security and comfort develop by having the feeling that one
exists in the mind and heart of the other. Most clients feel safe when their
therapist offers a soothing, affect-attuned bond and an accepting emotional
climate. The climate has to do with the total attitude of the therapist com-
municated by means of verbal expressions as well as body posture and facial
expression. Facial expression is an important part of relational attunement.
People read facial affect automatically at very high speed, especially those
affects that are crucial to survival, such as fear and anger. Vocal tone is
also important; rhythm, cadence, and energy need to be appropriate to the
emotion being worked with. A soothing, slower tone and manner are crucial
in accessing core vulnerable emotions. A more energetic, enthusiastic tone
may be helpful in supporting the more boundary-setting emotions of anger
and disgust.
Treatment of emotional dysregulation needs to recognize the importance
of the therapeutic relationship in providing a corrective emotional expe-
rience. The good therapeutic relationship provides a corrective emotional
experience by being responsive to the client’s feeling and validation of their
needs in contrast to the abusive or punitive relationship that the client expe-
rienced during their childhood. The therapy situation becomes a safe place in
which the client can affirm and express their feelings and needs and desires.
This corrective relationship is experienced in most sessions as the therapist
explores and empathizes with the client’s present difficulties. After explor-
ing present life difficulties, the discussion often goes back to childhood and
adolescence. During these explorations, the goal is to help the client access
their core painful emotions of the past and to experience empathic sooth-
ing of the therapist, who helps the client reown disowned needs from their
childhood so that they can recognize and satisfy their current needs. This is
an experiential, not a conceptual, process that helps access emotion schemes
and activate emotional structures of the brain, such as the amygdala, as well as
parts where emotional memories are stored. The therapist helps the client
activate painful memories to access the painful emotions and helps them
transform by revitalizing the previous unacknowledged needs. Emotional
296  •  Changing Emotion With Emotion

memories are then rewritten and changed by the memory reconsolidation

process (Nader, 2003). This is all based on developing a secure attachment
between therapist and client.

Using Empathic Clarification

A particular form of empathic responding is helpful in dealing with the emo-

tional dysregulation that often occurs with clients with complex personality
problems. One of the difficult processes with these fragile clients is when
there appear to be discrepancies between what clients say and what they
do or feel. For example, they may deny any responsibility for their actions
and attribute blame to others in situations in which they were blatantly at
fault. Many therapists often deal with this aspect of dysfunctional coping
by using a form of confrontation. However, given that the internalization of
the therapist’s soothing presence is an important aspect of developing affect
regulation, confrontation is contraindicated.
As an alternative way of responding to situations of dysregulation in
client interpersonal patterns, I recommend balancing emotional valida-
tion of dysfunctional coping modes with a push for change. When a client
adopts dysfunctional patterns of coping based on their maladaptive emotion
schemes and self-organizations during a session, their therapist needs to
show empathic understanding that validates the coping effort but highlights
how the dysfunctional pattern fails to get the client’s needs met.
Therapists do not focus on skill training or point out clients’ contributions
to problematic interpersonal patterns, denial of underlying motivations, or
avoidance behaviors, as might occur in confrontations. Confrontations of
this sort usually raise clients’ anxiety and defensiveness, which is contrary
to forming a safe, secure relationship. However, something more than the
safety of the relationship is needed for dealing with these difficult patterns—
something that is an alternative to confronting discrepancy or skill training.
What is needed is for the therapist to convey understanding of the client’s
behaviors in terms of the client’s protective coping efforts, underlying emo-
tions, and unmet needs. Therapist responses that I have found work best
when their components occur in a particular sequence.
An emotion-focused response for clients who are depressed or anxious
but not emotionally dysregulated is sequenced more or less like this:

1. Begin with an empathic reflection of the client’s secondary emotion.

2. Focus empathically on the client’s primary painful maladaptive emotion.
3. Identify the unmet need in the primary emotion.
 Emotion Regulation  •  297

As an example of the preceding sequence, the therapist would say, “Yeah,

you are feeling so angry at the way you were treated. It left you feeling so
unimportant, and you really need to feel seen and respected.” The first step
is to reflect a secondary feeling that the client has explicitly expressed, and
the next steps are to conjecture about the primary underlying vulnerable and
painful emotion, and the need.
But, in situations in which the client’s reactions are highly dysfunctional
and their emotions are dysregulated, it is better to change the sequencing in
the response. The therapist needs to:

1. Reframe, through reflection or conjecture, the client’s difficulty in terms

of underlying needs.
2. State an understanding of the client’s core painful disowned emotion that
is under the more surface secondary/instrumental emotion or behavior.
3. Restate that the secondary reaction makes sense as an attempt to satisfy
the unmet need.
4. Refocus on core pain and unmet need at the end.

This sequence is shown in the following response to a client’s statements

about his present girlfriend and past ones, who he says left him “because
he loves them too much.” The present girlfriend’s view was that she left him
because he was too needy. He broke her finger in an altercation. He says
this is not true and that the girlfriend is being unfairly influenced by couple
therapists the pair had seen. The emotion-focused therapist, rather than
saying something like, “Could it be that the girlfriends left you because of
your anger?” responds by saying,
So, as I understand it, you so need and want closeness. All your life, you have
yearned for closeness. When you didn’t get it with your girlfriend, it left you
feeling so painfully lonely and abandoned. So then you got to feeling hopeless
and angry, and began to fight for what you are missing. But what you really
need is closeness, and it’s so painful when you don’t get it.

The client’s attention is guided by this response to the need and pain under-
lying the dysfunctional behavior. The therapist does not have to contradict
or invalidate the client’s experience.
It is helpful to think of three Rs to guide this intervention: reframe,
restate, refocus. As shown in the preceding example, the secondary reaction
is reframed as a reaction to a primary underlying vulnerable and painful
feeling and need. The understanding is validating and conveys “it makes
sense” that you react this way when you have this painful feeling and unmet
need, and the client feels understood and accepted. Then the focus is shifted
298  •  Changing Emotion With Emotion

to the exploration of the painful feeling without any confrontation or raising

of the client’s protective defenses. The therapist then repeatedly restates
the understanding in terms of the painful unmet need and feeling that, at
a deeper level, drive the problematic behavior. It’s important to refocus
repeatedly on the painful feelings that need to be processed, as in: “But what
we really have to focus on is to help you deal with this feeling of loneliness
and inadequacy because this is what drives the anger.”
Do not focus on insight into unconscious motivation or modifying behav-
ior, or on problem solving and skill training. Rather, follow the sequence:

Need —
> Core pain — > Secondary emotion or behavior
that fails to get the need met

Throughout the process, the therapist maintains therapeutic presence,

empathic attunement to affect, acceptance, respect, and genuineness.
In another example, a client says,
There is no way for me to find a girlfriend, and I’m really desperate. It’s a
social problem. It is much easier for women to find a partner. That is so unfair!
I tried everything, but it didn’t help. I was on Tinder for 1 year, and I only got
one match from somebody I know. Laura is my only chance. She has to come
together with me. She really owes this to me, and she needs to understand
this. If it doesn’t work with her, I’ll kill myself, and she’ll know that she was
the reason.

The therapist responds,

Yeah, all of this is very painful. You want desperately to be together, and when
she is hesitant, this leaves you feeling so afraid of losing her and so powerless,
and this understandably makes you angry. But, somehow, this anger doesn’t
really help you to get what you want, and what seems most painful is this
feeling—sort of a fear, a fear of being rejected, abandoned, and being all alone
without her. Can we talk a bit about what that’s like?

This form of responding ties the client’s dysregulated emotions and actions
to core needs and emotional pain (and to historical origins, if possible), and
takes a subjective view, not an objective view. Rather than blaming clients,
which is essentially what confrontation implies, therapists are empathic, have
positive regard (the client tried the best possible solution at this moment),
view blocks as self-protection, and are compassionate to clients’ suffering.
Rather than making explicit a client’s dysfunctional pattern, the underlying
motivation driving the pattern, and the cost, therapists focus on understand-
ing the painful emotion and validating the need.
Empathic clarification as discussed here involves a repeated switching
among emotions, behaviors, and needs: The therapist validates the client’s
 Emotion Regulation  •  299

means of coping as an understandable outcome of the situation and the

client’s life history, and as driven by the unmet need. At the same time, the
client’s attention is brought, without blame, to the negative consequences
of the behaviors.

Developing a Case Formulation

The first strategy in using experiential methods for treating the deeper layers
of emotional dysregulation is to develop a case formulation that helps guide
intervention toward the core painful emotion. The therapist’s initial step is
to collaboratively identify and come to agreement with the client on what
the client’s core painful emotion and self-organization are that govern their
way of functioning. Case formulation provides both participants with an
understanding of what the client’s core painful emotion schemes are as well
as the client’s associated needs. From this understanding, the therapy devel-
ops a focus on the client’s core concerns and operating self-organizations,
such as, being sensitive to abandonment, feeling deprived, feeling unwor-
thy, and feeling wronged. It is these self-organizations that generate the
dysregulated emotions and that are worked with at an experiential level
with the aim of their transformation, not their regulation. Their transfor-
mation leads to the client’s no longer being emotionally dysregulated. What
often is in need of regulation is the dysregulated secondary emotions that
are reactions to the more primary, painful emotions in these organizations.
Thus, the dreaded fear of abandonment leads to dysregulated rage or panic
and the shame of feeling unworthy leads to overwhelming self-loathing and
to self-harm, whereas suppression of underlying anger or shame leads to
substance abuse.
Case formulation helps clarify what to focus on in treatment and to move
beyond the many secondary reactive states characterized by exaggerated
emotions of sadness, anguish, anger, and shame. In addition to dysregulated
secondary emotions, core maladaptive states from childhood maltreatment
can leave people dysregulated and experiencing overwhelming feelings of
sadness, feeling emotionally empty, feeling lonely and socially unaccept-
able, and feeling not worthy of being loved. Clients suffer from feeling sad,
scared, alone, unworthy, and unlovable, and feel the enormous pain and
fear of abandonment caused by their abusive histories. These histories, how-
ever, express themselves through secondary depressive, fearful, and desperate
feelings as well as feelings of inferiority.
Other forms of dysregulation involve excessive anger, frustration, and
impatience because needs have never been considered or satisfied. Some
300  •  Changing Emotion With Emotion

clients react with uncontrolled aggression and can hurt people or damage
objects. Others use a “wall of anger” to protect themselves from others
whom they perceive as threatening. Other clients manage emotions with
impulsive discharge, reacting immediately in an attempt to meet their needs
or desires. They are unable to postpone their gratification or to predict the
consequences of their actions. Some attempt to regulate by eating, watch-
ing TV, abusing drugs, or having promiscuous sex. Others are organized to
withdraw or suppress their feelings and depersonalize. All these different
types of dysregulation emanate from underlying core painful emotions and
the client’s patterned self-organizations, and it is the underlying schemes
and self-organizations that need to be the target of treatment. If change
takes place at this deeper level, dysregulated emotions will disappear. If
people feel worthy, grieve their losses, let go of or forgive past hurts, let go
of anger and resentment, and feel better, they no longer have a need for the
secondary emotions.

Building New Meanings and Behaviors to Get Needs Met

Most of the methods covered in this book, such as focusing, attuning, reexpe­
riencing the past in the present, overcoming blocks, and changing emotion
with emotion, can be applied to the activation of the specific emotion schemes
and self-organizations involved in emotional dysregulation. These methods
give the client the possibility to experience adaptive anger and sadness and
compassion, to build new narrative meanings and behaviors related to getting
needs met, or both. Imagery work and chair dialogues (Greenberg, 2017),
which are helpful in treating and transforming emotion schemes and self-
organizations, are the two main methods for treating dysregulation. These
methods, described in previous chapters, are briefly discussed next in terms
of their use for emotional dysregulation.

Imaginal Transformation
Imagery can be used in a number of different ways to evoke clients’ core
painful emotions and to transform their anguish by accessing the transfor-
mative emotion of compassion. The visual system and emotion are highly
related, so imagination is a good way to evoke unresolved painful emo-
tions. Imagination can be used to enact dialogues between self and other
or even between parts of self, or to experience new emotions. It can be
helpful for clients to evoke compassion toward the self or imagine adding
comforting people or resources to situations or scenes so they can experi-
ence different scenes in new ways. In imaginal transformation, schemes and
 Emotion Regulation  •  301

self-organizations related to traumatic memories are activated with their

associated painful emotions. In working with a client’s present distress of,
say, feeling rejected or ashamed, the therapist can ask the client to find, in
their imagination, a situation in which they experienced an emotion similar
to the present negative emotion. Here, an emotional bridge is being formed
between present and past. In this way, traumatic experiences, often from
childhood, can be changed and can acquire new meaning through support
experienced in the imagery of reliving the past with new outcomes. The
therapist or another adult protective person chosen by the client is asked to
enter the old scene to help the client meet the child’s needs. Alternately, the
client’s soothing capacity can be activated by imagining the self as one’s cur-
rent adult reentering the evoked scene and providing a reparative response.
Thus, the therapist can ask the client to reenter, in their imagination, a
scene in which they were being bullied or neglected and to access their core
emotions. These painful feelings can be transformed by the client’s express-
ing what was needed or by imagining having a safety-providing protector
who helps them get what they needed. Clients can imagine a police officer,
or even the therapist, who offers the protection that was missing. Alter-
natively, other aids to empower or protect the client can be imagined; for
example, having clients being able to hide from the perpetrator, handcuffing
them, or locking them outside the room. Imaginary experiences like these
can help generate new emotions of assertive anger and compassion toward
the self that help change the old maladaptive emotions of fear, shame, and
sadness.
In this type of imaginary transformation, the therapist might say,
Try closing your eyes and remember your experience in this situation. Get a
concrete image if you can. Go into it. Be your child in this scene. Please tell me
what is happening. What do you see, smell, hear in the situation? What do you
feel in your body, and what is going through your mind?

After a while, the therapist can ask the client to shift perspective. The thera-
pists says,
Now, I would like you to view the scene as an adult. What do you see, feel, and
think? Do you see the look on the child’s face? What do you want to do? Can
you do it? How can you intervene? Can you try it now in your imagination?

Changing perspectives again, the therapist asks the client to become the child
and also asks,
What do you as the child feel and think? What do you need from the adult?
Can you ask for what you need or wish? What does the adult do? What else do
you need? Ask for it. Is there someone else you would like to come in to help?
Can you receive the care and protection offered?
302  •  Changing Emotion With Emotion

This intervention concludes with the therapist asking,

Check how you feel inside right now. What does all this mean to you, about
you, and about what you needed? Can you come back to the present—to your-
self as an adult now here with me? How do you feel? Can you say goodbye to
the child for now?

During imaginal transformation, emotions of fear, shame, and sadness

are changed both by the therapist’s presence in the room or by another’s
entering the scene in imagination and meeting the child’s need. This process
helps clients realize that they deserve to be recognized and protected. In
addition, the client has a different experience of the traumatic situation:
a possibility to experience similar situations in the future in a safe way.
With the continuation of treatment, the relationship with the therapist and
the schematic transformation that is created during the imagery create a
healthy organization in the client, who is now able to get needs met in a
constructive fashion.

Chair Dialogues
When clients experience dysregulated emotional states, chair work can help
to fight the critic or develop a sense of deserving to have unmet needs met
by others. The effect of the use of chair dialogues is a transformation of
the painful emotions; the ensuing down-regulation of the symptomatic dys-
regulated emotion; and the experiencing of an up-regulation of positive,
self-soothing emotions.
A primary source of emotional dysregulation often is self-attacking and
self-blaming, which create an unbearable negative affect. Frequently, this
dysregulation originates from the internalized voice of critical, demanding,
and punitive attachment figures. This internalization of negative voices
makes clients afraid that they did something wrong, see themselves as bad
and worthless, and believe that their feelings and desires are unacceptable.
They feel under tremendous pressure and set excessively high standards and
goals. Then, they become angry at themselves, hate themselves, and punish
themselves in some way.
Different types of chair work involve dialogues between different parts. For
example, in self-critical splits, one aspect of the self is critical or coercive. In
this work, the punitive voice attacks the self, which reacts. Thoughts, feelings,
and needs within each part of the self are explored and communicated in a
dialogue to achieve working through the painful feelings—often of shame—
and accessing a sense of deserving to have had needs met until there is a
softening of the critical voice. Resolution involves integration between sides.
Two-chair enactment at self-interruptive splits, as discussed in Chapter 8,
 Emotion Regulation  •  303

are worked with by making the interrupting part of the self explicit. Clients
become aware of how they interrupt their emotions and are guided to enact
the ways they do it, and then to react to and challenge the interruptive part
of the self. Resolution involves expression of the previously blocked expe-
rience. Empty-chair dialogue is used to work on unfinished business with a
significant other. Here, the client’s internal view of a significant other is acti-
vated, and the client experiences and expresses their emotional reactions to
the other to access the unmet needs. Resolution involves shifts in views of
both the other and self and either holding the other accountable or under-
standing or forgiving the other.
Self-soothing dialogues, as discussed in Chapter 10, are helpful when
clients experience anguish about past trauma, neglect, abandonment, or
humiliation. Self-soothing is facilitated in a chair dialogue in which clients
are asked if they, as adults or some other compassionate figure, could soothe
their vulnerable or wounded self. The goal is to evoke compassion for the self
(see, e.g., Gilbert, 2010). This intervention is a more active way, over and
above the relationship with the therapist, to directly facilitate self-soothing
by assisting the client to offer compassion to the suffering self, which can be
done by activating compassion and comforting self-talk in chair dialogues.
Therapists introduce this task when clients are in anguish and have dif-
ficulty being self-compassionate and accepting of themselves. To facilitate
the evocation of self-compassion and caring for the self, therapists, as in age
regression work, can suggest to their clients that they engage in a dialogue
with an imagined vulnerable self or themselves as a wounded child and
soothe and care for that self. Clients are encouraged to be responsive, caring,
and comforting to themselves. Compassion toward the self transforms neg-
ative emotion with the more positive emotion of compassion, which undoes
the negative feelings (Greenberg, 2011; Tugade & Fredrickson, 2004).
When clients become dysregulated, there is a possibility that they may
enter dissociated states. Modified chair work can enhance the client’s meta-
cognitive ability and prevent dissociation. Rather than activating the pain-
ful emotions, the chairs are used to recognize different parts of the self
and understand how they affect each other (Pos & Greenberg, 2012; Pos
& Paolone, 2019). Chair work interventions normally are used to intensify
experience to activate adaptive alternate emotional resources and self-
organizations. For the client with problems of dysregulation, though, these
interventions may be too emotionally dysregulating and disorganizing.
They may be unwise because, instead of contact between the parts and
ultimate integration, these clients can experience increased emotional dis­
organization. Chair work has the potential for intensively activating clients’
304  •  Changing Emotion With Emotion

object relations (Kernberg, 1967), including the self’s primitive defenses

(McWilliams, 1994), such as black-and-white thinking, polarization, or
primitive freezing in response to the overwhelming activated affect (Pine,
1986; Porges, 2004). Getting a working distance and externalizing the emo-
tion, then, are more helpful than increasing arousal. Maintaining contact in
the relationship is important because chair work can leave clients feeling
somewhat “abandoned.” Dysregulated clients often display limited reflec-
tive functioning or mentalization capacity. Emotional activation could lock
clients more deeply into whatever self-organizations were online and lead
to behavior coming fully from the presently active state with little capacity
to meta-observe it from a reflective position or experientially remember a
previously more organized state.
Chair work, however, can provide structure to the dysregulated client’s
experience of self, stimulate metacognitive awareness, attenuate emotional
activation, and increase the experience of self-coherence. Chair dialogues
that are conducted in this more reflective, cognitive manner to create aware-
ness of how different aspects of self function can help regulate emotion.
Strategies can be used to work with the maladaptive relationships between
self states in conflict and can help the client take a more reflective and
metacognitive stance toward their warring parts and what binds them in
conflict. Once adjusted, chair dialogues, rather than disorganize and dysreg-
ulate clients, can provide a particular kind of “scaffolding” for these clients’
self-reflective processes or mentalization (Fonagy et al., 2002), and this
scaffolding has the potential to contribute to their sense of integration. An
example of therapy with a more fragile client follows.

ENTERING THE REGULATION PHASE OF TREATMENT: A CASE

DESCRIPTION

The client, Lily, a 27-year-old Caucasian of Russian descent, entered therapy

with problems of self-harm and emotional outbursts. The initial phase of
treatment emphasized identifying emotions and needs and developing an
understanding of how emotions were a result of Lily’s childhood unmet
needs that had, at the time, been an adaptive response to attachment needs
that had not been satisfied in childhood, adolescence, and at present. To
facilitate this process, the therapist asked open-ended questions of what it
was like for Lily growing up in her family and questions about her childhood
and adolescence. The therapist maintained as much eye contact as possible
to show sincere interest in Lily’s life story and to validate her emotional
 Emotion Regulation  •  305

experiences, except when she was self-punitive. Self punitive self-blaming

states were dealt with according to the sequence laid out earlier in this
chapter of seeing the anger at self as secondary and going underneath to the
unmet need and core pain.
The second phase in therapy involved developing automatic regulation.
This had been occurring all along by internalization of the safe, soothing,
and empathically attuned relationship with the therapist. For example, when
Lily began therapy, she was detached. The therapist empathized with and
validated her feelings of detachment, and then bypassed them and went to
the underlying feelings of lonely abandonment, neglect, or abuse. The thera­
pist used imaginal transformation and chair work to access the core pain-
ful maladaptive emotions. Once contact with underlying emotion had been
made, new, healthy, adaptive emotions were accessed to change the old
emotions. In preparation for going in to Lily’s most painful feelings and to
enhance her tolerance to her dreaded emotions, a safe place was installed.
The therapist did this by having Lily close her eyes and visualize her safe
space, going into it, and experiencing the emotions of comfort and the feel-
ings of safety. Then, at times when Lily was in a more calm and relaxed
mood, the therapist invited her to visualize the past situation that had led
to those strong emotions. Once visualized by Lily, the therapist focused on
what Lily was feeling, allowing her to feel both what she needed and her
related emotions. Present emotions are used to bridge to childhood situa-
tions in which Lily had felt a similar emotion.
The therapist then asks Lily questions. Ideally, this questioning is done
using the present tense as though it is happening now—maintaining the
“as if” condition. So, the therapist asks Lily, “Where are you? How old are
you? What is happening?” The therapist asks if Lily can see the child, what
she looks like as the child, and how the child feels. The client now begins
to slowly take on the facial expression of a scared child. Her voice changes
to a more childlike voice—softer—and she whispers what she sees and the
vulnerable feelings have been reached. The therapist empathizes with and
validates the emotions, and invites in a knight in shining armor to stop any
aggression so that Lily can know what being protected feels like. If any-
where in this process Lily becomes, or approaches, feeling overwhelmed and
unable to tolerate the pain, the therapist asks her to go to her safe place. By
doing this, the activation of dissociative processes is staved off.
Once Lily’s need for a sense of safety, genuine interest, and value is met,
the therapist takes her back to the current scene. Now that she has felt pro-
tection and care for her vulnerable self, Lily does not feel as frightened or
invalid any longer; instead, she feels deserving of needs and acts to satisfy
306  •  Changing Emotion With Emotion

them in a functional way. In this way, the client interiorizes a new, healthy
model of self in relationship.
Lily is now able to recognize her emotions. She connects them to her child-
hood experiences, expresses and satisfies her needs in the present, and auto-
matically feels emotionally regulated. During therapy, she sometimes would
rapidly shift states, which were triggered when a critical or hostile voice
emerged that made her feel she was bad or unlovable. In those situations, the
therapist used chair work to help Lily notice how the self-critic was activated
and triggered her painful feelings. Such work enhances a client’s awareness
of different parts of themselves and their interactions, and by enacting what
they do to themselves, they enhance their metacognitive abilities.
Another central part of therapy was dealing with Lily’s punitive self-
critical voice of always putting herself down and blaming herself, saying, “You
are stupid, wrong, will never be normal or liked.” The process of resolution
involves going through the collapsing into hopelessness and getting to the
underlying shame and fear until the client accesses their needs for comfort
and safety, and they begin to assert themselves against the critical voice.
This process was modeled and validated in two chair dialogues many years
ago (Greenberg, 1984), and it has been developed and tested in a variety
of studies (Greenberg, 2017). By asserting the self and a softening or the
weakening of the punishing part, an integration occurs between the puni-
tive critic and the vulnerable experiencing self. The client is able to recog-
nize and diminish the punishing part when it arises, letting the healthy part
that recognizes their emotions and needs have a voice. This constant coact-
ivation of Lily’s vulnerable part and her healthy part enhanced her emotion
regulation capability.
By the end of therapy, Lily stated that she felt much more connected
to her vulnerable feelings and needs, and that she listens to them and no
longer feels overwhelmed by emotions, nor is she a victim to them. The
therapy allowed Lily to experience possibly her first responsive and caring
relationship—and the first time she trusted anyone and showed her vulner-
able side—and to share her vulnerability and work with it using the imagi-
nary chair work. Sessions lasted for a little over a year: biweekly for the first
5 months and once a week thereafter.

CONCLUSION

Emotion regulation can be deliberate, as in coping self-soothing, or auto-

matic, as in transformational self-soothing. Each has its place and needs
to be applied at the right time. When people are so highly dysregulated
 Emotion Regulation  •  307

that they are acting destructively and are unable to cope with daily living
and maintaining relationships, they need direct instruction in coping skills.
When this is not the case, deeper work is needed to access underlying pain-
ful emotions to work on and to transform the processes of emotion genera-
tion. This perspective also suggests thinking of a two-stage process in which
the first stage for highly dysregulated people is skill-based treatment to be
followed by a transformation of underlying self-organizations and emotion
schemes. Ultimately, the goal is to eventually access new, adaptive feelings.
Once this happens, therapists can focus on helping their clients construct
new narratives. In Chapter 12, I discuss the construction of new narratives
to consolidate change.
12 NARRATIVE AND
EMOTION

Being human involves creating meaning and using language to shape per-
sonal experiences into narratives. We are born to create meaning and we
are born into meaning systems (Frankl, 1959). We cannot, not create mean-
ing. As we have seen, people have both an emotion system and a meaning-
creating system, and although emotional experience provides information
and action tendency, it does not carry fully formed meaning within it. Emo-
tions give people direct feedback on a moment-to-moment basis about what
is important and meaningful for them in a specific situational context, and
that information organizes them for adaptive action in the world. Emotion
has an aim and moves us in a direction, but we need to guide the tendency
by making sense of what it is telling us, and we need to decide how to
achieve its aim. We need to bring cognition to emotion to make sense of
it, create meaning, and decide on actions. Human beings’ primary way of
making meaning is through the stories we construct (Angus & Greenberg,
2011; Bruner, 1986, 1990). Accordingly, in this chapter, I discuss the role of
narrative in working with emotion (Angus & Greenberg, 2011; Greenberg
& Angus, 2004).

https://doi.org/10.1037/0000248-013
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

309
310  •  Changing Emotion With Emotion

In making sense of what people feel, we not only label what we feel by
symbolizing bodily felt emotion in words, but, most importantly, we orga-
nize our emotional experience into narratives. We organize our experience
into stories, which allow us to reflect on what has happened to us and to
create new meaning. Clients externalize emotionally meaningful experiences
in stories such that their “lived stories” become “told stories” that they can
then share with others and reflect on for further meaning-making. The
narrative organization of emotional experiences supplies a sequential time
frame so that experience is organized in stories with beginnings, middles,
and ends. Causal connections can then be made between actions and emo-
tions and meanings, which helps to organize experience that may have been
confusing or disorganized. In addition, meaning—and the language it is
expressed in—is not simply the private property of any particular individual
but, rather, belongs to the larger social context of shared forms of language-
based understanding. People, thus, learn to make sense of life events in
forms that fit their culture, and the meanings they make are sustained in
their most important interpersonal relationships (Angus & Greenberg, 2011;
Bruner, 1986, 1990; Greenberg & Angus, 2004; Sarbin, 1986).
Therapy, then, is a process of clients’ coming to consciously articulate
and possibly change their stories. The act of storying experience in psycho­
therapy is an essential self-organizing process that provides a platform
for subsequent reflection and further personal meaning-making (Angus &
Greenberg, 2011). Therapists need to listen carefully to their clients’ most
important stories because the stories give them access to how people are
attempting to make sense of their emotions, themselves, and their worlds.
In psychotherapy, clients’ narratives are the essential starting point for
meaning-making (Angus & McLeod, 2004). In the process of articulating
and reflecting on life experiences in psychotherapy, personal narratives
become deeper—fused with emotional meaning and significance—taking
more information into account and becoming more integrated. There is
more than one way to tell a life story, so therapy helps people tell new stories
(Angus & Greenberg, 2011).
Personally significant narratives are often indicated by the experience
and expression of emotion; therefore, it is important for therapists to listen
for stories that are emotionally charged and experientially alive. Narrative
organizes and gives meaning to emotions by identifying what was felt, about
whom, and in relation to what need or issue. Storying disconnected emo-
tional experiences helps self-understanding and meaning-making. So, what
powers the mechanism of story change in psychotherapy? Moving from pri-
mary maladaptive to adaptive emotion.
 Narrative and Emotion  •  311

UNDERSTANDING THE NARRATIVE EMOTION RELATIONSHIP

From a neuroscience perspective, Damasio (1999) suggested that the first,

essential impetus to story an experience is the awareness of an inner bodily
felt feeling, thus indicating the intimate relationship between emotion and
narrative. People’s first narrative is a nonverbal imagistic narrative of our
feeling of what happened. It is through the storying of affect that we come
to know what has happened to our body. Knowing, which is the most funda-
mental level of consciousness, springs to life when changes in the status of
the body-self—such as emotional responses—are connected to environ-
mental impacts (Damasio, 1999). The first stories were constructed by pre-
linguistic primitive human beings who coded experience into something
like, “You throw a stone at me, and when it hits my body, it hurts.” Thus,
meaning was created long before language. Prelinguistic narratives, such as
the preceding one, organize the experience into ones that have beginnings,
middles, and ends as well as agents, actions, and intentions.
Narrative meanings can be formed without words, and they are formed
about people’s most personal experience: what happened to their emotional
bodies. In essence, knowing springs to life in the unfolding story of changes
to the body’s state. People, thus, live in a world that is experienced and orga-
nized as an unfolding story in time. Knowledge, from nonverbal imagining
to verbal literacy, depends on the ability to map what happens over time,
inside and around our organism, and to and with our organism. Both narra-
tive and emotion processes also operate at tacit levels of consciousness, and
both are fundamental in the generation of conscious meaning.
The self then emerges from the dialectical interaction between ongoing,
moment-by-moment experience and higher level meaning-making processes
that attempt to interpret, order, and explain elementary experiential processes
(Greenberg, 2015; Greenberg & Pascual-Leone, 1995). Affectively toned,
preverbal, preconscious processing is a major source of self-experience that
is articulated, organized, and ordered into a coherent narrative (Greenberg,
2011; Greenberg & Angus, 2004; Greenberg & Pascual-Leone, 1995). Indi-
viduals constantly create the self they are about to become by synthesizing
biologically based information and culturally acquired learning. And although
biology and culture may sometimes conflict, they are not inherently in oppo-
sition to one another. Rather, they are both necessary and important streams
of a dialectical synthesis that, together, form meaning. People live most viably
by managing to integrate biological and social, emotion and reason, and head
and heart.
To better understand themselves, people continually work at making
sense of their experience, and they do so by symbolizing, storying, and
312  •  Changing Emotion With Emotion

explaining their lived experiences to themselves. They, thereby, construct an

ongoing narrative that organizes their emotions into personal stories that
enhance a sense of continuity over time. It is in this manner that a stable
sense of personal identity emerges. Within this framework, it is the narrative
framing of emotional processes, at both tacit and conscious levels, that leads
to the development of new views of self, other, and world that are key to
change experiences in psychotherapy.

MAKING SUBJECTIVE EXPERIENCE AVAILABLE FOR

EXPLORATION AND CHANGE

Narrative framing of emotional processes is important in promoting personal

change experiences in psychotherapy. Roger Schank (2000) went so far as
to suggest that people need to tell someone else a story that describes our
experiences because the process of creating the story creates the memory
structure that contains the gist of the story. For Schank, telling a story is not
a rehearsal; rather, it is an act of creation that, in turn, becomes a memory.
Narrative and memory are intimately intertwined.
In my view, all significant stories are based on a core emotion, and all
core emotions are embedded within a significant story (Greenberg & Angus,
2004). Narrative organization of emotional experience in which intentions,
purposes, expectations, hopes, and desires are articulated allows us to under-
stand what an experience means to us. The meaning of an emotion is only
truly understood when its occurrence is organized into a coherent story
within a sequential framework that identifies what is felt, about whom, and
in relation to what need (Angus & Greenberg, 2011). There are stories of
loss, of pride, of love, of ecstasy, of jealousy, of anger and of despair. Each
story is characterized by an emotional theme, and emotional experience is a
key indicator of the personal significance of the narrative.
Angus and colleagues (Angus et al., 1999, 2017) developed a measure,
the Narrative-Emotion Process Coding System, that codes client process in
session into three possible categories: (a) external narrative mode: talking
about what happened; (b) reflexive narrative mode: talking about what it
means; and (c) internal narrative mode: talking about what it feels like. Client
narratives, therefore, can be coded as working within the landscape of action,
meaning, or feeling. In working with emotion, the therapist needs to guide
clients who generally present by talking about what happened to talk about
what it meant and, ultimately, what it feels like.
 Narrative and Emotion  •  313

One of the important insights generated by the narrative processes research

program (Angus et al., 1999; Boritz et al., 2011, 2014, 2017; Lewin, 2001)
at York University has been the discovery that good outcome cases can be dis-
tinguished from poor outcome cases by a particular pattern of narrative pro-
cessing. In good outcome emotion-focused cases, therapists focused clients
inward when the clients were themselves engaged in reflexive processing. The
clients, once they focused internally and having been guided by their thera-
pist’s internally focused response then, of their own accord, reflected on their
emotional experiences to create new meaning. Therapist shifted clients’ focus
from meaning to feeling, and then clients shifted from internal emotional
differentiation back to meaning-making.
The program also found that therapist movement from external—what
happened?—directly to internal—what it feels like—was not as effective.
Thus, if a client says, “I saw my ex-boyfriend yesterday and immediately
walked away,” it is not good for the therapist to focus on what the client
feels or to ask, “What did you feel?” Instead, it is better to first follow the
client into what it means before going to what it feels like. If the client says
something like, “This breakup was so sudden. He must have been planning
it without telling me,” it is now better to go to what it feels like. This finding
should act as a reminder that this key focus on what it feels like and the
attendant question “What do you feel?” that is frequently used in working
with emotion can be highly overused—and asked at the wrong times. Ther-
apists working with emotion should not automatically use this as a catchall
phrase. Going into the landscape of feeling is best to deepen meaning or
put words to feeling when clients are already implicitly aroused in the body
and are trying to make sense of their experience, not when a person is in
a nonaroused, external mode of processing and simply is describing what
happened.
When introducing a topic, clients often start off by talking about what
happened—what my colleague and I termed the “same old story” (Angus &
Greenberg, 2011), which provides a generalized description of experiences
and relationships. Therapists then help clients to access specific personal
memories that make what is being talked about more concrete and spe-
cific. In doing so, the client’s subjective emotional experience becomes more
available and begins to be explored. A process of sense-making takes place,
which helps to develop a perspective on the “problem,” and what is felt is
clarified. If, however, there is a lot of unstoried affect, the client will feel dis-
organized, which will lead to emotional dysregulation. Emotion regulation
then is enhanced by organizing these experiences into a coherent narrative.
314  •  Changing Emotion With Emotion

WORKING WITH NARRATIVE CONSTRUCTION

The construction of a narrative based on emotion can be thought of as

involving four steps. The initial step is similar to that described in focusing
and awareness in Chapters 3 and 6. This first step involves the rapid syn­
thesis of tacit affective responses from sensations and emotion memories to
generate an inner bodily felt sense. In the second step, the person symbol­
izes what is felt by attending to the bodily felt sense to differentiate and
name the feeling to create meaning. Next comes the conscious articulation
of new meaning by means of narrative construction. At this stage, a conscious
narrative account is constructed that provides a causal explanation of emo-
tional experience. The fourth step entails the consolidation of an identity
narrative by integrating different aspects of experience into the narrative.
This new narrative is an explicit indicator of significant client change events
in psychotherapy (Angus & McLeod, 2004).

Attending

The first key processing strategy involves paying attention at a sensory

motor level to the bodily felt sense like a sinking in the stomach and the
action tendency of withdrawal associated with feeling humiliated by, for
example, being unable to answer a question at a business meeting. This
complex felt sense needs to be attended to before it can be symbolized. As
Gendlin (1996) described, the felt sense incorporates the whole situation;
it is not just the word for an emotion. A complex bodily felt sense of, for
example, the aforementioned shame-based experience includes the emotion
of shame about failure but also contains narrative elements, such as the
sequence of events, the desire to appear knowledgeable to colleagues, the
experience of feeling the judgment of others, and the tendency to “want to
hide and disappear.” This fundamental experience is coded first as a word-
less narrative in imagistic sensory and kinesthetic form, and it is to this that
clients must attend to turn their lived story into a told story.
The therapist works with clients to attend to and become aware of their
emotionally salient lived experiences so they can tolerate, accept, and even­
tually explicate and story their vulnerable emotions. Consider how this process
occurs when a client is telling the following story about a surprise encounter
at a movie theater that happened the night before. He states that, while
standing in line for a movie, he turned around to look at some movie posters
and suddenly realized that standing behind him was someone whom he
either wished desperately to avoid or whom he was amorously longing to
 Narrative and Emotion  •  315

meet. Depending on which set of emotions, desires, and feelings prevailed

in the moment, he would be able to narrate two entirely different senses
of internal complexity that were generated in the context of the unfolding
story of the chance meeting at the theater. In relation to each story, he could
talk about how he felt in and about the unfolding narrative scene, and expli-
cate complex felt meanings, such as the intentions, beliefs, purposes, and
goals of self and other.
Many of these tacit meanings—and the “story” of the event—were not
processed consciously in the moment before opening his mouth to greet the
other person at the movie theater. What was actually said would either be
coolly dismissing or charmingly disarming, depending on, in part, the past
history of the relationship of the client and the other person as well as current
goals, intentions, expectations, and appraisals. If no clear experience had
emerged at the moment of the surprise encounter at the theater, this person’s
performance might have appeared to be awkward in response to feeling over-
whelmed by a complex tangle of mixed emotions and feelings. Thus, beyond
the specific performance generated—what is actually said or done—there lies
at the periphery of awareness a host of tacitly synthesized, bodily felt mean-
ings that, with attentional allocation, can be brought to focal awareness,
symbolized, and their meaning articulated (James, 1890; Perls et al., 1951).
It is from this experiential ground that personal meanings are differen-
tiated and symbolized, articulated in the context of an unfolding narrative
scene, and meaningfully understood. It is the quest for knowing and naming
what is felt, and for knowing what it means or says about me in the context
of a specific situation or relationship, that heralds the shift to the next level
of experiential processing: symbolizing.

Symbolizing

Symbolizing and differentiating embodied feeling states, now in aware-

ness, compose the first step to new meaning-making (Angus & Greenberg,
2011). Clients need to symbolize their emotion, such as feeling sad, usually
in words, and embed the words within a broader narrative context, such
as: “I feel sad that my mother never asks me about myself, not even about
my children.” Undifferentiated states of high emotional arousal, or what we
(Angus & Greenberg, 2011) have called unstoried emotions, are almost always
experienced as painfully disorganizing and are very distressing for clients.
Therapists, then, need to help clients symbolize—in words—what they expe-
rienced in a particular situation. This type of differentiation of emotional
experience leads to the creation of new meaning.
316  •  Changing Emotion With Emotion

A crucial part of the making-meaning process is the making of linguistic

distinctions that help capture an implicit bodily felt sense of meaning. For
instance, one might symbolize a given internal sense as feeling sad or dis­
appointed or rejected in the context of when a partner forgets one’s birthday.
All of these synthesized meanings of internal felt senses—sad, disappointed,
rejected—convey different aspects of the same experienced situation in a
way that, for example, “dismayed” or “afraid” would not. The words “sad,”
“disappointed,” and “rejected” are all adequate but capture different aspects
of the whole experience.
Conscious experience does not sit fully formed “in” us. Rather, it emerges
from a dialectical synthesis that involves the integration of (a) attention
to an internal bodily felt sense (a tension in the chest) and (b) a naming
of that felt sense (“I feel disappointed”) in the context of having my birth-
day forgotten (“I was looking forward to being recognized”). Engaging in
this dialectical synthesis helps clients to find words to capture and express
the inner felt sense of a lived story, which now, as a told story, provides
a launching pad for the further differentiation of new personal mean-
ings. How people articulate their feelings—in language embedded within
a narrative—is crucial for the creation of new conscious experientially
based understanding.
In experiential processing, the bodily felt sense acts as a constraint on the
possible conscious conceptual constructions that can satisfy it, eliminating
many other possible meanings (Greenberg & Pascual-Leone, 1995, 2001).
As such, preconceptual, tacitly felt meanings carry implications that act to
constrain, but not fully determine, the construction of personal meanings.
Rather, felt meanings are synthesized with conceptual, explicit meanings
to form narrative descriptions of personal events. It is the reflexive ability
to decenter from the direct experience of the emotional responses that
facilitates the articulation of what was felt in relation to whom and about
what issue.
It is not only the activation of bodily felt experiences and emotional
responses that is crucial for therapeutic change in therapy. Emotional
responses also need to be accompanied by client reflexivity, an elaboration
and transformation of the personal meaning surrounding an emotionally
charged event. It is difficult for a therapist to shift a client toward emotional
differentiation and meaning-making when the client is not actively engaged
in a self-reflexive processing stance. In poor outcome cases, the client plays
a more passive role when exploring feelings, often providing more of a
description of discrete bodily sensations rather than experienced and sym-
bolized feelings or emotions.
 Narrative and Emotion  •  317

Articulating Narratives

Following the description of what happened and the symbolization of what

was felt in context comes the conscious articulation of narratives. Organiz-
ing symbolized feelings, needs, thoughts, and aims into a coherent story
enables experience to be understood and accepted as part of a life story.
Now, complex experiences of conflict, of puzzling reactions of painful mem-
ories, are organized into understandable, new stories. For instance, under-
standing how a condemning internal voice leads to feelings of worthlessness
helps clients to recognize that they are the agents of their experience of
depression. Situations that activated painful emotions now are understood
in a less negative light, and new narratives, such as, “It was not me who was
unlovable; it was that you were incapable of love” are formed.
The reflexive system, a conscious, more controlled level of emotional
processing, generates “cooler” emotional representations (i.e., emotional
representations with lower arousal levels) and provides higher level concep-
tualizations of who did what to whom. It creates storied understanding of
what happened, what was felt, and what it means. Promoting reflection on
emotional experience as well as helping people make sense of their experi-
ence encourages its assimilation into their ongoing self-narratives.

Facilitating Identity

Now, it is possible for clients to change their most important personal stories.
This final step results in the emergence of new self/other identity narratives
(Whelton & Greenberg, 2000). A narrative identity involves the integration
of accumulated experience over time and of various self-representations
across situations into some sort of coherent narrative of who one is. At core,
the self is embodied, but a body needs a story to act meaningfully; to relate
past and future; to situate dreams, goals, regrets, plans, lost opportunities,
hopes, and all the stuff of a truly human life (Angus & Greenberg, 2011;
Whelton & Greenberg, 2000). All this contributes to achieving a sense of
self-understanding and identity formation in which the questions “Who am
I?” and “What do I stand for?” are addressed.

Facilitating the Unfolding of Narratives

The strategic use of open-ended questions can be an invaluable tool when

engaging clients in productive storytelling and meaning-making. For instance,
the question “Could you provide me a specific example of that happening
in your life?” helps clients shift to the disclosure and narration of specific,
318  •  Changing Emotion With Emotion

image-based personal memories that are more likely to activate experienced

emotions and entry into the client’s landscape of consciousness. Alterna-
tively, a question like, “So, when he slammed the door and walked out on
you, what was happening inside you? It felt as if . . . ?” promotes symbol-
izing internal experience. Questions to promote meaning-making help cli-
ents reflect on the personal significance of new emotional understandings.
A question like “What does that story say about you?” helps clients to reflect
on, symbolize, and acknowledge important values and aims that define who
they are.
Although it is important to focus on client stories of emotional pain for
narrative change, it is equally important to help clients identify and story
personal experiences of positive stories of hope, resilience, and positive out-
comes when they arise. Positive outcome stories challenge negative views
of self and enhance a sense of client agency and desire for personal change.
Focusing on painful or so-called negative emotion facilitates deepening
and disclosing of implicit feelings and meaning, whereas positive emotions
broaden and build (Fredrickson, 1998).

Clinical Example of an Emotion-Based Narrative Change

When a client shifts from maladaptive emotions, such as fear and shame or
sadness, to adaptive emotions, such as healthy anger and sadness, meaning-
ful story change happens, and new stories emerge (Greenberg, 2002; Paivio
& Pascual-Leone, 2010). A shift to a new emotional response activates new
action tendencies, and this plus the new feelings result in stories with new
outcomes. Emotional change, by definition, results in narrative change. In
addition, as clients shift from expressing secondary feelings, such as reactive
anger and blaming, to experiencing primary adaptive emotions, such as sad-
ness and loneliness, new and more adaptive action tendencies are evoked,
and, again, this leads to narrative change.
For example, in an emotion-focused therapy session, a middle-aged
man disclosed how he felt incredibly angry at his wife for choosing to go
away without him for a weekend with her friends. However, with further
empathic exploration of key stories of loss and fears of abandonment in his
childhood, he was able to acknowledge some of his previously unacknowl-
edged primary adaptive emotions of sadness that accompanied his early
experiences of loss. The shift from secondary maladaptive anger to access to
primary adaptive sadness provided the client with a new experiential aware-
ness of how a long-held, maladaptive fear of abandonment, and the deep
sadness that it evoked, was triggering feelings of anger and abandonment
 Narrative and Emotion  •  319

in his marriage. Importantly, this new emotional awareness also equipped

him with a new understanding of the source of his painful feelings of aban-
donment. He was now able to express his sadness at loss and his need for
deeper connections with his wife without blame or resentment. His wife’s
understanding and concern enhanced his feelings of safety and security in
the marriage. Significantly, he also reported feeling less vulnerable when
spending time on his own and, as a result, feeling far less resentful of his
wife when she chose to be with her friends.

IDENTIFYING EMOTION NARRATIVE MARKERS

Early on, a trauma narrative marker was identified as an opportunity for

trauma narrative retelling (Elliott et al., 2004). When a client first reveals
a trauma, it is best to have them unfold the story in whatever way they
can, retelling the incident and possibly engaging in the recounting of an
episodic memory. The therapist’s role is to listen empathically and provide
empathic understanding responses rather than more exploratory or conjec-
tural responses. The therapeutic goal is to provide understanding and sup-
port to help the person begin to organize a more coherent story but not to
heighten or stimulate deeper experiencing or more arousal.
Subsequently, Angus and colleagues (Angus & Greenberg, 2011; Boritz
et al., 2014) defined a number of different types of in-session markers of dif-
ferent types of narratives that help illuminate the narrative landscape. These
markers help therapists identify where clients are in their narrative con-
struction process. Although all of the different types of narrative are ideally
responded to with empathic understanding, each type of narrative benefits
from empathy with a particular focus—one suited to that narrative process.
The markers are broken into two types: problem-based stories and change
stories. The problem stories are same old story, empty story, unstoried emo-
tions, and superficial story, whereas the change stories are competing plot­
lines story, inchoate story, unexpected outcome story, and discovery story.

Problem Stories: The Arriving Phase

Problem stories arise as part of the arriving at emotions stage of treatment.

Same old story occurs when the client expresses a dominant, often overly
general view of self and relationships. This story is marked by lack of agency,
and the client is stuck in the story. It is often expressed in a complaining tone
with fused anger and sadness. The same litany of complaints is repeated
320  •  Changing Emotion With Emotion

with a sense of resignation and hopelessness because people feel stuck. They
are stuck in secondary emotions. The best way to respond is to empathize
with the story, acknowledge the sense of “stuckness,” and then conjecture
about underlying primary feelings.
In an empty story, the client describes an event with a focus on exter-
nal details and behavior and repetition of overly general, autobiographical
memories (ABM) like, “My father was always absent”; these empty stories
are marked by a lack of internal referents or emotional arousal. Interven-
tion involves focusing on the missing emotions with a view to ending with
a new story based on new emotions. There is a shifting from overly general
ABMs to specific ABMs like, “I remember my fifth birthday. He was supposed
to come and take me out, and he never came, and I was left crying on the
doorstep.” Therapists ask for specific examples, conjecture about what was
felt, and empathize with the episodic memories and emotional experience
as they emerge.
Unstoried emotions involve a process in which clients experience under-
or overregulated emotional arousal without coherent narration of the expe-
rience. Intervention involves identifying cues that triggered the emotion
and symbolizing emotions in words. The end state involves helping clients
assimilate emotion into narrative organized into emotion episodes with
beginnings, middles, and ends. In these situations, clients lack a context
for understanding what the emotion belongs to, so therapists help clients
engage in a safe reentry into the experience and move from the landscape
of feeling to reconnect with the landscape of action by narrating what hap-
pened. They then move to the landscape of meaning to understand what
they felt. This marker often occurs in the context of first disclosures of
trauma. Therapists’ empathic attunement in combination with reassurance
and empathic validation helps the client safely reenter the lived story of a
specific trauma experience to access specific ABM narratives and differenti-
ate their subjective experience of the frightening experience. Trauma expe-
riences are now located in a specific time; emotions are causally connected
with action and intentions, and are organized within a narrative framework
with a beginning, middle, and end.
In superficial stories, clients talk about events, hypotheticals, self, others,
or unclear referents in a vague, abstract manner with limited internal focus.
The therapist’s aim here is to deepen the narrative mainly through empathic
conjecture into underlying feelings as well as to evoke episodic memories
to get at more concrete experience. Untold stories are also of interest. These
occur when the client is not saying something that is emotionally important
often out of fear or shame. This requires empathic exploration to help the
 Narrative and Emotion  •  321

client move from a lived story into a told story. The therapist helps the client
to disclose implicit emotions and helps the client shift from overly general
memories to episodic memories.

Change Stories: The Leaving Phase

In terms of change stories, the client now enters the leaving phase. Having
arrived at emotions and storied them in awareness, it is now time to leave
them and create new stories. Competing plotlines stories are identified when
clients experience challenges to their same old stories wherein states of
emotional incoherence, confusion, and puzzlement begin to emerge in ther-
apy sessions. Here, therapists focus on developing the subdominant story
to develop its voice. Inchoate stories are identified when clients are turning
their attention inward to sort through, piece together, articulate, and make
sense of an emerging bodily felt experience. These stories are facilitated by
empathy and the use of client-focusing strategies (Gendlin, 1996). Unexpected
outcome stories emerge when clients express surprise, excitement, content-
ment, or inner peace in response to experiencing new emotional responses,
taking positive action, or both. Intervention involves elaborating and consol-
idating the unexpected outcome, and exploring and validating the positive
outcome and narrative reconstruction. The therapist engages in reflexive
inquiry of the unique outcome stories to identify client agency and enhance
story salience. Discovery stories involve the articulation of understandings or
views of self and other that result in narrative reconstruction and consoli-
dation of client experiences of novelty and change. Therapists validate and
help elaborate the newly discovered views.

CONCLUSION

In therapy, stories emerge from the body if there is a facilitative listener

there to receive them and are brought into the world through the help of
language. Effective therapists actively facilitate clients to shift from external
narratives to the processing of emotion schematic experiences and to creat-
ing fuller reflexive narratives in a bid to help them make conscious sense
of their own emotional experiences. Working at the purely conceptual or
linguistic level to make narrative change does not produce enduring emo-
tional change. Instead, therapeutic interventions are more likely to succeed
if they first target the emotion schematic processes that automatically gen-
erate the emotional experience underlying clients’ felt senses of themselves.
322  •  Changing Emotion With Emotion

Next, the emotional experience needs to be consciously reflected on, and

the tacit representation of the unfolding “wordless” narrative scene needs to
be made explicit. This type of narrative construction organizes emotions and
integrates them with action sequences and meanings. This integration of
emotion and narrative enables the construction of a storied explanation of
“what happened,” “what it meant,” and, most important, “what it felt like,”
which can then be told to others and reflected on for further understanding
and meaning construction. Therapy, then, is a process of coming to know
emotions—storying them—and, in so doing, changing them.
LOOKING AHEAD
A Unified Approach to Psychotherapy

Emotion is a universal phenomenon. Given its central role in human func-

tioning, it makes sense to view the proposed principle of changing emotion
with emotion as a universal change process. Likewise, we can view this
and other emotional change principles as transdiagnostic, transtheoretical,
and transcultural (transcultural includes gender, class, race, and religion).
In this book, I suggest that maladaptive emotion and dysfunctional emotional
processing is a core area of dysfunction underlying different disorders and
mental health problems.
In this concluding chapter, I suggest for the field of clinical psychology
and psychotherapy the beginning of an integrative, unified view of emotional
change based on principles of changing emotion with emotion, empathic
attunement to affect, emotion awareness, bodily focus, blocking and unblock-
ing, focus on needs, memory reconsolidation, emotion regulation, and narra-
tive symbolization of emotion. These are the major processes covered in this
book. My hope is that this book will stimulate the examination of and perhaps,
ultimately, the adoption of a view that puts emotional change as a fundamental
aspect of therapeutic change and offers it as a trans­diagnostic, transtheoretical
alternative to the ever-increasing proliferation of disease-specific treatments

https://doi.org/10.1037/0000248-014
Changing Emotion With Emotion: A Practitioner’s Guide, by L. S. Greenberg
Copyright © 2021 by the American Psychological Association. All rights reserved.

323
324  •  Changing Emotion With Emotion

and therapeutic systems. Currently, there is still a vast array of psychotherapy

interventions—at least more than 200 in an informal count on Wikipedia—
with different approaches that rest on different philosophical and theoretical
assumptions, and that emphasize different domains of human functioning and
adaptation.
At a minimum, the field needs an addition of emotion to the current
cognitive behavioral perspective that has dominated for the past decades.
What is possibly achievable at the moment is a unified emotion-focused,
cognitive behavior therapy (CBT) approach based on foundational emotional,
cognitive, and behavioral change principles. Over time, even more extensive
integration that incorporates more principles of change will be achieved. In
the long run, the field will need to have a metatheory that allows researchers
and practitioners to view the big picture and to navigate the variety of different
approaches in a way that allows them to coordinate diverse treatment options.
A transdiagnostic approach suggests a more unified approach to the
treatment of psychological disorders than the current differential treatment
perspective commonly held over the past 40 years. It has become evidently
clear that the diagnostic classifications and their corresponding disorder-
specific treatments suffer from serious limitations of reliability and validity,
and that there is clearly heterogeneity within diagnostic groups. For example,
depression is not a consistent syndrome (Fried & Nesse, 2015), and different
diagnostic groups do not represent distinct emotional disorders. Hence, there
are high rates of not otherwise specified diagnoses (T. A. Brown, Di Nardo,
et al., 2001; Clark et al., 2017; Le Grange et al., 2012). Some attempt has
been made to rectify these problems in the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Asso­
ciation, 2013) and to recognize cultural context and common factors behind
diagnoses. The issue of different treatments for different diagnostic groups,
however, remains, and the field would benefit from specifying underlying
principles of working with human psychological processes, specifically with
emotional processes that span diagnostic groups. Establishing universal
emotional change principles would be most helpful for client treatment,
trainers, and clinicians alike.
Rather than adopting a medical model and thinking of mental health diag-
noses as representing separate disease entities, there is increasing aware­ness
that common processes or mechanisms operate across disorders (Brewin et al.,
2010; Harvey et al., 2004; Hayes & Hofmann, 2018). Trans­diagnostic treat-
ments that target core processes—those factors that maintain disorders—are
needed. The proliferation of different treatments for different disorders results
in setting up a significant barrier to comprehensive treatment, dissemination,
 Looking Ahead  •  325

and training. Most disorders have maladaptive emotions at their base, and
most treatments now include methods to work on emotion. Emotion strate-
gies, such as awareness, acceptance, ability to change emotion with emotion,
ability to overcome blocking or avoid emotion, exposure, memory reconsol-
idation, emotion regulation, and narrative construction, are already in wide
use. A single, unified treatment that targets the essential emotional processes
that cause and maintain problems in my view would benefit more clients.
It would deepen therapy and promote longer lasting change by treating
the underlying disease at its emotional roots rather than its symptomatic
manifestations.
Originally, before the dominance of the differential treatment paradigm,
which was spurred by the research question “What treatment by whom for
whom?” (Paul, 1967), many approaches offered a unified treatment and
were transdiagnostic. A return to this path—but now with a focus on case
formulation rather than diagnosis—would help therapists apply principles
of change to each client in a more individualized fashion.
Although it is important in a unified approach to realize that there are
cultural and individual differences in the way emotions are viewed and
expressed (examples are reviewed in Chapter 4), at the core, all human
beings, clients, therapists, and people from different cultures, different
families, and different diagnostic groups have emotions, and they all need
to pay attention to them because they help us to survive and thrive. Despite
cultural differences in emotional expression, a core set of factors is involved
in treating emotional suffering regardless of the disorder and the culture.
Mental health treatment would be greatly improved by the development of
transtheoretical principles, which would enhance efforts at psychotherapy
integration, stop the ever-increasing proliferation of therapeutic systems,
and put an end to school wars.
Single-school approaches dominated the practice of psychotherapy in the
1960s and 1970s. The majority of therapists identified with a particular
school of thought (e.g., psychoanalytic, behavioral, humanistic), tended
to see their model as representing truth, and engaged in vigorous—and
sometimes vitriolic—debates with practitioners from other approaches. The
1980s saw the rise of eclecticism, the unsystematic blending of ideas and
techniques from the various schools of thought. Eclecticism is noteworthy
because it reflected an attitudinal shift from single-school approaches to
more openness to looking at complementary aspects of treatment from
different angles. In the 1990s and 2000s, psychotherapy integration became
a genuine movement. The Society for the Exploration of Psychotherapy
Integration formed in the mid-1980s and began swelling in size and influence.
326  •  Changing Emotion With Emotion

The early 1990s witnessed the publication of two handbooks in integrative

psychotherapy (Norcross & Goldfried, 1992; Stricker & Gold, 1993), which
detailed a multitude of important developments toward a more integrative
approach to the field.
Still, fundamental differences exist in the field in epistemology and views
of functioning, and a common language is lacking. The lack of agreement
results in difficulties in developing an effective, integrative training program.
Students often are taught one predominant approach or another, and CBT
approaches dominate North American graduate programs. Training, therefore,
is limiting, and practitioners cannot apply treatments that best fit different
clients and problems. Instead, they can only administer the single method
they were trained in. Some universities teach various schools of thought
separately and then give students the option to practice from one or another,
or students are left to their own devices to generate their own blend or inte-
gration. A few training programs attempt to teach integrative approaches,
but even these lack a comprehensive focus and still do not give emotion a
prominent role.
As the psychotherapy integration movement has grown over the years,
different approaches to integration have emerged, and now, four routes
to integration are generally recognized, although there certainly are other
possible approaches (see Ingram, 2006). The most general approach has
been the common-factors approach. Identified strongly with Jerome Frank’s
(1973) classic work Persuasion and Healing, the common-factors approach is
conceptually grounded in a sophisticated folk psychology that emphasizes
the general processes of healing that cut across all of the approaches, such
as establishing a productive healing relationship, The evidence-based treat-
ment movement begun in the 1990s has failed to overcome school wars.
Rather, it has just created a presumptive CBT victory in the school wars, even
though there is growing evidence from unbiased studies and reviews showing
that all approaches are roughly equivalent. The claim of CBT superiority,
while creating territorial dominance, has also generated much underground
resistance and has not stopped the proliferation of new approaches, such
as third-wave CBT approaches, schema-focused therapy, emotion-focused
therapy, accelerated experiential dynamic therapy, eye-movement desensiti-
zation and reprocessing, and attachment-focused therapy.
Ultimately, I envisage and hope for a shift in how the field of psycho-
therapy is conceptualized. Magnavita (2008), for example, called for the
construction of a unified clinical science that consists of the intersection and
amalgamation of personality theory, developmental psychopathology, and
psychotherapy in a way that allows for the identification of the structures,
 Looking Ahead  •  327

processes, and mechanisms that are involved in the major domains of human
functioning. I foresee a time when students are provided with a transtheoret-
ical, transdiagnostic, transcultural overview that allows them to understand
how to work in a unified way with different systems. It would be based on
an understanding of basic principles and methods of change to work with
emotion, motivation, cognition, behavior, interaction, systems, culture and
biology, and the relationship between these systems. This would have enor-
mous implications for training, research, and practice.
A unified theory (Anchin & Magnavita, 2008; Magnavita & Anchin, 2014)
would provide a way to assimilate and integrate key insights from the major
therapeutic perspectives into a coherent whole and provide a holistic picture
that would allow clinicians and researchers a map of the various ways in which
to intervene. I hope to have shown in this book how working with emotion
as a fundamental process and using emotion to change emotion will help
develop a unified transdiagnostic, transtheoretical approach to treatment that
will improve training and treatment efficacy.
References

Abbass, A. (2002). Intensive short-term dynamic psychotherapy in a private

psychi­atric office: Clinical and cost effectiveness. The American Journal of
Psychotherapy, 56(2), 225–232. https://doi.org/10.1176/appi.psychotherapy.
2002.56.2.225
Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques.
Seven Leaves Press.
Adams, K. E. (2010). Therapist influence on depressed clients’ therapeutic experi-
encing and outcome [Unpublished doctoral dissertation]. York University.
Adams, K. E., & Greenberg, L. S. (1996, June). Therapists’ influence on depressed
clients’ therapeutic experiencing and outcome [Paper presentation]. Forty-Third
Annual Convention for the Society for Psychotherapy Research, St. Amelia
Island, FL, United States.
Adler, G., & Myerson, P. G. (1973). Confrontation in psychotherapy. Jason
Aronson.
Adolphs, R., & Anderson, D. J. (2018). The neuroscience of emotion: A new synthesis.
Princeton University Press.
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation
strategies across psychopathology: A meta-analytic review. Clinical Psychology
Review, 30(2), 217–237. https://doi.org/10.1016/j.cpr.2009.11.004
Alexander, F., & French, T. M. (1946). Psychoanalytic therapy: Principles and
application. Ronald Press.
American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Anchin, J. C., & Magnavita, J. J. (2008). Toward the unification of psychotherapy:
An introduction to the journal symposium. Journal of Psychotherapy Integration,
18(3), 259–263. https://doi.org/10.1037/a0013556
Anderson, E. (2015). “The White space.” Sociology of Race and Ethnicity, 1(1),
10–21. https://doi.org/10.1177/2332649214561306

329
330 • References

Angus, L. E., Boritz, T., Bryntwick, E., Carpenter, N., Macaulay, C., & Khattra, J.
(2017). The Narrative-Emotion Process Coding System 2.0: A multi-
methodological approach to identifying and assessing narrative-emotion
process markers in psychotherapy. Psychotherapy Research, 27(3), 253–269.
https://doi.org/10.1080/10503307.2016.1238525
Angus, L. E., & Greenberg, L. S. (2011). Working with narrative in emotion-
focused therapy: Changing stories, healing lives. American Psychological Asso-
ciation. https://doi.org/10.1037/12325-000
Angus, L. E., Levitt, H., & Hardtke, K. (1999). The narrative processes coding
system: Research applications and implications for psychotherapy practice.
Journal of Clinical Psychology, 55(10), 1255–1270. https://doi.org/10.1002/
(SICI)1097-4679(199910)55:10<1255::AID-JCLP7>3.0.CO;2-F
Angus, L. E., & McLeod, J. (Eds.). (2004). The handbook of narrative and psycho-
therapy. SAGE Publishing. https://doi.org/10.4135/9781412973496
Auszra, L., Greenberg, L. S., & Herrmann, I. (2013). Client emotional productivity—
Optimal client in-session emotional processing in experiential therapy.
Psychotherapy Research, 23(6), 732–746. https://doi.org/10.1080/10503307.
2013.816882
Bagby, R. M., Parker, J. D. A., & Taylor, G. J. (1994). The twenty-item Toronto
Alexithymia Scale—I. Item selection and cross-validation of the factor struc-
ture. Journal of Psychosomatic Research, 38(1), 23–32. https://doi.org/10.1016/
0022-3999(94)90005-1
Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment
for emotional disorders. Behavior Therapy, 35(2), 205–230. https://doi.org/
10.1016/S0005-7894(04)80036-4
Barnow, S. (2012). Emotionsregulation und psychopathologie: Ein überblick
[Emotion regulation and psychopathology. An overview]. Psychologische
Rundschau, 63(2), 111–124. https://doi.org/10.1026/0033-3042/a000119
Barrett, L. F. (2017). How emotions are made: The secret life of the brain. Houghton
Mifflin Harcourt.
Barrett-Lennard, G. T. (1993). The phases and focus of empathy. The British
Journal of Medical Psychology, 66(1), 3–14. https://doi.org/10.1111/j.2044-
8341.1993.tb01722.x
Barrett-Lennard, G. T. (1997). The recovery of empathy—Toward others and self.
In A. C. Bohart & L. S. Greenberg (Eds.), Empathy reconsidered: New directions
in psychotherapy (pp. 103–121). American Psychological Association. https://
doi.org/10.1037/10226-004
Bateman, A., & Fonagy, P. (2004). Psychotherapy for borderline personality dis­
order: Mentalization-based treatment. Oxford University Press. https://doi.org/
10.1093/med:psych/9780198527664.001.0001
Berkowitz, L. (2000). Causes and consequences of feelings. Cambridge University
Press.
Bion, W. R. (1967). Notes on memory and desire. The Psychoanalytic Forum, 2,
271–280.
 References • 331

Blume-Marcovici, A. C., Stolberg, R. A., & Khademi, M. (2013). Do therapists

cry in therapy? The role of experience and other factors in therapists’ tears.
Psychotherapy, 50(2), 224–234. https://doi.org/10.1037/a0031384
Bohart, A. C., Elliott, R., Greenberg, L. S., & Watson, J. C. (2002). Empathy.
In J. Norcross (Ed.), Psychotherapy relationships that work (pp. 89–108).
Oxford University Press.
Bohart, A. C., & Greenberg, L. S. (Eds.). (1997). Empathy reconsidered: New direc-
tions in theory research & practice. American Psychological Association.
Bohart, A. C., & Greenberg, L. S. (2002). EMDR and experiential psychotherapy.
In F. Shapiro (Ed.), EMDR as an integrative psychotherapy approach: Experts
of diverse orientations explore the paradigm prism (pp. 239–261). American
Psychological Association.
Bolger, E. A. (1999). Grounded theory analysis of emotional pain. Psychotherapy
Research, 9(3), 342–362. https://doi.org/10.1080/10503309912331332801
Boritz, T., Barnhart, R., Angus, L., & Constantino, M. J. (2017). Narrative flexibility
in brief psychotherapy for depression. Psychotherapy Research, 27(6), 666–676.
https://doi.org/10.1080/10503307.2016.1152410
Boritz, T. Z., Angus, L., Monette, G., & Hollis-Walker, L. (2008). An empirical
analysis of autobiographical memory specificity subtypes in brief emotion-
focused and client-centered treatments of depression. Psychotherapy Research,
18(5), 584–593. https://doi.org/10.1080/10503300802123245
Boritz, T. Z., Angus, L., Monette, G., Hollis-Walker, L., & Warwar, S. (2011).
Narrative and emotion integration in psychotherapy: Investigating the relation-
ship between autobiographical memory specificity and expressed emotional
arousal in brief emotion-focused and client-centred treatments of depression.
Psychotherapy Research, 21(1), 16–26. https://doi.org/10.1080/10503307.
2010.504240
Boritz, T. Z., Bryntwick, E., Angus, L., Greenberg, L. S., & Constantino, M. J.
(2014). Narrative and emotion process in psychotherapy: An empirical test
of the Narrative-Emotion Process Coding System (NEPCS). Psychotherapy
Research, 24(5), 594–607. https://doi.org/10.1080/10503307.2013.851426
Borkovec, T. D., & Sides, J. K. (1979). The contribution of relaxation and expec-
tancy to fear reduction via graded, imaginal exposure to feared stimuli.
Behaviour Research and Therapy, 17(6), 529–540. https://doi.org/10.1016/
0005-7967(79)90096-2
Bowlby, J. (1988). A secure base: Parent–child attachment and healthy human
development. Basic Books.
Bowlby, J. (1998). Attachment and loss. Pimlico.
Bradley, B., DeFife, J. A., Guarnaccia, C., Phifer, J., Fani, N., Ressler, K. J., &
Westen, D. (2011). Emotion dysregulation and negative affect: Association
with psychiatric symptoms. The Journal of Clinical Psychiatry, 72(5), 685–691.
https://doi.org/10.4088/JCP.10m06409blu
Bradshaw, J. (1988). Healing the shame that binds you. Health Communications.
332 • References

Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images
in psychological disorders: Characteristics, neural mechanisms, and treatment
implications. Psychological Review, 117(1), 210–232. https://doi.org/10.1037/
a0018113
Brody, L. R., & Hall, J. A. (2008). Gender and emotion in context. In M. Lewis,
J. M. Haviland-Jones, & L. F. Barrett (Eds.), Handbook of emotions (3rd ed.,
pp. 395–408). Guilford Press.
Brown, B. (2012). Daring greatly: How the courage to be vulnerable transforms
the way we live, love, parent, and lead. Gotham Books.
Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B.
(2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood
disorders in a large clinical sample. Journal of Abnormal Psychology, 110(4),
585–599. https://doi.org/10.1037/0021-843X.110.4.585
Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability
of DSM-IV anxiety and mood disorders: Implications for the classification of
emotional disorders. Journal of Abnormal Psychology, 110(1), 49–58. https://
doi.org/10.1037//0021-843X.110.1.49
Bruner, J. S. (1986). Actual minds, possible worlds. Harvard University Press.
Bruner, J. S. (1990). Acts of meaning. Harvard University Press.
Buck, R. (2014). Emotion: A biosocial synthesis. Cambridge University Press. https://
doi.org/10.1017/CBO9781139049825
Bushman, B. J. (2002). Does venting anger feed or extinguish the flame? Cathar-
sis, rumination, distraction, anger, and aggressive responding. Personality
and Social Psychology Bulletin, 28(6), 724–731. https://doi.org/10.1177/
0146167202289002
Campos, J. J., Frankel, C. B., & Camras, L. (2004). On the nature of emotion
regulation. Child Development, 75(2), 377–394. https://doi.org/10.1111/
j.1467-8624.2004.00681.x
Capps, K. L., Fiori, K., Mullin, A. S., & Hilsenroth, M. J. (2015). Patient crying
in psychotherapy: Who cries and why? Clinical Psychology & Psychotherapy,
22(3), 208–220. https://doi.org/10.1002/cpp.1879
Carryer, J. R., & Greenberg, L. S. (2010). Optimal levels of emotional arousal in
experiential therapy of depression. Journal of Consulting and Clinical Psychol-
ogy, 78(2), 190–199. https://doi.org/10.1037/a0018401
Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., & Hayes, A. M. (1996).
Predicting the effect of cognitive therapy for depression: A study of unique
and common factors. Journal of Consulting and Clinical Psychology, 64(3),
497–504. https://doi.org/10.1037/0022-006X.64.3.497
Choi, E., Chentsova-Dutton, Y., & Parrott, W. G. (2016). The effectiveness of
somatization in communicating distress in Korean and American cultural
contexts. Frontiers in Psychology, 7, Article 383. https://doi.org/10.3389/
fpsyg.2016.00383
Chou, T., Asnaani, A., & Hofmann, S. G. (2012). Perception of racial discrimina-
tion and psychopathology across three U.S. ethnic minority groups. Cultural
 References • 333

Diversity & Ethnic Minority Psychology, 18(1), 74–81. https://doi.org/

10.1037%2Fa0025432
Clark, L. A., Cuthbert, B., Lewis-Fernández, R., Narrow, W. E., & Reed, G. M.
(2017). Three Approaches to Understanding and Classifying Mental Disorder:
ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain
Criteria (RDoC). Psychological Science in the Public Interest, 18(2), 72–145.
https://doi.org/10.1177/1529100617727266
Comas-Díaz, L., Hall, G. N., & Neville, H. A. (2019). Racial trauma: Theory,
research, and healing: Introduction to the special issue. American Psychologist,
74(1), 1–5. https://doi.org/10.1037/amp0000442
Coombs, M., Coleman, D., & Jones, E. E. (2002). Working with feelings: The
importance of emotion in both cognitive–behavioral and interpersonal therapy
in the NIMH Treatment of Depression Collaborative Research Program. Psycho-
therapy, 39(3), 233–244. https://doi.org/10.1037/0033-3204.39.3.233
Cousins, S. D. (1989). Culture and self-perception in Japan and the United States.
Journal of Personality and Social Psychology, 56(1), 124–131. https://doi.org/
10.1037/0022-3514.56.1.124
Cozolino, L. J. (2002). The neuroscience of psychotherapy: Building and rebuilding
the human brain. Norton.
Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014).
Maximizing exposure therapy: An inhibitory learning approach. Behaviour
Research and Therapy, 58, 10–23. https://doi.org/10.1016/j.brat.2014.04.006
Daldrup, R. J., Beutler, L. E., Engle, D., & Greenberg, L. S. (1988). Focused
expressive psychotherapy: Freeing the over-controlled patient. Guilford Press.
Damasio, A. R. (1994). Descartes’ error: Emotion, reason, and the human brain.
G. P. Putnam.
Damasio, A. R. (1999). The feeling of what happens: Body and emotion in the
making of consciousness. Harcourt Brace.
Daros, A. R., & Williams, G. E. (2019). A meta-analysis and systematic
review of emotion-regulation strategies in borderline personality disorder.
Harvard Review of Psychiatry, 27(4), 217–232. https://doi.org/10.1097/
HRP.0000000000000212
Darwin, C. (1897). The expression of emotions in man and animals. Philosophical
Library.
Davidson, R. J., & Harrington, A. (Eds.). (2002). Visions of compassion: Western
scientists and Tibetan Buddhists examine human nature. Oxford University Press.
de la Fuente, V., Freudenthal, R., & Romano, A. (2011). Reconsolidation or
extinction: Transcription factor switch in the determination of memory course
after retrieval. The Journal of Neuroscience, 31(15), 5562–5573. https://
doi.org/10.1523/JNEUROSCI.6066-10.2011
Dere, J., Falk, C. F., & Ryder, A. G. (2012). Unpacking cultural differences in
alexithymia: The role of cultural values among Euro-Canadian and Chinese-
Canadian students. Journal of Cross-Cultural Psychology, 43(8), 1297–1312.
https://doi.org/10.1177/0022022111430254
334 • References

Diamond, G., & Liddle, H. A. (1996). Resolving a therapeutic impasse between
parents and adolescents in multidimensional family therapy. Journal of
Consulting and Clinical Psychology, 64(3), 481–488. https://doi.org/10.1037/
0022-006X.64.3.481
Diener, M. J., Hilsenroth, M. J., & Weinberger, J. (2007). Therapist affect focus
and patient outcomes in psychodynamic psychotherapy: A meta-analysis. The
American Journal of Psychiatry, 164(6), 936–941. https://doi.org/10.1176/
ajp.2007.164.6.936
Dzokoto, V. A., Opare-Henaku, A., & Kpobi, L. A. (2013). Somatic referencing
and psychologisation in emotion narratives: A USA–Ghana comparison.
Psychology and Developing Societies, 25(2), 311–331. https://doi.org/10.1177/
0971333613500875
Ekman, P., & Davidson, R. J. (Eds.). (1994). The nature of emotion: Fundamental
questions. Oxford University Press.
Elliott, R. (2013). Person-centered/experiential psychotherapy for anxiety diffi-
culties: Theory, research and practice. Person-Centered & Experiential Psycho-
therapies, 12(1), 16–32. https://doi.org/10.1080/14779757.2013.767750
Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011). Empathy.
Psychotherapy, 48(1), 43–49. https://doi.org/10.1037/a0022187
Elliott, R., Greenberg, L. S., Watson, J. C., Timulak, L., & Freire, E. (2013).
Research on humanistic–experiential psychotherapies. In M. J. Lambert (Ed.),
Bergin & Garfield’s handbook of psychotherapy and behavior change (6th ed.;
pp. 495–538). John Wiley & Sons.
Elliott, R., Rodgers, B., & Stephen, S. (2014, June). The outcomes of person-centred
and emotion-focused therapy for social anxiety: An update [Paper presentation].
Conference of the Society for Psychotherapy Research, Copenhagen, Denmark.
Elliott, R., & Shahar, B. (2017). Emotion-focused therapy for social anxiety
(EFT-SA). Person-Centered and Experiential Psychotherapies, 16(2), 140–158.
https://doi.org/10.1080/14779757.2017.1330701
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
Elliott, R., Watson, J. C., Timulak, L., & Sharbanee, J. (in press). Research on
humanistic-experiential psychotherapies: Updated review. In M. Barkham,
W. Lutz, & L. G. Castonguay (Eds.), Bergin & Garfield’s handbook of psycho-
therapy and behavior change (7th ed.). John Wiley & Sons.
Field, T. M. (1998). Massage therapy effects. American Psychologist, 53(12),
1270–1281. https://doi.org/10.1037/0003-066X.53.12.1270
Fischer, A. H., & Manstead, A. S. R. (2000). The relation between gender and
emotions in different cultures. In A. H. Fischer (Ed.), Gender and emotion:
Social psychological perspectives (pp. 71–94). Cambridge University Press.
Flack, W. F., Jr., Laird, J. D., & Cavallaro, L. A. (1999). Emotional expression
and feeling in schizophrenia: Effects of specific expressive behaviors on
 References • 335

emotional experiences. Journal of Clinical Psychology, 55(1), 1–20. https://

doi.org/10.1002/(SICI)1097-4679(199901)55:1<1::AID-JCLP1>3.0.CO;2-K
Foa, E. B., & Jaycox, L. H. (1999). Cognitive-behavioral theory and treatment of
posttraumatic stress disorder. In D. Spiegel (Ed.), Efficacy and cost-effectiveness
of psychotherapy (pp. 23–61). American Psychiatric Publishing.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to
corrective information. Psychological Bulletin, 99(1), 20–35. https://doi.org/
10.1037/0033-2909.99.1.20
Foa, E. B., & Kozak, M. J. (1998). Clinical applications of bioinformational theory:
Understanding anxiety and its treatment. Behavior Therapy, 29(4), 675–690.
https://doi.org/10.1016/S0005-7894(98)80025-7
Foa, E. B., Riggs, D. S., Massie, E. D., & Yarczower, M. (1995). The impact of fear
activation and anger on the efficacy of exposure treatment for PTSD. Behavior
Therapy, 26(3), 487–499. https://doi.org/10.1016/S0005-7894(05)80096-6
Foa, E. B., Rothbaum, B. O., & Furr, J. M. (2003). Augmenting exposure therapy
with other CBT procedures. Psychiatric Annals, 33(1), 47–53. https://doi.org/
10.3928/0048-5713-20030101-08
Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation,
mentalization, and the development of the self. Other Press.
Forgas, J. P. (1995). Mood and judgment: The affect infusion model (AIM). Psycho-
logical Bulletin, 117(1), 39–66. https://doi.org/10.1037/0033-2909.117.1.39
Fosha, D. (2000). The transforming power of affect: A model for accelerated change.
Basic Books.
Fosha, D. (2004). “Nothing that feels bad is ever the last step”: The role of positive
emotion in experiential work with difficult emotional experiences. Clinical
Psychology & Psychotherapy, 11(1), 30–43. https://doi.org/10.1002/cpp.390
Frank, J. (1973). Persuasion and healing: A comparative study of psychotherapy
(2nd ed.). Johns Hopkins University Press.
Frankl, V. E. (1959). Man’s search for meaning: An introduction to logotherapy.
Simon & Schuster.
Fredrickson, B. L. (1998). What good are positive emotions? Review of General
Psychology, 2(3), 300–319. https://doi.org/10.1037/1089-2680.2.3.300
Fredrickson, B. L. (2001). The role of positive emotions in positive psychology.
The broaden-and-build theory of positive emotions. American Psychologist,
56(3), 218–226. https://doi.org/10.1037/0003-066X.56.3.218
Fredrickson, B. L. (2009). Positivity: Groundbreaking research reveals how to
embrace the hidden strength of positive emotions, overcome negativity, and thrive.
Crown Publishers.
Fredrickson, B. L., & Levenson, R. W. (1998). Positive emotions speed recovery
from the cardiovascular sequelae of negative emotions. Cognition and Emotion,
12(2), 191–220. https://doi.org/10.1080/026999398379718
Fredrickson, B. L., Mancuso, R. A., Branigan, C., & Tugade, M. M. (2000). The
undoing effect of positive emotions. Motivation and Emotion, 24, 237–258.
https://doi.org/10.1023/A:1010796329158
336 • References

Freud, S. (1955). Repression. In J. Strachey (Ed. & Trans.), The standard edition
of the complete psychological works of Sigmund Freud (Vol. 14; pp. 141–158).
Hogarth Press. (Original work published 1915)
Freud, S. (1976). Introductory lectures on psycho-analysis. In J. Strachey (Ed.),
The complete psychological works (Vol. 15). W. W. Norton & Company. (Original
work published 1917)
Fried, E. I., & Nesse, R. M. (2015). Depression is not a consistent syndrome:
An investigation of unique symptom patterns in the STAR*D study. Journal of
Affective Disorders, 172, 96–102. https://doi.org/10.1016/j.jad.2014.10.010
Frijda, N. H. (1986). The emotions. Cambridge University Press.
Frijda, N. H. (2016). The evolutionary emergence of what we call “emotions.”
Cognition and Emotion, 30(4), 609–620. https://doi.org/10.1080/02699931.
2016.1145106
Gallese, V. (2009). Mirror neurons, embodied simulation, and the neural basis of
social identification. Psychoanalytic Dialogues, 19(5), 519–536. https://doi.org/
10.1080/10481880903231910
Gard, M. G., & Kring, A. M. (2007). Sex differences in the time course of emotion.
Emotion, 7(2), 429–437. https://doi.org/10.1037/1528-3542.7.2.429
Gazzaniga, M. S. (1998). The mind’s past. University of California Press.
Geller, S. M., & Greenberg, L. S. (2002). Therapeutic presence: Therapists’ expe-
rience of presence in the psychotherapy encounter. Person-Centered & Expe-
riential Psychotherapies, 1(1–2), 71–86. https://doi.org/10.1080/14779757.
2002.9688279
Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: A mindful approach
to effective therapy. American Psychological Association. https://doi.org/
10.1037/13485-000
Gendlin, E. T. (1969). Focusing. Psychotherapy, 6(1), 4–15. https://doi.org/10.1037/
h0088716
Gendlin, E. T. (1981). Focusing. Bantam Books.
Gendlin, E. T. (1991). On emotion in therapy. In J. D. Safran & L. S. Greenberg
(Eds.), Emotion, psychotherapy, and change (pp. 255–279). Guilford Press.
Gendlin, E. T. (1996). Focusing-oriented psychotherapy: A manual of the experiential
method. Guilford Press.
Gilbert, P. (1992). Depression: The evolution of powerlessness. Lawrence Erlbaum.
Gilbert, P. (2010). The compassionate mind: A new approach to life’s challenges.
New Harbinger Publications.
Gilboa-Schechtman, E., & Foa, E. B. (2001). Patterns of recovery from trauma:
The use of intraindividual analysis. Journal of Abnormal Psychology, 110(3),
392–400. https://doi.org/10.1037/0021-843X.110.3.392
Glaser, B. G., & Strauss, A. (1967). Discovery of grounded theory. Strategies for
qualitative research. California Sociology Press.
Goldfried, M. R. (1980). Toward the delineation of therapeutic change prin-
ciples. American Psychologist, 35(11), 991–999. https://doi.org/10.1037/
0003-066X.35.11.991
 References • 337

Goldfried, M. R. (2012). The corrective experience: A core principle for thera-
peutic change. In L. G. Castonguay & C. E. Hill (Eds.), Transformation in psycho­
therapy: Corrective experiences across cognitive behavioral, humanistic, and
psychodynamic approaches (pp. 13–29). American Psychological Association.
https://doi.org/10.1037/13747-002
Goldfried, M. R., & Davison, G. C. (1976). Clinical behavior therapy. Holt, Rinehart
and Winston.
Goldman, R. N., & Fox-Zurawic, A. (2012, July 10–14). Self-soothing in emotion-
focused therapy: Findings from a task analysis [Paper presentation]. Confer-
ence of World Association for Person-Centred and Experiential Psychotherapy
& Counselling, Antwerp, Belgium.
Goldman, R. N., & Greenberg, L. S. (2015). Case formulation in emotion-focused
therapy: Co-creating clinical maps for change. American Psychological Associ-
ation. https://doi.org/10.1037/14523-000
Goldman, R. N., Greenberg, L. S., & Angus, L. (2006). The effects of adding
emotion-focused 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
Greenberg, L. S. (1984). A task analysis of intrapersonal conflict resolution.
In L. N. Rice & L. S. Greenberg (Eds.), Patterns of change: Intensive analysis of
psychotherapy process (pp. 67–123). Guilford Press.
Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through
their feelings. American Psychological Association. https://doi.org/10.1037/
10447-000
Greenberg, L. S. (2007). A guide to conducting a task analysis of psycho­
therapeutic change. Psychotherapy Research, 17(1), 15–30. https://doi.org/
10.1080/10503300600720390
Greenberg, L. S. (2011). Emotion-focused therapy. American Psychological
Association.
Greenberg, L. S. (2015). Emotion-focused therapy: Coaching clients to work through
their feelings (2nd ed.). American Psychological Association. https://doi.org/
10.1037/14692-000
Greenberg, L. S. (2017). Emotion-focused therapy (Rev. ed.). American Psycho-
logical Association.
Greenberg, L. S. (2019). Theory of functioning in emotion-focused therapy.
In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-
focused therapy (pp. 37–59). American Psychological Association. https://
doi.org/10.1037/0000112-002
Greenberg, L. S., & Angus, L. E. (2004). The contributions of emotion processes
to narrative change in psychotherapy: A dialectical constructivist approach.
338 • References

In L. E. Angus & J. McLeod (Eds.), The handbook of narrative and psychotherapy:
Practice, theory, and research (pp. 330–349). SAGE Publishing. https://doi.org/
10.4135/9781412973496.d25
Greenberg, L. S., Auszra, L., & Herrmann, I. R. (2007). The relationship among
emotional productivity, emotional arousal, and outcome in experiential therapy
of depression. Psychotherapy Research, 17(4), 482–493. https://doi.org/
10.1080/10503300600977800
Greenberg, L. S., & Bolger, E. (2001). An emotion-focused approach to the
overregulation of emotion and emotional pain. Journal of Clinical Psychology,
57(2), 197–211. https://doi.org/10.1002/1097-4679(200102)57:2<197::AID-
JCLP6>3.0.CO;2-O
Greenberg, L. S., & Elliott, R. (1997). Varieties of empathic responding. In A. C.
Bohart & L. S. Greenberg (Eds.), Empathy reconsidered: New directions in
psychotherapy (pp. 167–186). American Psychological Association. https://
doi.org/10.1037/10226-007
Greenberg, L. S., Ford, C. L., Alden, L. S., & Johnson, S. M. (1993). In-session
change in emotionally focused therapy. Journal of Consulting and Clinical
Psychology, 61(1), 78–84. https://doi.org/10.1037/0022-006X.61.1.78
Greenberg, L. S., & Geller, S. M. (2001). Congruence and therapeutic presence.
In G. Wyatt (Eds), Rogers’ therapeutic conditions: Evolution, theory and practice:
Vol 1. Congruence (pp. 131–149). PCCS Books.
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., & Goldman, R. N. (2019). Theory of practice of emotion-
focused therapy. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook
of emotion-focused therapy (pp. 61–89). American Psychological Association.
https://doi.org/10.1037/0000112-003
Greenberg, L. S., & Iwakabe, S. (2013). Emotion-focused therapy and shame.
In R. L. Dearing & J. Tangney (Eds.), Shame in the therapy hour (pp. 69–90).
American Psychological Association. https://doi.org/10.1037/12326-003
Greenberg, L. S., & Johnson, S. M. (1988). Emotionally focused therapy for couples.
Guilford Press.
Greenberg, L. S., Malberg, N. T., & Tompkins, M. A. (2019). Working with emotion
in psychodynamic, cognitive behavior, and emotion-focused psychotherapy. Ameri-
can Psychological Association. https://doi.org/10.1037/0000130-000
Greenberg, L. S., & Malcolm, W. (2002). Resolving unfinished business: Relating
process to outcome. Journal of Consulting and Clinical Psychology, 70(2),
406–416. https://doi.org/10.1037/0022-006X.70.2.406
Greenberg, L. S., & Paivio, S. C. (1997). Working with emotions in psychotherapy.
Guilford Press.
Greenberg, L. S., & Pascual-Leone, J. (1995). A dialectical constructivist approach
to experiential change. In R. A. Neimeyer & M. J. Mahoney (Eds.), Construc-
tivism in psychotherapy (pp. 169–191). American Psychological Association.
https://doi.org/10.1037/10170-008
 References • 339

Greenberg, L. S., & Pascual-Leone, J. (2001). A dialectical constructivist view of

the creation of personal meaning. Journal of Constructivist Psychology, 14(3),
165–186. https://doi.org/10.1080/10720530125970
Greenberg, L. S., & Pascual-Leone, A. (2006). Emotion in psychotherapy:
A practice-friendly research review. Journal of Clinical Psychology, 62(5),
611–630. https://doi.org/10.1002/jclp.20252
Greenberg, L. S., Rice, L. N., & Elliott, R. K. (1993). Facilitating emotional change:
The moment-by-moment process. Guilford Press.
Greenberg, L. S., & Ruchanski-Rosenberg, R. (2002). Therapists’ experience of
empathy. In J. C. Watson, R. N. Goldman, & M. S. Warner (Eds.), Client-centered
and experiential psychotherapy in the 21st century: Advances in theory, research
and practice (pp. 204–220). PCCS Books.
Greenberg, L. S., & Safran, J. D. (1987). Emotion in psychotherapy: Affect, cognition,
and the process of change. Guilford Press.
Greenberg, L. J., Warwar, S. H., & Malcolm, W. M. (2008). Differential effects
of emotion-focused therapy and psychoeducation in facilitating forgiveness
and letting go of emotional injuries. Journal of Counseling Psychology, 55(2),
185–196. https://doi.org/10.1037/0022-0167.55.2.185
Greenberg, L. S., & Watson, J. (1998). Experiential therapy of depression:
Differential effects of client-centered relationship conditions and process
experiential interventions. Psychotherapy Research, 8(2), 210–224. https://
doi.org/10.1080/10503309812331332317
Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression.
American Psychological Association. https://doi.org/10.1037/11286-000
Gross, J. J. (1998). The emerging field of emotion regulation: An integrative
review. Review of General Psychology, 2(3), 271–299. https://doi.org/10.1037/
1089-2680.2.3.271
Gross, J. J. (1999). Emotion and emotion regulation. In L. A. Pervin & O. P. John
(Eds.), Handbook of personality: Theory and research (2nd ed., pp. 525–552).
Guilford Press.
Gross, J. J. (2002). Emotion regulation: Affective, cognitive, and social
consequences. Psychophysiology, 39(3), 281–291. https://doi.org/10.1017/
S0048577201393198
Gross, J. J. (2013). Emotion regulation: Taking stock and moving forward.
Emotion, 13(3), 359–365. https://doi.org/10.1037/a0032135
Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation
processes: Implications for affect, relationships, and well-being. Journal of
Personality and Social Psychology, 85(2), 348–362. https://doi.org/10.1037/
0022-3514.85.2.348
Gross, J. J., & Levenson, R. W. (1997). Hiding feelings: The acute effects of inhib-
iting negative and positive emotion. Journal of Abnormal Psychology, 106(1),
95–103. https://doi.org/10.1037/0021-843X.106.1.95
Hareli, S., Kafetsios, K., & Hess, U. (2015). A cross-cultural study on emotion
expression and the learning of social norms. Frontiers in Psychology, 6,
Article 1501. https://doi.org/10.3389/fpsyg.2015.01501
340 • References

Harlow, H. F. (1960). Primary affectional patterns in primates. American Journal

of Orthopsychiatry, 30(4), 676–684. https://doi.org/10.1111/j.1939-0025.
1960.tb02085.x
Harvey, A., Watkins, E., Mansell, W., & Shafran, R. (2004). Cognitive behavioural
processes across psychological disorders: a transdiagnostic approach to research
and treatment. Oxford University Press. https://doi.org/10.1093/med:psych/
9780198528883.001.0001
Hayes, S. C., & Hofmann, S. G. (Eds.). (2018). Process-based CBT: The science
and core clinical competencies of cognitive behavioral therapy. New Harbinger
Publications.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2008). Acceptance and commitment
therapy: The process and practice of mindful change (2nd ed.). Guilford Press.
Hebb, D. O. (1949). The organization of behavior. Wiley.
Heidegger, M. (2000). Introduction to metaphysics (G. Fried & R. Polt, Trans.;
rev. ed.). Yale University Press. (Original work published 1953)
Hendricks, M. N. (2002). Focusing-oriented/experiential psychotherapy. In D. J.
Cain (Ed.), Humanistic psychotherapies: Handbook of research and practice
(pp. 221–251). American Psychological Association. https://doi.org/10.1037/
10439-007
Herrmann, I. R., Greenberg, L. S., & Auszra, L. (2016). Emotion categories and
patterns of change in experiential therapy for depression. Psychotherapy
Research, 26(2), 178–195. https://doi.org/10.1080/10503307.2014.958597
His Holiness the Dalai Lama. (2001). Ethics for the new millennium. Riverhead
Books.
Hofmann, S. G., & Doan, S. N. (2018). The social foundations of emotion: Develop-
mental, cultural, and clinical dimensions. American Psychological Association.
https://doi.org/10.1037/0000098-000
Hupbach, A., Hardt, O., Gomez, R., & Nadel, L. (2008). The dynamics of memory:
Context-dependent updating. Learning & Memory, 15(8), 574–579. https://
doi.org/10.1101/lm.1022308
Hwang, J. (2006). A processing model of emotion regulation: Insights from the attach-
ment system [Doctoral dissertation, Georgia State University]. ScholarWorks.
Dissertation Abstracts International: Section B. The Sciences and Engineering,
67(4-B), 2280.
Iberg, J. R. (1991). Applying statistical control theory to bring together clinical
supervision and psychotherapy research. Journal of Consulting and Clinical
Psychology, 59(4), 575–586. https://doi.org/10.1037/0022-006X.59.4.575
Inda, M. C., Muravieva, E. V., & Alberini, C. M. (2011). Memory retrieval and
the passage of time: From reconsolidation and strengthening to extinction.
The Journal of Neuroscience, 31(5), 1635–1643. https://doi.org/10.1523/
JNEUROSCI.4736-10.2011
Ingram, B. L. (2006). Clinical case formulations: Matching the integrative treat-
ment plan to the client. Wiley.
 References • 341

Ito, M., Greenberg, L. S., Iwakabe, S., & Pascual-Leone, A. (2010, June 2–5).
Compassionate emotion regulation: A task analytic approach to studying the
process of self-soothing in therapy session [Paper presentation]. World Congress
of Behavioral and Cognitive Therapies, Boston, MA, United States.
James, W. (1890). The principles of psychology. Henry Holt and Company.
Jaycox, L. H., Foa, E. B., & Morral, A. R. (1998). Influence of emotional engagement
and habituation on exposure therapy for PTSD. Journal of Consulting and Clinical
Psychology, 66(1), 185–192. https://doi.org/10.1037/0022-006X.66.1.185
Johnson, S. M., & Greenberg, L. S. (1988). Relating process to outcome in
marital therapy. Journal of Marital and Family Therapy, 14(2), 175–183.
https://doi.org/10.1111/j.1752-0606.1988.tb00733.x
Jones, E. E., & Pulos, S. M. (1993). Comparing the process in psychodynamic
and cognitive–behavioral therapies. Journal of Consulting & Clinical Psychology,
61(2), 306–316. https://doi.org/10.1037/0022-006X.61.2.306
Jurist, E. (2019). Minding emotions: Cultivating mentalization in psychotherapy.
The Guilford Press.
Kashdan, T. B., Barrios, V., Forsyth, J. P., & Steger, M. F. (2006). Experiential
avoidance as a generalized psychological vulnerability: Comparisons with
coping and emotion regulation strategies. Behaviour Research and Therapy,
44(9), 1301–1320. https://doi.org/10.1016/j.brat.2005.10.003
Kendi, I. X. (2019). How to be an antiracist. One World.
Kendler, K. S. (1996). Major depression and generalised anxiety disorder: Same
genes, (partly) different environments—Revisited. The British Journal of
Psychiatry, 168(S30), 68–75. https://doi.org/10.1192/S0007125000298437
Kennedy-Moore, E., & Watson, J. C. (1999). Expressing emotion: Myths, realities,
and therapeutic strategies. Guilford Press.
Kernberg, O. (1967). Borderline personality organization. Journal of the
American Psychoanalytic Association, 15(3), 641–685. https://doi.org/10.1177/
000306516701500309
Kernberg, O. F. (1984). Object relations theory and clinical psychoanalysis. Jason
Aronson.
Kerr, T., Walsh, J., & Marshall, A. (2001). Emotional change processes in
music-assisted reframing. Journal of Music Therapy, 38(3), 193–211. https://
doi.org/10.1093/jmt/38.3.193
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters,
E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV
disorders in the National Comorbidity Survey Replication. Archives of General
Psychiatry, 62(6), 593–602. https://doi.org/10.1001/archpsyc.62.6.593
Kircanski, K., Lieberman, M. D., & Craske, M. G. (2012). Feelings into words:
Contributions of language to exposure therapy. Psychological Science, 23(10),
1086–1091. https://doi.org/10.1177/0956797612443830
Kitayama, S., Markus, H. R., & Kurokawa, M. (2000). Culture, emotion, and
well-being: Good feelings in Japan and the United States. Cognition and
Emotion, 14(1), 93–124. https://doi.org/10.1080/026999300379003
342 • References

Klein, M. H., Mathieu, P. L., Gendlin, E. T., & Kiesler, D. J. (1969). The Experiencing
Scale: A research and training manual: Volume 1. Wisconsin Psychiatric Institute.
Klein, M. H., Mathieu-Coughlan, P., & Kiesler, D. J. (1986). The experiencing
scales. In L. S. Greenberg & W. Pinsof (Eds.), The psychotherapeutic process:
A research handbook (pp. 21–71). Guilford Press.
Kramer, U., & Pascual-Leone, A. (2016). The role of maladaptive anger in
self-criticism: A quasi-experimental study on emotional processes. Counselling
Psychology Quarterly, 29(3), 311–333. https://doi.org/10.1080/09515070.
2015.1090395
Kramer, U., Pascual-Leone, A., Berthoud, L., de Roten, Y., Marquet, P., Kolly, S.,
Despland, J. N., & Page, D. (2016). Assertive anger mediates effects of
dialectical behavior-informed skills training for borderline personality dis-
order: A randomized controlled trial. Clinical Psychology & Psychotherapy,
23(3), 189–202. https://doi.org/10.1002/cpp.1956
Kramer, U., Pascual-Leone, A., Despland, J.-N., & de Roten, Y. (2015). One
minute of grief: Emotional processing in short-term dynamic psychotherapy
for adjustment disorder. Journal of Consulting and Clinical Psychology, 83(1),
187–198. https://doi.org/10.1037/a0037979
Lane, R. D., Ryan, L., Nadel, L., & Greenberg, L. (2015). Memory reconsolidation,
emotional arousal, and the process of change in psychotherapy: New insights
from brain science. Behavioral and Brain Sciences, 38, Article E1. Advance
online publication. https://doi.org/10.1017/S0140525X14000041
LeDoux, J. E. (1996). The emotional brain: The mysterious underpinnings of
emotional life. Simon & Schuster.
LeDoux, J. E. (2012). Rethinking the emotional brain. Neuron, 73(4), 653–676.
https://doi.org/10.1016/j.neuron.2012.02.004
Le Grange, D., Swanson, S. A., Crow, S. J., & Merikangas, K. R. (2012). Eating
disorder not otherwise specified presentation in the U.S. population. Inter-
national Journal of Eating Disorders, 45(5), 711–718. https://doi.org/10.1002/
eat.22006
Leijssen, M. (1998). Focusing microprocesses. In L. S. Greenberg, J. C. Watson,
& G. Lietaer (Eds.), Handbook of experiential psychotherapy (pp. 121–154).
Guilford Press.
Leijssen, M. (1996–1997). Focusing processes in client-centered/experiential
psychotherapy. An overview of my research findings. The Folio: A Journal for
Focusing and Experiential Therapy, 15(2), 1–6.
Leijssen, M., Lietaer, G., Stevens, I., & Wels, G. (2000). Focusing training
for stagnating clients: An analysis of four cases. In J. Marques-Teixeira &
S. Antunes (Eds.), Client-centered and experiential psychotherapy (pp. 207–224).
Vale & Vale.
Levinas, E. (1969). Totality and infinity: An essay on exteriority (A. Lingis, Trans.).
Duquesne University Press.
Levinas, E. (2000). Entre nous: On thinking-of-the-other (B. Harshav & M. B.
Smith, Trans.). Columbia University Press.
 References • 343

Levine, P. (2010). In an unspoken voice: How the body releases trauma and restores
goodness. North Atlantic Books.
Levy Berg, A., Sandell, R., & Sandahl, C. (2009). Affect-focused body psycho-
therapy in patients with generalized anxiety disorder: Evaluation of an
integrative method. Journal of Psychotherapy Integration, 19(1), 67–85.
https://doi.org/10.1037/a0015324
Lewin, J. K. (2001). Both sides of the coin: Comparative analyses of narrative
process patterns in poor and good outcome dyads engaged in brief experiential
psychotherapy for depression [Unpublished master’s thesis]. York University.
Lieberman, M. D., Eisenberger, N. I., Crockett, M. J., Tom, S. M., Pfeifer, J. H.,
& Way, B. M. (2007). Putting feelings into words: Affect labeling disrupts
amygdala activity in response to affective stimuli. Psychological Science, 18(5),
421–428. https://doi.org/10.1111/j.1467-9280.2007.01916.x
Lin, K. M. (1983). Hwa-Byung: A Korean culture-bound syndrome? The
American Journal of Psychiatry, 140(1), 105–107. https://doi.org/10.1176/
ajp.140.1.105
Linehan, M. M. (1993). Cognitive–behavioral treatment of borderline personality
disorder. Guilford Press.
Luedke, A. J., Peluso, P. R., Diaz, P., Freund, R., & Baker, A. (2017). Predicting
dropout in counseling using affect coding of the therapeutic relationship: An
empirical analysis. Journal of Counseling and Development, 95(2), 125–134.
https://doi.org/10.1002/jcad.12125
MacLeod, R., Elliott, R., & Rodgers, B. (2012). Process-experiential/emotion-
focused therapy for social anxiety: A hermeneutic single-case efficacy design
study. Psychotherapy Research, 22(1), 67–81. https://doi.org/10.1080/
10503307.2011.626805
Magnavita, J. J. (2008). Toward unification of clinical science: The next wave in
the evolution of psychotherapy? Journal of Psychotherapy Integration, 18(3),
264–291. https://doi.org/10.1037/a0013490
Magnavita, J. J., & Anchin, J. C. (2014). Unifying psychotherapy: Principles,
methods, and evidence from clinical science. Springer Publishing Company.
Makinen, J. A., & Johnson, S. M. (2006). Resolving attachment injuries in couples
using emotionally focused therapy: Steps toward forgiveness and reconcilia-
tion. Journal of Consulting and Clinical Psychology, 74(6), 1055–1064. https://
doi.org/10.1037/0022-006X.74.6.1055
Maren, S. (2011). Seeking a spotless mind: Extinction, deconsolidation, and
erasure of fear memory. Neuron, 70(5), 830–845. https://doi.org/10.1016/
j.neuron.2011.04.023
Markowitsch, H. J. (1998). Differential contribution of right and left amygdala
to affective information processing. Behavioural Neurology, 11(4), 233–244.
Markus, H. R., & Kitayama, S. (1991). Culture and the self: Implications for
cognition, emotion, and motivation. Psychological Review, 98(2), 224–253.
https://doi.org/10.1037/0033-295X.98.2.224
344 • References

Markus, H. R., & Kitayama, S. (2001). The cultural construction of self and
emotion: Implications for social behavior. In W. G. Parrott (Ed.), Emotions in
social psychology: Essential reading (pp. 119–137). Psychology Press.
Maslow, A. H. (1954). Motivation and personality. Harper and Row.
Maslow, A. H. (1968). Toward a psychology of being (2nd ed.). D. Van Nostrand.
McCullough, L. (1999). Short-term psychodynamic therapy as a form of
desensitization: Treating affect phobias. In Session: Psychotherapy in Practice,
4(4), 35–53. https://doi.org/10.1002/(SICI)1520-6572(199924)4:4<35::AID-
SESS4>3.0.CO;2-G
McCullough, L., Kuhn, N., Andrews, S., Kaplan, A., Wolf, J., & Hurley, C. L.
(2003). Treating affect phobia: A manual for short term dynamic psychotherapy.
Guilford Press.
McGaugh, J. L. (2002). Memory consolidation and the amygdala: A systems
perspective. Trends in Neurosciences, 25(9), 456–461. https://doi.org/10.1016/
S0166-2236(02)02211-7
McGilchrist, I. (2009). The master and his emissary: The divided brain and the
making of the Western world. Yale University Press.
McKinnon, J. M., & Greenberg, L. S. (2013). Revealing underlying vulnerable
emotion in couple therapy: Impact on session and final outcome. Journal of
Family Therapy, 35(3), 303–319. https://doi.org/10.1111/1467-6427.12015
McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality
structure in the clinical process. Guilford Press.
Merleau-Ponty, M. (1962). Phenomenology of perception (C. Smith, Trans.).
Routledge and Kegan Paul. (Original work published 1945)
Merleau-Ponty, M. (1964). Sense and nonsense (H. L. Dreyfus & P. A. Dreyfus,
Trans.). Northwestern University Press. (Original work published 1948)
Merleau-Ponty, M. (1968). The visible and the invisible (C. Lefort, Ed., & A. Lingis,
Trans.). Northwestern University Press.
Merrill, C. (2008). Carl Rogers and Martin Buber in dialogue: The meeting of
divergent paths. The Person-Centred Journal, 15(1–2), 4–12.
Mesquita, B., & Albert, D. (2007). The cultural regulation of emotions. In J. J.
Gross (Ed.), Handbook of emotion regulation (pp. 486–503). Guilford Press.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people
change (3rd ed.). Guilford Press.
Min, S. K., Suh, S.-Y., & Song, K.-J. (2009). Symptoms to use for diagnostic
criteria of Hwa-Byung, an anger syndrome. Psychiatry Investigation, 6(1),
7–12. https://doi.org/10.4306/pi.2009.6.1.7
Missirlian, T. M., Toukmanian, S. G., Warwar, S. H., & Greenberg, L. S. (2005).
Emotional arousal, client perceptual processing, and the working alliance in
experiential psychotherapy for depression. Journal of Consulting and Clinical
Psychology, 73(5), 861–871. https://doi.org/10.1037/0022-006X.73.5.861
Morikawa, Y. (1997). Making practical the focusing manner of experiencing
in everyday life: A consideration of factor analysis. The Journal of Japanese
Clinical Psychology, 15(1), 58–65.
 References • 345

Morin, A. (2020, September 20). 7 strategies to help you on your anti-racism

journey. Verywell Mind. https://www.verywellmind.com/anti-racism-strategies-
5069386
Munder, T., Brütsch, O., Leonhart, R., Gerger, H., & Barth, J. (2013). Researcher
allegiance in psychotherapy outcome research: An overview of reviews. Clinical
Psychology Review, 33(4), 501–511. https://doi.org/10.1016/j.cpr.2013.02.002
Murray, H. A. (1938). Explorations in personality. Oxford University Press.
Myers, D. G. (1996). Exploring psychology (3rd ed.). Worth Publishers.
Nadel, L., & Bohbot, V. (2001). Consolidation of memory. Hippocampus, 11, 56–60.
https://doi.org/10.1002/1098-1063(2001)11:1<56::AID-HIPO1020>
3.0.CO;2-O
Nadel, L., Hupbach, A., Gomez, R., & Newman-Smith, K. (2012). Memory forma-
tion, consolidation and transformation. Neuroscience and Biobehavioral Reviews,
36(7), 1640–1645. https://doi.org/10.1016/j.neubiorev.2012.03.001
Nadel, L., & Moscovitch, M. (1997). Memory consolidation, retrograde amnesia
and the hippocampal complex. Current Opinion in Neurobiology, 7(2), 217–227.
https://doi.org/10.1016/S0959-4388(97)80010-4
Nader, K. (2003). Memory traces unbound. Trends in Neuroscience, 26(2), 65–72.
https://doi.org/10.1016/S0166-2236(02)00042-5
Nader, K., & Hardt, O. (2009). A single standard for memory: The case for
reconsolidation. Nature Reviews Neuroscience, 10, 224–234. https://doi.org/
10.1038/nrn2590
Nader, K., Schafe, G. E., & LeDoux, J. E. (2000). Fear memories require
protein synthesis in the amygdala for reconsolidation after retrieval. Nature,
406(6797), 722–726. https://doi.org/10.1038/35021052
Nichols, M. P., & Efran, J. S. (1985). Catharsis in psychotherapy: A new perspec-
tive. Psychotherapy, 22(1), 46–58. https://doi.org/10.1037/h0088525
Nichols, M. P., & Zax, M. (1977). Catharsis in psychotherapy. Gardner Press.
Norcross, J. C., & Goldfried, M. R. (Eds.). (1992). Handbook of psychotherapy
integration. Basic Books.
Oatley, K., Keltner, D., & Jenkins, J. M. (2006). Understanding emotions (2nd ed.).
Blackwell Publishing.
Ogden, P. (2015). Sensorimotor psychotherapy: Interventions for trauma and
attachment. W. W. Norton.
Ogrodniczuk, J. S., Piper, W. E., & Joyce, A. S. (2008). Alexithymia and therapist
reactions to the patient: Expression of positive emotion as a mediator. Psy-
chiatry, 71(3), 257–265. https://doi.org/10.1521/psyc.2008.71.3.257
Orlinsky, D. E., & Howard, K. I. (1986). Process and outcome in psychotherapy.
In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior
change (3rd ed.; pp. 311–384). John Wiley & Sons.
Paivio, S. C., & Greenberg, L. S. (1995). Resolving “unfinished business”: Efficacy
of experiential therapy using empty-chair dialogue. Journal of Consulting
and Clinical Psychology, 63(3), 419–425. https://doi.org/10.1037/0022-006X.
63.3.419
346 • References

Paivio, S. C., Hall, I. E., Holowaty, K. A. M., Jellis, J. B., & Tran, N. (2001).
Imaginal confrontation for resolving child abuse issues. Psychotherapy Research,
11(4), 433–453. https://doi.org/10.1093/ptr/11.4.433
Paivio, S. C., & Nieuwenhuis, J. A. (2001). Efficacy of emotion focused therapy
for adult survivors of child abuse: A preliminary study. Journal of Traumatic
Stress, 14, 115–133. https://doi.org/10.1023/A:1007891716593
Paivio, S. C., & Pascual-Leone, A. (2010). Emotion-focused therapy for complex
trauma: An integrative approach. American Psychological Association. https://
doi.org/10.1037/12077-000
Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal
emotions. Oxford University Press.
Panksepp, J., & Biven, L. (2012). The archeology of mind. W. W. Norton &
Company.
Parrott, W. G., & Sabini, J. (1990). Mood and memory under natural conditions:
Evidence for mood incongruent recall. Journal of Personality and Social
Psychology, 59(2), 321–336. https://doi.org/10.1037/0022-3514.59.2.321
Pascual-Leone, A. (2018). How clients “change emotion with emotion”: A pro-
gramme of research on emotional processing. Psychotherapy Research, 28(2),
165–182. https://doi.org/10.1080/10503307.2017.1349350
Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional processing in expe-
riential 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
Pascual-Leone, A., & Yeryomenko, N. (2016). The client “experiencing” scale
as a predictor of treatment outcomes: A meta-analysis on psychotherapy
process. Psychotherapy Research, 27(6), 653–665. https://doi.org/10.1080/
10503307.2016.1152409
Pascual-Leone, J. (1987). Organismic processes for neo-Piagetian theories: A dia-
lectical causal account of cognitive development. International Journal of Psy-
chology, 22(5–6), 531–569. https://doi.org/10.1080/00207598708246795
Pascual-Leone, J. (1991). Emotions, development, and psychotherapy: A
dialectical-constructivist perspective. In J. D. Safran & L. S. Greenberg (Eds.),
Emotion, psychotherapy, and change (pp. 302–335). Guilford Press.
Pascual-Leone, J., & Johnson, J. (1991). The psychological unit and its role in
task analysis. A reinterpretation of object permanence. In M. Chandler &
M. Chapman (Eds.), Criteria for competence: Controversies in the assessment of
children’s abilities (pp. 153–187). Lawrence Erlbaum Associates.
Pascual-Leone, J., & Johnson, J. (2011). A developmental theory of mental
attention: Its applications to measurement and task analysis. In P. Barrouillet
& V. Gaillard (Eds.), Cognitive development and working memory: A dialogue
between neo-Piagetian and cognitive approaches (pp. 13–46). Psychology
Press.
Paul, G. L. (1967). Strategy of outcome research in psychotherapy. Journal of
Consulting Psychology, 31(2), 109–118. https://doi.org/10.1037/h0024436
 References • 347

Peluso, P. R., & Freund, R. R. (2018). Therapist and client emotional expression
and psychotherapy outcomes: A meta-analysis. Psychotherapy, 55(4), 461–472.
https://doi.org/10.1037/pst0000165
Peluso, P. R., Liebovitch, L. S., Gottman, J. M., Norman, M. D., & Su, J. (2012).
A mathematical model of psychotherapy: An investigation using dynamic
non-linear equations to model the therapeutic relationship. Psychotherapy
Research, 22(1), 40–55. https://doi.org/10.1080/10503307.2011.622314
Pennebaker, J. W. (1990). Opening up: The healing power of confiding in others.
William Morrow.
Perls, F. S. (1969). Gestalt therapy verbatim. Real People Press.
Perls, F. S. (1973). The Gestalt approach & eye witness to therapy. Bantam Books.
Perls, F. S., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy. Julian Press.
Piliero, S. (2004). Patients reflect on their affect-focused experiential psychotherapy:
A retrospective study [Doctoral dissertation, Adelphi University]. Dissertation
Abstracts International: Section B. The Sciences and Engineering, 65(4-B), 2108.
Pine, F. (1986). On the development of the “borderline-child-to-be.” American
Journal of Orthopsychiatry, 56(3), 450–457. https://doi.org/10.1111/j.1939-
0025.1986.tb03476.x
Porges, S. W. (2004). Neuroception: A subconscious system for detecting threats
and safety. Zero to Three, 24(5), 19–24.
Porges, S. W. (2007). The polyvagal perspective. Biological Psychology, 74(2),
116–143. https://doi.org/10.1016/j.biopsycho.2006.06.009
Porges, S. W. (2011). The polyvagal theory: Neuro-physiological foundations
of emotions, attachment, communication, self-regulation. W. W. Norton &
Company.
Pos, A. E., & Greenberg, L. S. (2012). Organizing awareness and increasing
emotion regulation: Revising chair work in emotion-focused therapy for border­
line personality disorder. Journal of Personality Disorders, 26(1), 84–107.
https://doi.org/10.1521/pedi.2012.26.1.84
Pos, A. E., Greenberg, L. S., Goldman, R. N., & Korman, L. M. (2003). Emotional
processing during experiential treatment of depression. Journal of Consulting
and Clinical Psychology, 71(6), 1007–1016. https://doi.org/10.1037/0022-
006X.71.6.1007
Pos, A. E., Greenberg, L. S., & Warwar, S. H. (2009). Testing a model of change
in the experiential treatment of depression. Journal of Consulting and Clinical
Psychology, 77(6), 1055–1066. https://doi.org/10.1037/a0017059
Pos, A. E., & Paolone, D. A. (2019). Emotion-focused therapy for personality
disorders. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of
emotion-focused therapy (pp. 381–402). American Psychological Association.
https://doi.org/10.1037/0000112-017
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change
of smoking: Toward an integrative model of change. Journal of Consulting
and Clinical Psychology, 51(3), 390–395. https://doi.org/10.1037/0022-
006X.51.3.390
348 • References

Purton, C. (2004). Person-centred therapy: The focusing-oriented approach.

Palgrave Macmillan.
Rice, L. N., & Kerr, G. P. (1986). Measures of client and therapist vocal qual-
ity. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process:
A research handbook (pp. 73–105). Guilford Press.
Rice, L. N., Koke, C., Greenberg, L. S., & Wagstaff, A. (1979). Manual for client
vocal quality. York University Counselling and Development Centre.
Rice, L. N., & Wagstaff, A. K. (1967). Client voice quality and expressive style as
indexes of productive psychotherapy. Journal of Consulting Psychology, 31(6),
557–563. https://doi.org/10.1037/h0025164
Richman, L. S., & Leary, M. R. (2009). Reactions to discrimination, stigmatization,
ostracism, and other forms of interpersonal rejection. Psychological Review,
116(2), 365–383.
Roemer, L., Salters, K., Raffa, S. D., & Orsillo, S. M. (2005). Fear and avoidance of
internal experiences in GAD: Preliminary tests of a conceptual model. Cognitive
Therapy and Research, 29, 71–88. https://doi.org/10.1007/s10608-005-1650-2
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. (1959). A theory of therapy, personality and interpersonal rela-
tionships, as developed in the client-centered framework. In S. Koch (Ed.),
Psychology: A study of a science (Vol. 3, pp. 184–256). McGraw Hill.
Rogers, C. R. (1980). A way of being. Houghton Mifflin.
Ruby, M. B., Falk, C. F., Heine, S. J., Villa, C., & Silberstein, O. (2012). Not all
collectivisms are equal: Opposing preferences for ideal affect between East
Asians and Mexicans. Emotion, 12(6), 1206–1209. https://doi.org/10.1037/
a0029118
Russell, J. A. (2003). Core affect and the psychological construction of emotion.
Psychological Review, 110(1), 145–172. https://doi.org/10.1037/0033-295X.
110.1.145
Sachse, R. (2019). Case conceptualization in clarification-oriented psycho­
therapy. In U. Kramer (Ed.), Case formulation for personality disorders: Tailoring
psychotherapy to the individual client (pp. 113–135). Elsevier Academic Press.
https://doi.org/10.1016/B978-0-12-813521-1.00007-2
Safdar, S., Friedlmeier, W., Matsumoto, D., Yoo, S. H., Dwantes, C. T., Kakai, H., &
Shigemasu, E. (2009). Variations of emotional display rules within and across
cultures: A comparison between Canada, USA, and Japan. Canadian Journal
of Behavioural Science, 41(1), 1–10. https://doi.org/10.1037/a0014387
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational
treatment guide. Guilford Press.
Sarbin, T. R. (Ed.). (1986). Narrative psychology: The storied nature of human
conduct. Praeger.
Schank, R. C. (2000). Tell me a story: Narrative and intelligence. Northwestern
University Press.
 References • 349

Scherer, A., Boecker, M., Pawelzik, M., Gauggel, S., & Forkmann, T. (2017).
Emotion suppression, not reappraisal, predicts psychotherapy outcome. Psycho-
therapy Research, 27(2), 143–153. https://doi.org/10.1080/10503307.2015.
1080875
Schore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology
of emotional development. Lawrence Erlbaum Associates.
Schore, A. N. (2003). Affect dysregulation and disorders of the self. W. W. Norton
& Company.
Shahar, B. (2014). Emotion-focused therapy for the treatment of social anxiety:
An overview of the model and a case description. Clinical Psychology & Psycho-
therapy, 21(6), 536–547. https://doi.org/10.1002/cpp.1853
Shahar, B., Bar-Kalifa, E., & Alon, E. (2017). Emotion-focused therapy for
social anxiety disorder: Results from a multiple-baseline study. Journal of
Consulting and Clinical Psychology, 85(3), 238–249. https://doi.org/10.1037/
ccp0000166
Shahar, B., Doron, G., & Szepsenwol, O. (2015). Childhood maltreatment,
shame-proneness and self-criticism in social anxiety disorder: A sequential
mediational model. Clinical Psychology & Psychotherapy, 22(6), 570–579.
https://doi.org/10.1002/cpp.1918
Sicoli, L. A. (2005). Development and verification of a model of resolving hopelessness
in process-experiential therapy of depression (Publication No. 2006-99014-142)
[Doctoral dissertation, York University]. ProQuest Dissertations and Theses
Global.
Silberschatz, G., Fretter, P. B., & Curtis, J. T. (1986). How do interpretations
influence the process of psychotherapy? Journal of Consulting and Clinical
Psychology, 54(5), 646–652. https://doi.org/10.1037/0022-006X.54.5.646
Sloan, E., Hall, K., Moulding, R., Bryce, S., Mildred, H., & Staiger, P. K. (2017).
Emotion regulation as a transdiagnostic treatment construct across anxiety,
depression, substance, eating and borderline personality disorders: A system-
atic review. Clinical Psychology Review, 57, 141–163. https://doi.org/10.1016/
j.cpr.2017.09.002
Spinoza, B. (1967). Ethics (part IV). Hafner Publishing Company.
Sroufe, A. L. (1996). Emotional development: The organization of emotional life in
the early years. Cambridge University Press.
Staunton, H. (Ed.). (1898). The plays of Shakespeare (Vol. 1). George Routledge.
Stern, D. N. (1985). The interpersonal world of the infant: A view from psycho-
analysis and developmental psychology. Basic Books.
Stricker, G., & Gold, J. R. (Eds.). (1993). Comprehensive handbook of psychotherapy
integration. Plenum Press.
Tamietto, M., & de Gelder, B. (2010). Neural bases of the non-conscious percep-
tion of emotional signals. Nature Reviews Neuroscience, 11, 697–709. https://
doi.org/10.1038/nrn2889
Taylor, C. (1990). Human agency and language. Cambridge University Press.
350 • References

Timulak, L. (2015). Transforming emotional pain in psychotherapy: An emotion-

focused approach. Routledge.
Timulak, L., & McElvaney, J. (2016). Emotion-focused therapy for generalized
anxiety disorder: An overview of the model. Journal of Contemporary Psycho-
therapy, 46(1), 41–52. https://doi.org/10.1007/s10879-015-9310-7
Totton, N. (2003). Body psychotherapy: An introduction. Open University Press.
Tugade, M. M., & Fredrickson, B. L. (2004). Resilient individuals use positive
emotions to bounce back from negative emotional experiences. Journal of
Personality and Social Psychology, 86(2), 320–333. https://doi.org/10.1037/
0022-3514.86.2.320
Vrana, G. (2020). A task analysis of the resolution of aversion to emotion and
self-interruption in emotion-focused therapy [Unpublished doctoral disserta-
tion]. York University.
Warwar, S. H. (2005). Relating emotional processing to outcome in experiential
psychotherapy of depression. Dissertation Abstracts International: B. The Sci-
ences and Engineering, 66, 581.
Warwar, S. H., & Greenberg, L. S. (1999). Client Emotional Arousal Scale–III–R
[Unpublished manuscript]. York Psychotherapy Research Clinic, York
University.
Warwar, S. H., Greenberg, L. S., & Perepeluk, D. (2003, June). Reported in-session
emotional experience in therapy [Paper presentation]. 34th International Annual
Meeting of the Society for Psychotherapy Research, Weimar, Germany.
Warwar, S. H., Links, P. S., Greenberg, L., & Bergmans, Y. (2008). Emotion-
focused principles for working with borderline personality disorder. Journal
of Psychiatric Practice, 14(2), 94–104. https://doi.org/10.1097/01.pra.
0000314316.02416.3e
Watson, J. C. (2019). Role of the therapeutic relationship in emotion-focused
therapy. In L. S. Greenberg & R.N. Goldman (Eds.), Clinical handbook of
emotion-focused therapy (pp. 111–128). American Psychological Association.
https://doi.org/10.1037/0000112-005
Watson, J. C., Timulak, L., & Greenberg, L. S. (2019). Emotion-focused therapy
for generalized anxiety disorder. In L. S. Greenberg & R. N. Goldman (Eds.),
Clinical handbook of emotion-focused therapy (pp. 315–336). American Psycho-
logical Association. https://doi.org/10.1037/0000112-014
Watson, J. C. (2002). Re-visioning empathy. In D. J. Cain (Ed.), Humanistic
psychotherapies: Handbook of research and practice (pp. 445–471). American
Psychological Association. https://doi.org/10.1037/10439-014
Watson, J. C. (2016). The role of empathy in psychotherapy: Theory, research
and practice. In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psycho-
therapies: Handbook of research and practice (2nd ed., pp. 115–145). American
Psychological Association.
Watson, J. C., & Bedard, D. L. (2006). Clients’ emotional processing in psycho-
therapy: A comparison between cognitive-behavioral and process-experiential
 References • 351

therapies. Journal of Consulting and Clinical Psychology, 74(1), 152–159.

https://doi.org/10.1037/0022-006X.74.1.152
Watson, J. C., Chekan, S. S., & McMullen, E. (2017). Emotion-focused psycho-
therapy for GAD: Individual case comparison of a good and poor outcome case.
Person-Centered and Experiential Psychotherapies, 16(2), 118–139. https://
doi.org/10.1080/14779757.2017.1330707
Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2007). Case studies in emotion-
focused treatment of depression: A comparison of good and poor outcome.
American Psychological Association. https://doi.org/10.1037/11586-000
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. (1996). Pathways to change in the psychotherapy
of depression: Relating process to session change and outcome. Psychotherapy,
33(2), 262–274. https://doi.org/10.1037/0033-3204.33.2.262
Watson, J. C., & Greenberg, L. S. (2017). Emotion-focused therapy for general-
ized anxiety. American Psychological Association. https://doi.org/10.1037/
0000018-000
Watson, J. C., & McMullen, E. J. (2005). An examination of therapist and client
behavior in high- and low-alliance sessions in cognitive-behavioral therapy
and process experiential therapy. Psychotherapy, 42(3), 297–310. https://
doi.org/10.1037/0033-3204.42.3.297
Watson, J. C., & Prosser, M. (2002). Development of an observer-related
measure of therapist empathy. In J. Watson, R. Goldman, & M. Warner (Eds.),
Client-centered and experiential psychotherapy in the 21st century: Advances in
theory, research, and practice (pp. 3030–314). PCCS Books.
Watson, J. C., Steckley, P. L., & McMullen, E. J. (2014). The role of empathy in
promoting change. Psychotherapy Research, 24(3), 286–298. https://doi.org/
10.1080/10503307.2013.802823
Webb, T. L., Miles, E., & Sheeran, P. (2012). Dealing with feeling: A meta-
analysis of the effectiveness of strategies derived from the process model of
emotion regulation. Psychological Bulletin, 138(4), 775–808. https://doi.org/
10.1037/a0027600
Webster, M. (2019). Emotion-focused psychotherapy: A practitioner’s guide. The
Annandale Institute.
Weiss, J., Sampson, H., & Mt. Zion Psychotherapy Research Group. (1986). The
psychoanalytic process: Theory, clinical observations, and empirical research.
Guilford Press.
Weston, J. L. (2018). Protection from dangerous emotions: interruption of emotional
experience in psychotherapy [Unpublished doctoral dissertation]. York Uni-
versity. https://yorkspace.library.yorku.ca/xmlui/bitstream/handle/10315/
34982/Weston_Janice_L_2018_PhD.pdf?sequence=2&isAllowed=y
352 • References

Whelton, W. J. (2004). Emotional processing in psychotherapy: Evidence across

therapeutic modalities. Clinical Psychology & Psychotherapy, 11(1), 58–71.
https://doi.org/10.1002/cpp.392
Whelton, W. J., & Greenberg, L. S. (2000). The self as a singular multiplicity:
A process-experiential perspective. In J. C. Muran (Ed.), Self-relations in the
psychotherapy process (pp. 87–110). American Psychological Association.
https://doi.org/10.1037/10391-004
White, R. W. (1959). Motivation reconsidered: The concept of competence.
Psychological Review, 66(5), 297–333. https://doi.org/10.1037/h0040934
Wile, D. B. (1992). Couples therapy: A nontraditional approach. John Wiley & Sons.
Williams, J. M. G., Barnhofer, T., Crane, C., Herman, D., Raes, F., Watkins, E.,
& Dalgleish, T. (2007). Autobiographical memory specificity and emotional
disorder. Psychological Bulletin, 133(1), 122–148. https://doi.org/10.1037/
0033-2909.133.1.122
Wingfield, A. H. (2010). Are some emotions marked “whites only”? Racialized
feeling rules in professional workplaces. Social Problems, 57(2), 251–268.
https://doi.org/10.1525/sp.2010.57.2.251
Winnicott, D. W. (1965). The maturational processes and the facilitating environ-
ment. International Universities Press.
Wong, C. F., Schrager, S. M., Holloway, I. W., Meyer, I. H., & Kipke, M. D. (2014).
Minority stress experiences and psychological well-being: The impact of
support from and connection to social networks within the Los Angeles
House and Ball communities. Prevention Science, 15, 44–55. https://doi.org/
10.1007/s11121-012-0348-4
Ye, Z. (2002). Different modes of describing emotions in Chinese: Bodily changes,
sensations, and bodily images. Pragmatics & Cognition, 10(1–2), 307–339.
https://doi.org/10.1075/pc.10.12.13ye
Yeomans, F. E., Clarkin, J. F., & Kernberg, O. F. (2015). Transference-focused
psychotherapy for borderline personality disorder: A clinical guide. American
Psychiatric Publishing. https://doi.org/10.1176/appi.books.9781615371006
Zimbardo, P. G., Ebbesen, E. B., & Maslach, C. (1977). Influencing attitudes and
changing behavior: An introduction to method, theory, and applications of social
control and personal power (2nd ed.). Addison-Wesley Publishing Company.
Index

A
Abandonment, 229, 262, 272–274 and narrative construction, 314
Abuse. See Childhood abuse and neglect and needs, 225
Accelerated experiential dynamic therapy, 41 in synthesis of new experience, 65
Accentuation pattern, 129 Activation (generally)
Acceptance of emotional experience, 172
and awareness, 35 of emotion schemes, 27, 31–33
in changing emotion with emotion, 67 with empathic evocation, 132
in emotional regulation, 290–291 of memories, 6, 75, 244, 246, 251, 295
facilitation of, 8 of needs, 230
in productive emotional processing, 44 Activation of emotion
psychopathology symptoms and, 282, by body expression, 72–73
283 for emotional change, 40
and sitting with emotion, 99 exercising caution with, 6
Acceptance-based models of change, 61 exploration for, 155
Accessing emotions. See also Activation of regulation vs., 286–287
emotion selecting adaptive emotion for, 67–68
in changing emotion with emotion for self-interrupting clients, 171–173
model, 63–64, 68 Adams, K. E., 54, 126
difficulties with. See Blocks to emotion Adaptive emotions. See also Primary
and emotion schemes, 28 adaptive emotions
for emotion transformation, 7 accessing, 63–64, 68
in expressive enactments, 72–73 defined, 24
primary emotions, 26, 50, 69 emotional change after denying, 68–69
as result of accessing needs, 236–238 in leaving phase, 33
with therapist or in therapy recognizing, 128
relationship, 73–74 selecting, for activation, 67–68
in two-chair enactments, 199 and treatment outcomes, 48–49
in wounded child work, 254–255 Adaptive needs, 47–48
Accessing needs, 228, 231–241, 265 Adaptive unconscious, 28
Action, narratives in landscape of, Affect. See also Empathic attunement to
125–126, 255, 312, 313, 320 affect
Action tendency for emotional change, 44
emotion as, 18–19, 309 emotions, feelings, and, 17–18
mobilizing agency based on, 230 negative affect syndrome, 56–57
353
 
354 • Index

Affective resonance, 115 appropriateness of expressing, 103–104

Affective theory, 226–227 gender and expression of, 107
Affect phobia approach, 61 as instrumental emotion, 25
Affect regulation nonverbal behaviors indicating, 199
automatic, 280, 281, 283, 284 positive and negative interpretations
emotion regulation vs., 280 of, 105
with empathic attunement, 121 as primary adaptive emotion, 26
in needs development, 221–224 race and expression of, 108
system for, 21–22, 225 regulation of, 287–288
Affiliative stance, 99 as secondary emotion, 25, 175
Affirmation, empathic, 132 self-interruption of, 178
African Americans, 108, 109, 111, 112 survival aim of, 221–222
Agency transformation of, 8, 65
with feeling vs. inhibiting emotions, treatment outcome and expression of,
20–21, 162 41
for needs activation, 230, 241 unblocking, 205–215
in productive emotional processing, 44 undoing fear with, 66
and same old story, 319–320 vulnerability experienced as, 174
for self-interrupting clients, 168, 183, 197 Anger disease, 102
in two-chair enactments, 199 Anglo Saxon culture, 111
Age regression work, 262–270. See also Angus, L. E., 312, 319
Wounded child work Anxiety
case example, 265–270 changing emotion with emotion to
described, 243 relieve, 76–89
developing capacity to care for the self emotion regulation and, 281, 282
in, 264–265 process-outcome studies of emotion
episodic memories in, 244 work for, 52
imaginal reentry and transformation sense of self associated with, 36–37
in, 263 two-chair enactment for client with,
speaking as child vs. speaking to child 201–202
in, 263–264 unblocking emotion to relieve, 204–215
wounded child metaphor in, 254, 256 Anxiety disorders, 4, 5, 41
Aldao, A., 282 Anxiety management, 287
Alexander, F., 5, 62 Appraisals, 28–29, 224–225
Alexithymia, clients with Approach emotions, 8, 65–66
blocks to emotion for, 163–164 Arousal, emotional, 152–158
creating space for feelings with, 167 and autobiographical memory, 247
culture and prevalence of, 102 in changing emotion with emotion
empathic conjectures for, 136–137 model, 48, 68
teaching words for emotion to, 164–167 culture and value of, 102
therapist as surrogate for experiences and emotional processing style, 130
of, 165–166 measuring, 155–158
treatment process for, 162 memories evoked by, 249–250
unstructured homework on identifying regulation of, 68
emotions for, 166–167 stimulation of, 153–154
Allegiance bias, 40 and therapeutic change, 53
Alliance, therapeutic, 8, 94, 106–107, timing of emotional processing and, 51
123–125 and treatment outcome, 41, 43, 45–47,
American Psychiatric Association, 5, 324 56
Amygdala, 19, 30, 250, 252, 295 working with felt sense vs., 152–153
Anger Arriving phase, 34–36
accessing, as new emotion, 72 accessing memories in, 246
as approach emotion, 8 case example, 77–84
 Index • 355

in changing emotion with emotion, 63 in changing emotion with emotion

core therapist skills in, 13 model, 68
described, 34 effects of, 184–185
empathic attunement to affect in, 115 experiential, 35–36, 61
with painful emotion scheme, 32–33 psychopathology symptoms and, 282,
problem stories in, 319–320 283
transdiagnostic processes in, 53 as response to vulnerability, 177–180
Articulation in self-interruption of emotion, 171
narrative, 314, 317 Awareness
of needs, 228 in arriving phase, 34–36
Asian Americans, 111 of aversion to emotion, 189, 191
Assertion, cultural influences on, 103 emotional, 34–36, 168, 171, 172, 293,
Attachment 294
and emotion dysregulation, 293 for emotion regulation, 291, 294
fear of damage to, 176, 193, 194 empathic exploration to guide, 132–133
as motivation, 222, 223 exercises for building, 293
with therapist, 295–296 present-centered, 119, 144–145
Attention as principle of emotional change, 33
for emotion regulation, 282 of purpose of self-interruption, 189,
to internal emotional signals, 136 191, 193–194
in narrative construction, 314–315 self-awareness of therapist, 96–97
to nonverbal behavior, 158–159 of self-interruption processes, 168, 189,
to present experience, 144–151 191–193
in productive emotional processing, 43 and therapeutic change, 53
questions promoting, 317–318 in two-chair enactment, 197, 199
to subdominant emotions, 71 of unmet needs, 226
in two-chair enactments, 199
Attitude, 13, 56
B
Attunement to affect. See Empathic
attunement to affect “Bad me” sense of self, 36–37
Auszra, L., 43 Barlow, D. H., 56–57
Authenticity, 95, 97 Basic emotions, 24, 31–32
Autobiographical memory, 244–249, 252, Bedard, D. L., 45
320 Behavioral approaches, 6, 285
Automatic affect regulation, 280, 281, Behavior of client, therapist feelings and,
283, 284 94–95
Automatic generation of emotion Berkowitz, L., 55, 72
(automatic emotions), 19, 293–304 Betrayal, 251–252
building new meanings and behaviors Biases, 40, 223, 224
to address needs, 300–304 Biological drives, needs vs., 221
case formulation for treating, 299–300 Bion, W. R., 119
cognitively derived emotion vs., 25 Blame, 25, 238–241, 296
corrective relationship and environment Blocks to emotion, 161–186
for, 293–296 challenges in working with self-
and dynamic emotional response, 30 interrupting clients, 180–183
and empathic clarification, 296–299 for clients with alexithymia, 163–164
Automatic transformational self-soothing, effects of self-interruption, 183–185
284–285 experiencing blocked emotions,
Aversion to emotion, awareness of, 189, 168–169
191 helping recognize self-interruptions,
Avoidance 168–180
alliance building with clients who use, improving ability to tolerate emotions,
123–125 202–204
356 • Index

for self-interrupting clients, 167–168 Cerebral cortex, 30

teaching words for emotion to Chair dialogues. See also Two-chair
overcome, 164–167 enactments
unintentional, 216 for emotional regulation, 302–304, 306
in wounded child work, 255 empty-chair dialogues, 258–259, 303
Bodily expression for soothing wounded child, 257, 258
in communication, 20 Change. See also Emotional change;
emotional activation and, 72–73 Therapeutic change
in empathic attunement to affect, models of, 60–62
116–117 narrative, 318–319
mood and, 55–56 neuronal, 65–66
Bodily felt experience, 143–160 personal, 312–313
as bridge from present to past, 270–276 social, 108–111
with emotional arousal and expression, Change stories, 320
152–158 Changing emotion with emotion, 7, 47–51,
in empathic attunement to affect, 120 59–90
following internal track through, 126, in affect regulation, 280
127 case example, 76–90
guiding attention to present experience defined, 59
with, 144–151 expanding emotional response
meaning making from, 316 repertoire for, 62–68
measuring depth of experiencing by, focusing and expressive action in,
151–152 152–153
in narrative construction, 314 memory reconsolidation in, 74–76
and narrative–emotion relationship, 311 models of change, 60–62
and nonverbal behavior in body work, for painful emotions, 20–21
158–160 paths to emotional change, 68–70
precursors to vulnerability in, 181 research on, 54–56
for self-interrupting clients, 173, 174, self-organization for, 71–74
176 in unified view of emotional change,
Bodily sensed awareness, 35 323
Body work, 158–160 withdrawal and approach emotions in,
Borderline personality disorder, 5, 6, 8, 65–66
281–283 Childhood abuse and neglect
Boritz, T., 247 accessing of needs by survivors of,
Bottle-up, blow-up effect, 68, 286 234–236, 238–241
Boundary-setting, cultural influences on, emotional dysregulation due to, 299
103 as marker for age regression work, 262
Brain stem, 153 unmet needs arising from, 229
British culture, 111 wounded child work with survivors of,
Brown, Brené, 100 253, 259–261
Buck, R., 224–225 Childhood memories, activation of, 6, 295
Buddhism, 119, 139, 144 China, 92
Choi, E., 102
Choose, motivation to, 289–290
C
Chronic stress, 110–111
Canada, 102 Classification of Affective-Meaning States,
Caring for the self, 264–265 48
Carryer, J. R., 46–47 Clearing space, 149, 167, 292
Case formulation, 139–140, 299–300 Client-centered therapy, 54, 148
Catastrophic expectations, 170, 176 Client Emotional Arousal Scale-III-R, 46,
Cathartic venting, 41 130, 155–158
CBT. See Cognitive behavior therapy Client emotional productivity, 42–43
 Index • 357

Client-guided internal search, 126–127 Controlling behaviors

Close friend intervention, in age regression bringing awareness to, 192–193
work, 258, 264 effects of, 184–185, 195
Coconstruction of experience, 124–125, 261 in response to vulnerability, 177–178
Cognition, emotional change and, 44, 66 self-interruption of emotion with, 170,
Cognitive approaches to deliberate 171
emotion regulation, 282, 285 in unresolved self-interruption, 197
Cognitive articulation of needs, 228 Coombs, M., 40
Cognitive behavior therapy (CBT), 40 Coping strategies
effectiveness of emotion-focused blocking emotions as, 162
therapy vs., 40 clients with dysfunctional, 296–299
emotion-focused, 324 deliberate coping regulation, 281–283
models of change in, 61 and wounded child work, 254–255
therapeutic presence in, 54 Corrective emotional experience
and unified approach to emotional in changing emotion with emotion, 7, 62
change, 326 of emotional regulation at automatic
Cognitive control, 170, 178 level, 293–296
bringing awareness to, 192, 193 as principle of emotional change, 33
effects of, 185 for therapeutic change, 5
in unresolved self-interruption, 197 in therapeutic relationship, 73–74, 295
Cognitively derived emotions, 25 undoing emotion with, 66
Cognitive map, 188 Counterproductive behavior, 137–138
Cognitive schemes, 27 Couple therapy, 51, 100, 104
Cognitive theory, 60 Crocodile tears, 25
Collaboration, in case formulation, 140, 299 Culture(s)
Collectivist cultures, 101, 105, 259 and appropriate emotions, 103–104
Comfort, 234–236, 292–293 and emotional responses, 101–103
Common factors approach, 324–326 helping clients find own solutions based
Communication, 19–20, 120–121, 143 on, 106
Comorbidity prevalence, 4 and rules of emotional expression,
Compassion 104–108, 325
in age regression work, 262–263, self, emotion, and, 101–102
265–270 universal action tendency across, 18–19
chair dialogues to increase, 303 universality of emotion work across,
in changing emotion with emotion, 77 92–93
in empathic attunement to affect, 139
internalization of, 284
D
in wounded child work, 257–258
Competing plotlines, 321 Damasio, A. R., 17, 311
Complex emotional states, 31–33 Dangerous emotions, 171–172, 274–276
Complex feelings, 24 Daros, A. R., 282
Comprehensiveness, in congruence, 98 Darwin, C., 64
Conditioned stimulus, 252 Death, fear of, 176, 177
Confrontation, 137–138, 238–241, 296–298 Debriefing, in age regression work, 263
Congruence, 44, 97–99 Declarative memory, 246–249
Conjectures, empathic, 133–137, 297, 320 Deficits in learning, blocks due to, 161
Conscious thought, in needs evaluation, Deliberate emotion regulation, 280–285
229–230 Denial, of adaptive emotion, 68–69
Control Depletion, 183–184
of actions vs. emotional experiences, 36 Depression
and Client Emotional Arousal Scale III-R, changing emotion with emotion to
157 treat, 49
fear of loss of, 107, 176, 194 disorder-specific treatments for, 324
358 • Index

emotion regulation and, 281, 282 Divided self, 168, 169, 177, 183
episodic memory retrieval and, 247 Doan, S. N., 22
process-outcome research on, 40, 43, Dominant culture therapists, as social
45, 56 change agents, 108–110, 112
process similarities for anxiety disorders Dormitive motivation, 222
and, 4 DSM-5 (Diagnostic and Statistical Manual
two-chair enactment for client with, of Mental Disorders, fifth edition,
201–202 American Psychiatric Association),
unblocking emotion for client with, 5, 324
205–215 Dynamic emotional response, 30–31
Depth of experiencing Dysregulated emotions
internal tracking to increase, 126 addressing, 285–288
measuring, 151–152 and attachment, 293
for self-interrupting clients, 181 case formulation for treating, 299–300
in semantic vs. episodic memories, defined, 24, 285
245–246 empathic clarification for clients with,
and therapist process, 54 296–299
and treatment outcome, 45
Depth of Experiencing (EXP) scale, 42,
E
130, 151–152
Deserving, feeling of, 227–230, 241 East Asian culture
Desire(s) emotional expression in, 102, 103, 105,
to allow emotion, 189–191, 196 107
and needs, 223, 224 emotion work with clients from, 259,
self-reflective valuation of, 229–230 272
Destructuring negative beliefs, 37 interdependent self in, 101
Detachment, therapist, 96–97 Eating disorders, 205–215, 281, 282
Developmental psychopathology, 326–327 Eclecticism, 325
Diagnostic and Statistical Manual of Mental EFT. See Emotion-focused therapy
Disorders, fifth edition (DSM-5, Elliott, R., 39–40, 131
American Psychiatric Association), Embodied emotion, 18
5, 324 Emotion(s). See also specific types
Dialectical constructivist view of emotion, affect, feelings, and, 17–18
111 appropriate, 103–104
Dialogical interventions. See Chair defining, 17
dialogues functions of, 18–20
Diary, tracking emotions in, 165, 166 interdependence of motivation and,
Diener, M. J., 6 224–225
Differential treatment approach, 324–325 mastery over, 74
Differentiation, 44, 203, 315 narrative markers of, 319–321
Direct instruction, on self-soothing, 283–284 reason vs., 21
Disclaimed emotions, path to change for relationship of narrative and, 311–312
client with, 69–70 self-disclosure of, by therapist, 91, 93–99
Discomfort, 108, 194–195 self-states and, 23
Discovery-oriented phase of task analysis, sitting with all types of, 91–92, 99–104
187–188 targeting, 5–6, 287–288
Discovery stories, 321 Emotional change, 39–57. See also
Disgust, 222 Changing emotion with emotion
Disorganized clients, 136–137, 303–304 activation and expression of emotion,
Dissociation, 184, 303 40–42
Distancing, in Eastern culture, 107 case example of focusing and, 149–151
Distraction, 282, 288–289 in changing emotion with emotion,
Distress tolerance, 288–289 54–56
 Index • 359

and narrative change, 318 process-outcome studies of, 41, 45, 51

principles of, 33–34 therapeutic presence in, 54
process-outcome studies of, 42–53 therapeutic relationship in, 6
sensing, 9 Emotion-friendly attitude, 13
task analysis to identify, 4 Emotion labeling, 166, 293
therapist process and, 53–54 Emotion log, 166–167
unified view of, 279, 323–327 Emotion-oriented treatments, 3–13. See also
Emotional competence, 163–167, 229–230 specific topics, e.g.: Therapist skills for
Emotional experience emotion-based approaches
body expression and intensity of, 55–56 across cultures, 92–93, 259, 272
in changing emotion with emotion, 63 alliance in, 123
coconstruction of, 261 with anxiety, 52
emotion schemes and, 29 body work in, 158
limited, 171, 183–185 empathic attunement in, 103, 146
mastery over, 74 framing rationale for, 231–234
and resolution of interpersonal mobilizing agency in, 230
difficulties, 51 phases of, 34–38
as therapeutic focus, 12 process-oriented approach to, 8–9
and therapeutic progress, 44–47 training on, 3–4
in transformational self-soothing, transdiagnostic transtheoretical
284–285
approach to, 3
treatment outcome and intensity of, 46
vulnerability in, 100
universality of, 104
Emotion schemes, 26–33
working on relationship to one’s
activation of, 31–33
emotions vs., 12
in case formulation, 299
Emotional exploration, 40, 127, 136, 155
changing, in therapy relationship,
Emotional history, therapist’s, 95
73–74
Emotional processing model of change, 60
in changing emotion with emotion
Emotional reactivity, 285
model, 89
Emotional response
development of need and, 220, 224
modulation of, 7, 287
Emotional response(s) dynamic nature of emotional response,
culture and, 101–103 30–31
dynamic nature of, 30–31 episodic memories to access, 244
expanding repertoire of, 62–68 exploration of, 155
to memories, 249–250 formation of maladaptive, 28
motivation to choose, 289–290 memory reconsolidation of, 80, 250–252
teaching clients to recognize, 164 models of change involving, 60, 62
of therapist, 97–99 and procedural memory, 246
in wounded child work, 253 and self-organization, 27–29
Emotional state, 31–33, 121, 122 in synthesis of new experience, 65
Emotional voice, 129 Emotion theory, 17–38
Emotion Category Coding System, 49 action tendency in, 18–19
Emotion episodes, moods vs., 24 and emotion types, 23–26
Emotion-focused CBT approach, 324 expression in, 19–20
Emotion-focused therapy (EFT) information in, 19
accessing maladaptive emotions in, and phases of emotion work, 34–38
254–255 principles of emotional change, 33–34
for anxiety, 52 schematic memory in, 26–33
and changing emotion with emotion therapeutic implications of, 20–23
model, 49 therapist understanding of, 13
experiential work in, 144 Emotivation, 225
meta-analysis on effectiveness of, 39–40 Empathic affirmation, 132
360 • Index

Empathic attunement to affect, 115–142 Experiential state, 28

bridging to past with, 270 Experiential training, 92
case formulation and, 139–140 Exploration
of clients with alexithymia, 164–166 emotional, 40, 127, 136, 155
and cultural sensitivity, 103 empathic, 132–136, 320–321
defined, 115 making subjective experience available
effects of, 121–123 for, 312–313
experience of, 120–121 Exposure therapy, 41
focusing on bodily felt sense in, 146 Expression of emotion
outcome research on, 53–54 appropriate, 103–104
and surrogacy for clients’ personal culture and, 103–108, 325
experiences, 165–166 for emotional change, 33, 40–42
therapeutic presence for, 118–119 as function of emotion, 19–20
therapist skills required for, 123–139 process-outcome studies of, 44–47
training on, 141 promoting exploration of, 155
and types of empathic responses, 131 in resolution of self-interruption,
Empathic clarification, 296–299 189–191
Empathic conjectures, 133–137, 297, 320 and societal oppression, 107–108
Empathic evocation, 132 stimulating arousal for, 152–155
Empathic exploration, 132–136, 320–321 therapeutic outcome and, 6
Empathic reflection, 172, 297 by therapist, 44, 93, 95
Empathic refocusing, 133 Expressive action, 152–155
Empathic responses, 6, 131–137 Expressive enactments, 72–73
Empathic understanding, 22, 97, 115–116, Externally oriented thinking (EOT), 102
131–134 External narrative mode, 312, 313
Empathic validation of needs, 137–138 External processing of memory, 248, 249
Empathy, internalization of, 281 External tracking, 125–126
Empirical analysis, 188 External voice, 129
Empowerment, 203–204 Extinction, 60, 61, 76, 252
Empty-chair dialogues, 258–259, 303 Eye gaze, 9, 159. See also Nonverbal
Empty story, 320 behavior
Enactments. See also Two-chair enactments
of compassion, 263
F
expressive, 72–73
of self-interruption, 192–193 Facial expression. See also Nonverbal
Encouragement, from therapist, 189–192 behavior
Entitlement to need, 230 and affect regulation, 121, 122
EOT (externally oriented thinking), 102 for alexithymic patients, 164–165
Episodic memory, 132, 244–245, 247–249, attunement to, 121, 295
256 as indicator of emotional change, 9
Ethics (Spinoza), 7 Facilitative congruence, 97–98
Evidence-based treatment movement, 326 Facilitative emotional responses, 97–99
Evocation, empathic, 132 False self, 254
Evolutionary basic emotions, 24, 31–32 Fear (generally)
Excuses, making, 150–151 action tendency in, 18
EXP. See Depth of Experiencing scale as primary maladaptive emotion, 26
Experiential avoidance, 35–36, 61 as secondary reactive emotion, 182–183
Experiential dynamic therapy, 41 for self-interrupting clients, 172, 173
Experiential processes, in changing self-states associated with, 23
emotion with emotion, 62 sense of self associated with, 36–37
Experiential response, insight-oriented survival aim of, 221–222
vs., 144 transformation of, 65, 66, 70, 72
Experiential self, 22 treatment outcome and expression of, 41
 Index • 361

unmet needs associated with, 228 Following, by therapist, 64, 127, 131
as withdrawal emotion, 8 Fragile personalities, clients with, 243,
Fear of abandonment, 272–274 285, 296
Fear of being overwhelmed by emotion, Frank, Jerome, 326
172, 173, 193 Frankl, Viktor, 289
Fear of consequences of emotion, 36, 173, Fredrickson, B. L., 55
175–176 French, T. M., 5, 62
Fear of damage to identity/attachment, Freud, S., 28, 254
176, 193, 194 Freund, R. R., 6, 44
Fear of danger, 274–276 Frijda, N. H., 18
Fear of death, 176, 177 Frustration, need, 226–227
Fear of emotion
and awareness of interruption, 193–194
G
reducing, in resolution of self-
interruption, 189–192, 195–196 GAD (generalized anxiety disorder), 52,
for therapists, 100 200
universality of, 107 Geller, S. M., 54, 119
validation of, 182–183 Gender differences, in emotional
Fear of expression of emotion, 176–177 expression, 107
Fear of loss of control, 107, 176, 194 Gender nonbinary individuals, 101
Fear of unknown, 176, 177 Gendlin, E. T., 145, 314
Feelings Generalized anxiety disorder (GAD), 52,
affect, emotions and, 17–18 200
body. See Bodily felt experience Germany, 104–105
complex, 24 Gestalt therapy, 54, 119, 131, 144, 290
creating space for, 167 Gestures, 158, 159
impact of disclosing, on therapy Ghana, 102
relationship, 94 Goldfried, M. R., 5, 62, 90
narratives in landscape of, 125, 126, Goldman, R. N., 45, 139–140
128, 255, 312, 313, 320 Graded exposure to blocked emotions,
symptomatic, 25 202–203
Felt sense, 120 Greenberg, L. S., 42, 43, 46–48, 51, 54,
for alexithymic patients, 164–165 55, 60–61, 119, 126, 130, 131,
and attention to present experience, 139–140, 155, 157
146–148 Grief, 48, 265
in focusing approach, 145–146, 149 Grounded theory, 169
working with emotional arousal vs., Guilt, 182
152–153
Fire disease, 102
H
Five-phase sequence of emotion
processing, 20 Harlow, H. F., 225
Flack, W. F., Jr., 55, 73 Heartfelt needs, 228, 231–241
Foa, E. B., 60 Hebb, D. O., 65
Focused voice, 129 Hedonism, 225
Focusing approach HEP (humanistic–experiential therapies),
case example, 149–151 39–40, 61
depth of experiencing and, 151–152 Herrmann, I. R., 49–50
described, 145–146 Historical trauma, 111
effectiveness of techniques, 148–149 History, emotional, 95
expressive action vs., 152–153 Hofmann, S. G., 22
and expressive stimulation, 155 Homework, on identifying emotions,
felt sense in, 147 166–167
with self-interrupting clients, 182 Hong Kong, 106
362 • Index

Hopelessness, 25 Internal critic, 238–241, 302, 306. See also

Humanistic approaches, 6 Self-criticism
Humanistic–experiential therapies (HEP), Internalization, 281, 284–285
39–40, 61 Internal narrative mode, 312, 313
Hurt, vulnerability experienced as, 174 Internal processing of memory, 248, 249
Hwa-Byung (anger disease), 102 Internal tracking, 125–128, 132–133
Interpersonal difficulties, resolving, 51,
106
I
Interpersonal process recall, 171, 182
Iberg, J. R., 148 Interpersonal stance, 98–99
Identifying emotions, homework on, Interpersonal therapy, 40
166–167 Interruption of emotion. See Self-
Identity interruption of emotion
fear of damage to, 176, 193, 194 Intrinsic needs, 221–224
narrative and, 312, 314, 317
of self-critic, clarifying, 110
J
Ignoring behavior, 271–274
Imagery James, William, 22, 144
activation of emotional experience by, James–Lange theory of emotions, 73
172 Japan, 101, 103–107
emotion awareness exercise using, 294 Jones, E. E., 40
for self-soothing, 291–292, 305 Jurist, E., 7
Imaginal exposure, 51
Imaginal reentry, 263
K
Imaginal transformation
in age regression, 256, 262, 263 King John (Shakespeare), 65
for emotional regulation, 300–302 Kitayama, S., 102
Imaginative identification, 117, 120 Klein, M. H., 151
Implicit processes, in emotion work, 28 Korea, 102
Inborn biases, 223, 224 Kozak, M. J., 60
Inchoate stories, 321
Independent self, 101, 103
L
Indigenous cultures, 107, 111
Indirect communication, 103 Latinx culture, 111
Individualist cultures, 105 Leading, by therapist, 64, 131, 133
Individual therapy, 104 Learning
Inferences, in empathic conjectures, 133 deficits to, and blocks to emotion, 161
Information, emotion as, 18, 19 and emotion schemes, 27
Inhibition, of emotion, 162, 167. See also procedural, 62
Self-interruption of emotion (SIE) to regulate emotions, 293
In-session markers Learning theory, 60, 226
of narratives, 319 Leaving phase, 36–38
of self-interruption, 169–171 case example, 84–89
Insight-oriented model of change, 61, 246 change stories in, 320
Insight-oriented response, 144 in changing emotion with emotion
Instrumental emotions, 24, 25, 287 model, 63
Integration, for resolution of self- described, 34
interruption, 189, 191 maladaptive feelings in, 8
Integrative psychotherapy, 325–326 new lived experience in, 246
Intensive short-term dynamic therapy, 41 with painful emotion scheme, 32–33
Interdependent self, 101, 103–104 transdiagnostic processes in, 53
Interfering behaviors, 107 LeDoux, J. E., 19
 Index • 363

Leijssen, M., 148–149 Meaning creation, 300–304

Levinas, E., 122 in development of needs, 221–224
Levine, P., 159 with emotions, 19, 311
Levy Berg, A., 159 from emotion schemes, 28
Lewin, J. K., 249 with narratives, 309–311
Liking new feelings based on, 73
acceptance vs., 291 questions promoting, 318
need to be liked, 234–236 symbolizing for, 166, 316
Limbic system, 30 Medication, for emotion regulation, 288
Limited emotional experience, 171, 183–185 Memory(-ies). See also Emotion schemes
Limited voice, 129 activation of emotional experience by,
Lived experience, acknowledging other’s, 172
110 autobiographical, 244–249, 252, 320
Long-term consequences of self-interruption, in changing emotion with emotion
194–195 model, 64
declarative vs. procedural, 246–249
and development of needs, 224
M
emotional response to, 30
Magnavita, J. J., 326 episodic, 132, 244–245, 247–249, 256
Maladaptive emotions. See also Primary narratives and, 312, 313
maladaptive emotions new feelings based on, 73
as basis for mental disorders, 325 recognition vs. recall, 137
defined, 24 in resolution of self-interruption, 189
disclaiming, and path to emotional semantic, 244–246
change, 69–70 Memory consolidation, 74, 75
in leaving phase, 36 Memory reconsolidation. See also
transformation of, 8, 219 Reconsolidation theory
undoing of, 66–67 for changing emotion with emotion,
in wounded child work, 254–255 74–76
Managing emotions, as focus of therapy, 12 for emotion transformation, 7
Manipulative emotion, 25. See also introducing clients to, 124
Instrumental emotion reexperiencing the past with, 249–252
Markers Mental disorders. See also specific disorders
for age regression work, 262 dysfunctional emotion processing in, 20
defined, 140 emotional regulation and, 279, 285
for focusing, 146 emotional suppression and, 42
of narratives, 319 emotion regulation and, 281–282
of self-interruption, 169–171 limited emotional awareness in, 168
specifying, in task analysis, 188 maladaptive emotions as basis for, 325
Markus, H. R., 102 Mentalization, 288
Masculinity, 112 Mentalization-based therapy, 6
Maslow, A. H., 226 Merleau-Ponty, M., 120
Mastery, 74, 222–223 Metaexperience, 117–118
McCullough, L., 61 Middle zone of awareness, 119
McKinnon, J. M., 51 Mindfulness, 119, 145
McMullen, E. J., 54 Mirroring, 116–117
Meaning Mirror neurons, 117, 141
checking fit of, in focusing, 149–151 Mixed emotional states, 31–33
narratives in landscape of, 255, 312, 320 Model explanation, in task analysis, 188
for self-interruption of emotion, 179 Modulation, of emotional response, 7, 287
semantic, 19–20 Moment-by-moment experience
in semantic, autobiographical, and empathic attunement to, 116, 128
episodic memory, 245 in mindfulness, 145
364 • Index

outcome research on, 54 markers of emotion in, 319–321

therapeutic presence in, 118–119 meaning making with, 309–310
understanding client’s, 8 narrative construction, 314–319
Mood, 24, 55–56 off-topic, 138
Mood-dependent memories, 246 relationship of emotion and, 311–312
Mood disorders, 5 treatment outcome and specificity of,
Mood repair, 54 247
Morikawa, Y., 148 in wounded child work, 255
Mother-in-law problem, 106 National Institute of Mental Health, 40
Motivation Needs, 219–241
to allow emotion, 189–191 accessing, 228, 231–241, 265
to choose, 289–290 accessing new emotions and, 63,
and development of needs, 221–223 236–238
dormitive, 222 activating new emotions by focusing on,
interdependence of emotion and, 71–72
224–225 adaptive, 47–48
for self-interruption, 193–194 affect regulation and meaning creation
Movement, body-focused work on, 159 in development of, 223–224
Music, 56 in age regression work, 262, 265
building new meanings and behaviors
to address, 300–304
N
case examples, 231–241
Nader, K., 75 in changing emotion with emotion
Naming emotions, 148, 164–167 model, 47–48
Narrative change, emotion-based, confronting internal critic with,
318–319 238–241
Narrative coding system, 125, 312 defining, 220–227
Narrative construction, 225, 314–319 emotion dysregulation due to, 299–300
articulating narratives, 317 emotion theory implications for,
attending, 314–315 21–22
case example, 318–319 empathic validation of, 137–138
facilitating identity, 317 evaluating worth of, 229–230
facilitating unfolding of narratives, framing therapeutic work in terms of,
317–318 231–234
markers of location in process of, intrinsic, 221–224
319–321 mobilizing agency to activate, 230
symbolizing, 315–316 motivation and development of,
Narrative-Emotion Process Coding System, 221–223
312 naming, 84–85
Narrative processing, therapeutic outcome neural circuits involved in, 224–226
and, 313 reclaiming, 227–231
Narratives, 309–322 in work on childhood abuse and
articulating, 314, 317 neglect, 234–236
autobiographical memory in, 244–245 Need satisfaction, 226–227
case example, 85–89 Negative affect syndrome, 56–57
changing emotion and, 66 Negative emotions, 54–55, 290–291
and development of needs, 224 Negative impact of self-interruption,
effect of memory reconsolidation on, 189–191, 194–195, 197
252 Neglect. See Childhood abuse and neglect
facilitating the unfolding of, 317–318 Neo-Piagetian developmental model of
making subjective experience available change, 60–61
with, 312–313 Neuroception, 122
 Index • 365

Neurons, 65–66 secondary emotions as, 24

New emotions sitting with, 99–100
from imaginal transformation, 301 transdiagnostic approach to working
in memory reconsolidation, 251, 252 with, 4–5
needs in generation of, 225–226 treatment goal of resolving, 140
New experience and unmet needs, 220
accessing needs to access, 236–238 validation of, 72
neuronal change in synthesis of, 65–66 working therapeutically with, 32–33
Nonverbal aspect of blocking, 200 in wounded child work, 254–255
Nonverbal behavior Paivio, S. C., 51
and affect regulation, 121 Paralinguistic communication, 170
in body work, 158–160 Parasympathetic nervous system, 222, 279
of clients with alexithymia, 164–165 Parrott, W. G., 54
empathic attunement to, 122 Pascual-Leone, A., 6, 47–49
expressing emotional arousal with, 154 Past
as markers of self-interruption, 198 bridge from present to, 270–276
in two-chair enactments, 199 influence of, on present, 123, 124
Norway, 92 reexperiencing. See Reexperiencing the
Not-knowing position, for therapist, 131, past
141–142 Paul, G. L., 325
Not otherwise specified diagnoses, 324 Peluso, P. R., 6, 44
Novelty, in memory reconsolidation, 251 People of color, 108–112
No-wonder responses, 132 Perceptual skills, 9, 128–131
Perls, F. S., 131, 226
Personal change, 312–313
O
Personal experiences, surrogacy for
Observer’s perspective, 289–291 clients’, 136, 165–166
Off-topic narratives, 138 Personal history, of self-interrupting
Ogden, P., 159 clients, 181
Openness, 118–119 Personality disorders, 286
Opposition, 171, 174 Personality theory, 326–327
Oppression, societal, 107–108, 110 Personal self-critic, 110
Other-directed blaming, 25 Personal therapy, for therapist, 96–97
Otherness, 112 Persuasion and Healing (Frank), 326
Overregulation of emotion, 285, 286, 320 Phenomenological approach, 9
Overwhelming emotion, fear of, 172, 173, Physical controls, 170, 178, 184–185,
193 192–193
Physical health, emotional regulation and,
290
P
Piliero, S., 41
Pace, vocal, 129–130. See also Vocal Pitch, of voice, 9. See also Vocal features
features Poignancy, indicators of, 128
Pain compass, 140 The Polyvagal Theory (Porges), 121–122
Painful emotions Porges, S. W., 121–122
in arriving phase, 34 Pos, A. E., 45
changing, with emotion, 20–21 Positive emotions, 54–55, 290
empathic responses to explore, 131 Positive framing, 100
impact of memory reconsolidation on, Positive outcome stories, 318
250–251 Positive reinforcement, 226, 227
and mental disorders, 5 Posttraumatic stress disorder, 41, 110–111,
positive reinforcement with responding 286
to, 226, 227 Posture, 9, 159. See also Nonverbal behavior
366 • Index

Preferences, needs and, 223–224 in resolution of self-interruption,

Preliminary model validation, 188 189–191
Prelinguistic narratives, 311 therapist interventions for, 53–54
Presence, therapeutic, 54, 118–119 timing of emotional arousal and, 51
Present and treatment outcome, 42–44
bridge to past from, 270–276 Process-oriented approach, 8–9, 22
guiding attention to, 144–151 Process-outcome studies of emotional
reexperiencing the past in. See change, 42–53
Reexperiencing the past for anxiety, 52
Present-centered awareness, 119, 144–145 experiencing and therapeutic progress,
Present-living mindset, 290 44–47
Primary adaptive emotions, 26 and model for changing emotion with
accessing, 50 emotion, 47–51
in changing emotion with emotion productive emotional processing,
model, 47, 48, 50 43–44
defined, 24 Productive emotional processing, 43–44,
focusing on needs to mobilize, 220 130–131
moving from primary maladaptive Prosser, M., 54
emotions to, 69–70 Protection
moving from secondary reactive emotion accessing unmet needs for, 238–241
to, 68–69 awareness of interruption as, 193–194
regulation of, 287 from dangerous emotions, 171–172,
and treatment outcomes, 49–50 181
Primary emotions (generally) and empathic responses to explore
accessing, 26, 69 painful emotions, 131
defined, 24 in imaginal transformation, 263
facilitative congruent communication inhibition of emotion for, 162
of, 98 negative effects of self-interruption for,
obscuring of, by secondary emotions, 183–185, 189, 191, 194–195
24–25 positive effects of self-interruption for,
self-interruption of, 169–170 185
Primary maladaptive emotions, 26 vagus nerve and, 121–122
in changing emotion with emotion model, in wounded child work, 255–256,
47–48 258–259
defined, 24 Psychodynamic models of change, 61
deliberate regulation of, 281 Psychoeducation
moving to primary adaptive emotions for clients with alexithymia, 162,
from, 69–70 164–167
regulation of, 287 on emotion regulation, 288
transformation of, 66–67 on two-chair enactment, 198–199
and treatment outcomes, 49–50 Psychotherapy
in wounded child work, 255 communication in, 143
Privilege, White, 108–109 insight-oriented, 144
Problem solving, 106, 282, 283 narratives in, 310
Problem stories, 319–320 unified approach to, 323–327
Procedural learning, 62 in unified clinical science, 326–327
Procedural memory, 246–249 Pulos, S. M., 40
Processing of emotions, 8 Pure emotions, 31–32
attending to client’s style for, 128–129
by children vs. adults, 45, 253
Q
dysfunctional, 20
five-phase sequence of, 20 Questioning, in focusing approach, 149,
productive, 43–44 151–152
 Index • 367

R episodic, autobiographical, and

semantic memory, 244–246
Race, emotional expression and, 108 memory reconsolidation, 249–252
Racial trauma, 110–111 wounded child work, 253–261
Racism, 92, 108, 109 Reflection
Rational-empirical model of self- activation of emotional experience by,
interruption resolution 172
allowing emotion and integration, 189, in chair work interventions, 304
191 empathic, 297
awareness of aversion to emotion, 189, as principle of emotional change, 33
191 for valuation of emotions and desires,
awareness of purpose of interruption, 229–230
189, 191, 193–194 Reflective self, 22
awareness of the how of interrupting, Reflexive narrative mode, 125–126, 312,
189, 191–193 313, 316, 317
desire to allow emotion, 189–191, Reflexive processing of memory, 248, 249
196 Refocusing, 133, 297, 298
motivation to allow emotion, 189–191 Reframing, in empathic clarification, 297
realization of negative impact of Regularity of vocal pace, 129–130. See also
interruption, 189–191, 194–195 Vocal features
reduction of fear of emotion, 189, 191, Regulation of emotion, 279–307
195–196 addressing dysregulation, 285–288
support and encouragement from affect regulation vs., 280
therapist, 189–192, 196 capacity for self-soothing, 281–285
and unresolved self-interruption, 190, case example, 304–306
191, 196–197 in changing emotion with emotion
Rational-empirical model synthesis, 188 model, 68
Rational model construction, 188 as core psychological dysfunction, 279
Reactivation, memory, 60, 75, 76, 252 culture and, 102
Reactive emotions. See Secondary reactive emotion activation vs., 286–287
emotion transformation vs., 7–8
emotions
exercising caution with, 6
Reactivity, 96, 285
helping develop client skills for,
Real-world stimulus, emotional response
288–293
to, 30
at level of automatic generation,
Reappraisal, 42, 282, 283
293–304
Reason
narratives for, 313
attempting to change emotion with,
need satisfaction and, 226
64–65 neurological processes in, 19
emotion vs., 21 as principle of emotional change, 33
focusing vs. reasoning, 151 in productive emotional processing, 44
Rebound effect, 286 response modulation vs., 7
Recall memory, 137 targets and methods for, 287–288
Receiving, in focusing approach, 149 Reinforcement, 226, 227
Recognition memory, 137 Relationship
Reconsolidation theory, 59, 61, 75 to one’s emotions, managing, 12
Reentry, imaginal, 263 therapeutic. See Therapeutic
Reexperiencing the past, 243–277 relationship
age regression work guidelines, Relaxation exercises, 292
262–270 Relevance, of self-disclosure by therapist,
bridge to past from present, 270–276 93–94
declarative vs. procedural memory, Reluctance to allow emotion, 190, 191
246–249 Reparative response, 301
368 • Index

Re-parenting, 64 Scripts, procedural memory, 246

“Replacement” of emotion, 66–67 Secondary emotions (generally)
Resignation, 25, 198 in changing emotion with emotion
Resilience, 37, 55 model, 47, 48
Response modulation, 7, 282 cognitively-derived emotions as, 25
Responsiveness, 118–119 defined, 24
Restating, in empathic clarification, 297, obscuring of primary emotions by, 24–25
298 protective function of, 181
Rice, L. N., 129 regulation of, 281, 286–288
Rogers, C. R., 53, 116, 131, 132, 139 in resolution of self-interruption, 190,
Role playing, 56 191
Rumination, 282, 283 in self-interruption of emotion, 169–172,
Rupture, alliance, 94 192
and treatment outcomes, 49
and unmet needs, 220
S
in wounded child work, 255
Sabini, J., 54 Secondary reactive emotions
“Sad me” sense of self, 36–37 addressing, with self-interrupting
Sadness clients, 181–183
adaptive, 220 moving to primary adaptive emotion
as approach emotion, 8 from, 68–69
nonverbal behaviors indicating, 199 regulation of, 299
as secondary reactive emotion, 182 as response to vulnerability, 175–177
sense of self associated with, 36–37 in self-interruption of emotion, 171,
suppression of, 179–180 175–177
survival aim of, 222 Self
unblocking, 205–215 actions against, 167–168
unmet needs associated with, 228 after interruption of emotion, 185
Safety as agent of shutting-down process, 183
and alliance building, 123, 124 capacity to care for, 264–265
and attending to internal emotional caring for, 264–265
signals, 136 culture, emotion, and, 101–102
for clients with alexithymia, 163–164 divided, 168, 169, 177, 183
culture and building sense of, 106–107 emotion theory implications for, 22–23
for developing automatic emotion experiential, 22
regulation, 293 false, 254
imaging safe place to self-soothe, interdependent, 101, 103–104
291–292, 305 and meaning creation, 311
as need, 222–223 reflective, 22
neuroperception of, 122 strength to protect, 258–259
in resolution of self-interruption, 190, as wounded child, 253
192, 195–196 Self-agency, 36–38
and self-interruption of emotion, 174, Self-awareness, 96–97
180 Self-criticism, 105, 110. See also Internal
in therapy relationship, 106–107 critic
Safran, J. D., 60–61 Self-description, 244
Same old story, 313, 319–320 Self-disclosure, 91, 93–99
Satisfaction, need, 226–227 Self-interruption of emotion (SIE). See also
Saving face, 106–107 Rational-empirical model of
Schank, Roger, 312 self-interruption resolution
Schemes, defined, 26–27. See also Emotion and activation of emotional experience,
schemes 172–173
Scherer, A., 41 in arriving phase, 35–36
 Index • 369

awareness of purpose of, 189, 191, Sighing, by patients, 165

193–194 Signaling system, emotion as, 18–20
chair dialogues to end, 302–303 Single-school approaches, 325
challenges in working on, 180–183 Sitting with emotion, 91–92, 99–104
defined, 167–168 being vulnerable, 100
effects of, 183–185 cultural influence on appropriate
helping clients recognize, 168–180 emotions, 103–104
process of, 169–171 influence of culturally-informed views
as protection from dangerous emotions, of on, 101–102
171–172 Situational evocation, of needs, 224
realization of negative impact of, Social anxiety, 52, 67
189–191, 194–195, 197 Social change agent, therapist as, 108–111
unresolved, 190, 191, 196–197 Societal oppression, 107–108, 110
vulnerability of clients who use, Society for the Exploration of
173–180 Psychotherapy Integration, 325
Self-observation, 61 Solutions, helping clients find own, 106
Self-organization Somatization, 102, 159
case formulation based on, 299–300 Soothing. See also Self-soothing
and changing emotion with emotion, by therapist, 74
71–74 of universal child/close friend, 258, 264
and dynamic nature of emotional South Africa, 109
response, 30
Space, for feelings, 149, 167, 292
and emotion schemes, 27–29
Specific disorder approach to diagnosis
self as process of, 22–23
and treatment, 4, 323–325
and transformational self-soothing, 284
Speech patterns, 129–130
Self-soothing
Spinoza, B., 7
building capacity for, 281–285
Stern, Daniel, 22
chair dialogues for, 303
Stress, chronic, 110–111
in changing emotion with emotion, 89
Subdominant emotions, 71
clients who protest, 264–265
Subjective experience, 29, 312–313
direct instruction on, 283–284
and emotional dysregulation, 285 Substance-related disorders, 281, 282
explicitly guiding clients to use, Suffering
291–293 acceptance of, 290–291
for self-interrupting clients, 180–181 alleviation of, in psychotherapy, 4
transformational, 281, 284–285 compassion and, 139
in wounded child work, 257–258 targeting emotion to end, 5–6
Semantic meaning, 19–20 Superficial stories, 320
Semantic memory, 244–246 Support
Sensorimotor awareness, 159 in accessing ability to tolerate blocked
Sensory information, 180, 314–315 emotion, 202
Shakespeare, William, 65 in resolution of self-interruption,
Shame 189–192, 196
bodily felt experience of, 314 in wounded child work, 253
in emotion work on social anxiety, 52 Suppression of emotions, 35. See also Self-
positive and negative interpretations interruption of emotion (SIE)
of, 105 in changing emotion with emotion
as secondary reactive emotion, 182 model, 68
sense of self associated with, 36–37 effects of, 286
transformation of, 65, 70, 219 models of change involving
unmet needs associated with, 228 transformation vs., 61
as withdrawal emotion, 8 psychopathology symptoms and, 282,
SIE. See Self-interruption of emotion 283
370 • Index

treatment outcome and, 41–42, 187 empathic understanding for building,

and two-chair enactment, 197 131–132
Surrogate, therapist as new emotions provided by, 73–74
in personal experience of client, 136, Therapeutic work, needs-based framing of,
165–166 231–234
for protection of client, 258–259 Therapist, new emotions provided by,
Survival 73–74
aim of emotions related to, 221–222 Therapist process, emotional change and,
emotion system’s role in, 19, 21, 223, 53–54
225 Therapist skills for emotion-based
Swedish culture, 111 approaches, 9, 91–112
Symbolizing ability to sit with all types of emotions,
in acceptance, 291 99–104
in focusing, 146–147, 149 empathic attunement to affect, 123–139
in narrative construction, 314–316 essential, 12–13
by patients with alexithymia, 165–166 in role of social change agent, 108–111
in productive emotional processing, 43 and self-disclosure of emotions by
questions promoting, 318 therapist, 93–99
and treatment outcome, 42 understanding rules of emotional
Sympathetic nervous system, 153, 222, expression, 104–108
250, 279 Three-step sequence for changing emotion
Synthesis with emotion, 69–70
of emotion schemes, 27–28 Timing
of new experience, 65–66 of age regression work, 265
Systemic racism, 92, 109 of emotional arousal and processing, 51
of self-disclosure of emotions, 98
of switch to internal narrative mode,
T
313
Task analysis, 4, 169, 187–188 Tolerance, of blocked emotions, 168,
Terminal contours, of speech, 130 202–204
Testing ways of being, 74 Training, 3–4, 92, 118, 141
Thailand, 105 Transcultural frame, for sitting with
Therapeutic alliance, 8, 94, 106–107, emotion, 92
123–125 Transdiagnostic transtheoretical approach
Therapeutic change changing emotion with emotion as, 62,
corrective emotional experience in, 5 90
emotional awareness and arousal for, 53 emotional awareness and arousal in, 53
empathic attunement to affect for, for emotion work, 3, 39
122–123 specific disorder approach vs., 4
implicit processes as target of, 28 therapeutic relationship in, 6
reflexivity and, 316 and unified view of emotional change,
Therapeutic presence, 54, 118–119 323–327
Therapeutic relationship for working with emotional pain, 4–5
building safety and trust in, 106–107 Transference-focused psychotherapy, 6
with clients with alexithymia, 163–164 Transformation
corrective emotional experience in, 295 in changing emotion with emotion
cultural sensitivity and formation of, model, 47–49, 63, 64
106–107 described, 7–9
effect of self-disclosure by therapist on, empathic attunement to affect for,
94–95 122–123
in emotion-focused therapy, 6 at generation of emotion, 281
and emotion regulation, 286–287 imaginal, 256, 262, 263, 300–302
 Index • 371

in leaving phase, 34 Undoing

of maladaptive emotion, 66–67 of blocks to emotion, 197
with memory reconsolidation, 250–251 of maladaptive emotion, 66–67
as principle of emotional change, 33, 34 of negative emotions, 54–55
suppression vs., 61 new emotional experiences with
synthesis of new experience for, 65 therapist for, 73–74
Transformational self-soothing, 284–285 of self-interruption, 168–169, 187–188.
Trauma See also Rational-empirical model of
body-focused work after, 159–160 self-interruption resolution
emotional dysregulation and early, 286 Unexpected outcome stories, 321
emotion work with survivors of, 6 Unhappiness, due to self-interruption,
historical, 111 195
as marker for age regression work, 262 Unhealthy behaviors, emotional regulation
racial, 110–111 with, 289
Trauma narrative retelling, 319 Unified approach to psychotherapy, 39,
Trust, 106–107, 164 56–57, 323–327
Truth, felt sense and, 147–148 Unified clinical science, 326–327
Tugade, M. M., 55 Unified view of emotional change, 279,
Turkey, 92–93, 104–105 323–327
Two-chair enactments, 55 United States, 101, 103
accessing ability to tolerate blocked Universal child, soothing, 258, 264
emotion with, 204 Unmet needs. See Needs
addressing self-interruption with, Unresolved feelings, in wounded child
179–180, 183 work, 256, 276
and awareness of interruption process, Unresolved self-interruption, 190, 191,
192–193 196–197
for emotional regulation, 302–304 Unresolved suffering, 284–285
markers in, 198 Unstoried emotions, 315, 320
unblocking emotion with, 197–202 Untold stories, 320–321
Two-stage treatment framework, for
emotion dysregulation, 283–284
V
Two-step sequence for changing emotion
with emotion, 68–69 Vagus nerve, 121–122
Validation
and acceptance of emotions, 291
U
in age regression work, 262
Unblocking emotion, 187–216 building alliance with, 123
of anger and sadness, 205–215 of client needs, 137–138, 219–220, 226,
and improving ability to tolerate 262
blocked emotions, 202–204 empathic, 132, 137–138
resolution of self-interruption, 189–196 of painful emotions, 72
two-chair enactments for, 197–202 preliminary, in task analysis, 188
understanding unresolved self- for reduction of fear of emotion,
interruption, 196–197 195–196
Unconditional regard, 139 of secondary emotions, 181–182
Unconditioned stimulus, 252 for self-interrupting client, 181–183
Unconscious, adaptive, 28 Validation phase, of task analysis, 188
Underregulation of emotion, 279, 285, Verbal cognitive aspect, of blocking,
286 199–200
Understanding Verbal expression, of aroused emotion,
empathic, 22, 97, 115–116, 131–134 153–154
in insight-oriented therapy, 144 Vietnam, 105
372 • Index

The Visible and the Invisible (Merleau-Ponty), Weston, J. L., 171, 175, 176, 178–179,
120 182, 183, 185
Vocal features Whelton, W. J., 55
and affect regulation, 121 White culture, 108, 109
in body work, 158 Williams, G. E., 282
and emotional processing style, Winnicott, D. W., 254
129–130 Withdrawal by client, response to, 138
monitoring, in empathic attunement, Withdrawal emotions, 8, 65–66, 105
121 Working phase of treatment, 43
and relational attunement, 295 Worth, of own needs, 229–230
Volume, of voice, 9 Wounded child, defined, 253
Vrana, G., 187, 189, 192, 196 Wounded child work, 253–261. See also
Vulnerability Age regression work
acceptance of, 290 bodily felt experience in, 271–276
culture and, 112 bridging from present to, 270–276
recognizing precursors to, 181 case example, 259–261, 272–276
reducing, in resolution of self- coconstruction of experience in, 261
interruption, 190, 192 compassion and self-soothing in,
of self-interrupting clients, 171–180 257–258
and sitting with emotion, 100 process of, 255–256
in wounded child work, 253–254 strength to protect the self in, 258–259

W Y
Warwar, S. H., 46, 130, 155, 157 Yeryomenko, N., 6
Watson, J., 43, 45, 53–54, 56 York University, 43, 169, 313
Ways of being, testing, 74
“Weak me” sense of self, 36–37, 90
Z
Webb, T. L., 282
Western culture, 101–103, 105, 107 Zen Buddhism, 119, 144
About the Author

Leslie S. Greenberg, PhD, is Distinguished Research Professor Emeritus of

Psychology at York University in Toronto, Canada, and the primary developer
of emotion-focused therapy. He authored two of the first clinical titles in the
field: Emotion in Psychotherapy: Affect, Cognition, and the Process of Change
(with Jeremy D. Safran; 1987) and Emotionally Focused Therapy for Couples
(with Susan M. Johnson; 1988). More recent books include Emotion-Focused
Couples Therapy: The Dynamics of Emotion, Love and Power (with Rhonda N.
Goldman; 2008), Therapeutic Presence: A Mindful Approach to Effective Therapy
(with Shari M. Geller; 2012), the second edition of Emotion-Focused Therapy:
Coaching Clients to Work Through Their Feelings (2015), Emotion-Focused
Therapy for Generalized Anxiety (with Jeanne C. Watson; 2017), and Forgive­
ness and Letting Go in Emotion-Focused Therapy (with Catalina Woldarsky
Meneses; 2019). Dr. Greenberg currently conducts international trainings
on emotion-focused approaches. He has received the Distinguished Career
(Senior) Award of the Society for Psychotherapy Research as well as the Carl
Rogers Award and the Award for Distinguished Professional Contributions
to Applied Research of the American Psychological Association. He also has
received the Canadian Psychological Association Award for Distinguished
Contributions to Psychology as a Profession. He is a past president of the
Society for Psychotherapy Research.

373