Emotion-Focused Therapy, a New Era in Healing?
I wrote this reflective essay for our Defenses (Psychodynamic and Emotion-Focused) class at the University of Rochester. The professor asked us to reflect on the affect-focused therapies we have been learning about. I included the reflection below.
Module 1 surveyed affect-focused psychotherapy, which places central emphasis on experiencing emotion as a pathway to psychological healing. Dukes et al. (2021) suggest that affect-focused therapy could present a new era of treatment, drawing on neuroscience and contemporary knowledge to move psychotherapy beyond the cognitive age of CBT. Affect-focused approaches have roots in psychodynamic, humanistic, and integrative traditions. Knapp et al. (2015) found CBT to be the most commonly reported primary orientation among mental health professionals, whereas Norcross et al. (2023) found psychodynamic/relational orientations to be most common among doctoral-level psychologists. Does this contrast suggest that, as clinicians gain training and experience, psychodynamic and integrative/eclectic approaches become more appealing? Might this new era of affect-focused approaches also require greater clinical sophistication?
Reflecting on my own experience and class discussions, I understand CBT as primarily working with cognitions and behaviors, or perhaps thoughts about emotions. A theme in class discussions was that basic CBT can seem too simplistic for deep change and more suited to symptom reduction. By comparison, affect-focused psychotherapy felt intuitively more complex, requiring greater knowledge and skill from the therapist to interact directly with emotional experience. Could such complexity facilitate more profound forms of change? To explore further, I will review the four kinds of affect-focused therapy we covered in Module 1.
In Affect Phobia Therapy (APT), McCullough et al. (2003) argue that early in life, people may unconsciously learn to fear expressing their own emotions (Affect Phobia). An APT therapist helps the client regulate anxiety, restructure their defenses, feel their emotions, and then experience themselves and others in new ways. To me, APT seems less theoretically demanding than clinically demanding, requiring skill in alliance building, anxiety regulation, and defense identification.
Davanloo (2005) founded Intensive Short-Term Dynamic Psychotherapy (ISTDP) with a primary goal of removing “resistance,” in a Freudian sense, by exerting “pressure,” in order for the client to experience their emotions. To me, ISTDP requires both substantial theoretical expertise, from Freud to today, and master-level clinical expertise. ISTDP seems complex; it targets clients with more entrenched problems, and its intervention approach of “pressure” creates the potential for misuse by a poorly trained practitioner.
APT and ISTDP struck me as similar in their psychodynamic origins and attention to defenses, although ISTDP seemed more theoretically elaborate and clinically intense. Imagine asking a client, “How do you feel?”, and the client responding with intellectualization. The therapist would then identify the response as intellectualization, and tell the client, and ask them again, “How do you feel?”. Imagine the client still responded with intellectualization. Asking “How do you feel?”, again, might exasperate a client. Does a continued need to ask, “How do you feel?”, indicate a therapist has not yet developed a sufficient therapeutic alliance to successfully implement this technique? Or does it indicate a client is not yet ready to become aware of their defense? I wonder if questioning could become interrogative rather than therapeutic.
The founder of AEDP, Fosha (2000), describes “core affect” as an experience humans can have when we don't block access to our emotions. Fosha views emotion as relational, with the therapist using their own emotional experience to help the client access and express core affect. AEDP is also part of the psychodynamic school. My understanding of Fosha’s approach suggests that there is a moderate amount of theory to be learned; however, essentially the approach requires therapists themselves to be able to experience their own emotions deeply and broadly. AEDP seems less about challenging defenses like APT or ISTDP; AEDP seems to be more anchored in the therapist’s “emotional self”. Therefore, in order to master AEDP, I posit that a therapist must have experienced and mastered a vast array of emotional experiences themselves, and then use their presence as a container to allow the client to open up their own emotional experience.
Finally, EFT’s founder, Greenberg (2006), states that emotions are fundamental to human experience, and that meaning in life comes from making sense of our emotions. In EFT, “emotion schemes” can be either primary or secondary, or adaptive or maladaptive. The EFT therapist acts as an emotion coach, helping clients become aware of, regulate, and transform emotions into new meaning and action. For me, EFT is similar to AEDP; however, I see the therapist's role in EFT as being an expert on emotions, but not necessarily one who needs to be experiential with the client. As part of the humanistic tradition, EFT believes that the client remains the primary agent of change.
Reflecting on AEDP, I believe it is the approach with which I resonate most. The therapist becomes an emotional tool, enabling the client to experience their own emotions. There is no simple handbook, theory, or technique to use. Its emphasis on the self of the therapist over technique aligns with my values; it feels more like a cure through love than a cure through pressure, which aligns more closely with my philosophical worldview. EFT was probably my second favorite approach. I found the ideas very insightful, including primary and secondary emotions and adaptive and maladaptive emotions. In EFT's attempt to develop a comprehensive theory, it is a little simplistic for my liking.
Upon reflecting on affect-focused therapies, I do intuitively agree that it seems like they could open a whole new era for psychotherapy. I see CBT as riding the wave of enlightenment thinking, which places human cognition at the center. Now, with advances in science, especially neuroscience, we can begin to see what is underneath cognition; this is leading to a new hypothesis that emotions actually underlie thought and that psychotherapy should make emotions central. In a way, this is actually a throwback to Freud’s original ideas of abreaction and catharsis being the central mechanism of psychological healing. This may be why many affect-focused therapies are emerging from the psychodynamic tradition.
To address the more fundamental question I posed at the start of this reflection, are affect-focused approaches more sophisticated and powerful? Intuitively, I say yes, and it follows that a practitioner may need substantially more experience and training in order to master these approaches. An APT practitioner will need to be highly attuned to a client’s anxiety levels, sensing where defenses and feelings lie. An ISTDP practitioner needs to master the observation and perception of the client’s statements and state, in order to up-regulate pressure at the exact right time. An AEDP practitioner needs to have overcome their own experiences of deep emotion in order to create a container for their client. An EFT practitioner needs a keen emotional sensory palette, being able to discern which emotions are which, and which are primary, secondary, adaptive, or maladaptive. Overall, these affect-based approaches seem to be more powerful and more demanding to master. I personally wish to learn them; however, I think I will take an eclectic approach, using the pieces I resonate with to create a uniquely personalized affect-based stance.
References
Davanloo, H. (2005). Intensive short-term dynamic psychotherapy. In B. J. Sadock & V. A. Sadock (Eds.), Kaplan & Sadock’s comprehensive textbook of psychiatry (8th ed., pp. 2628–2652). Lippincott Williams & Wilkins.
Dukes, D., Abrams, K., Adolphs, R., Ahmed, M. E., Beatty, A., Berridge, K. C., Broomhall, S., Brosch, T., Campos, J. J., Clay, Z., Clément, F., Cunningham, W. A., Damasio, A., Damasio, H., D’Arms, J., Davidson, J. W., de Gelder, B., Deonna, J., de Sousa, R., . . . Sander, D. (2021). The rise of affectivism. Nature Human Behaviour, 5, 816–820. https://doi.org/10.1038/s41562-021-01130-8
Fosha, D. (2000). The transforming power of affect: A model for accelerated change. Basic Books.
Greenberg, L. S. (2006). Emotion-focused therapy: A synopsis. Journal of Contemporary Psychotherapy, 36(2), 87–93. https://doi.org/10.1007/s10879-006-9001-3
Knapp, P., Kieling, C., & Beck, A. T. (2015). What do psychotherapists do? A systematic review and meta-regression of surveys. Psychotherapy and Psychosomatics, 84(6), 377–378. https://doi.org/10.1159/000433555
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.
Norcross, J. C., Rocha, M. N., & Chrysler, A. A. (2023). Psychologists conducting psychotherapy in 2022: Contemporary practices and historical patterns of the Society for the Advancement of Psychotherapy. Psychotherapy, 60(4), 587–592. https://doi.org/10.1037/pst0000493
