Cognitive Behavioural Chairwork

Distinctive Features

Matthew Pugh

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429657009
• Edition: 1
• Topic: Psicologia
• Subtopic: Salute mentale in psicologia

Cognitive Behavioural Chairwork: Distinctive Features provides a practical, accessible, and concise introduction to both the theory and practice of chairwork, one of the most powerful and exciting methods of intervention in cognitive behavioural therapy (CBT), and is the first book to synthesise its many applications in CBT and allied therapies.Part of the popular 'CBT Distinctive Features' series, this book contains a wealth of effective experiential procedures for working with automatic thoughts, emotions, behaviours, core beliefs, ambivalence, strengths, well-being, and cognitive processes such as worry and self-criticism. Readers will also learn how chairwork is applied in other areas, such as clinical supervision and associated psychotherapeutic approaches including compassion focused therapy, schema therapy, positive psychotherapy, and motivational interviewing. Techniques are presented in an easy-to-understand format and illustrated using clinical examples and therapy transcripts. The result is a comprehensive guide which demystifies chairwork and places it at the heart of CBT's continued evolution.Created for practising clinicians, researchers, and training therapists, Cognitive Behavioural Chairwork: Distinctive Features will appeal to both individuals who are new to chairwork and those who are familiar with its techniques.

Part I
Theoretical Features of Cognitive Behavioural Chairwork

1
A brief history of chairwork

Chairwork represents a collection of experiential interventions which utilise chairs and their relative positions for therapeutic purposes. Devised over a century ago, chair-based techniques are now employed in numerous contemporary psychotherapies including cognitive behavioural therapy (CBT) (Pugh, 2017), experiential therapy (Greenberg, Rice, & Elliott, 1993), psychodynamic therapy (Fosha, 2000), and family therapy (Tsvieli & Diamond, 2018). In fact, few interventions seem as ubiquitous to talking therapy as chairwork (excluding the therapeutic relationship, of course). This book opens with a review of the provenance and evolution of these techniques over time.

Jacob L. Moreno and ‘psychodrama’

Chairwork was conceived by Jacob L. Moreno (1889–1974), the founder of psychodrama. Moreno first studied psychoanalysis but promptly rejected many of its principles, including its reliance on discourse. “You analyse [people] and tear them apart”, he is reported to have told Sigmund Freud. “I let them act out their conflicting roles and help them to put the parts back together” (Moreno, 2014, p. 50). Moreno believed that perception was principally nurtured through action and so was most amenable to change via enactment. Theatre and performance, he argued, provided a means to recreate, observe, and resolve personal troubles. Given the prevailing orthodoxy of psychoanalysis at this time, Moreno’s ideas were nothing short of revolutionary.

Beginning in the 1920s, Moreno employed action-based methods to help “transform the clinical consulting room into a theatrical stage” (Landy, 2008, p. 197). These principles would form the basis of psychodrama: a group psychotherapy which his wife, Zerka, later refined. Under the guidance of a facilitator (the ‘director’), psycho-drama sessions involved the group working through the problems of a member (the ‘protagonist’). To facilitate this process, experiential techniques were employed to externalise aspects of the client’s internal world. These included mirroring (observing one’s behaviour re-enacted by another individual), doubling (hearing one’s internal voice spoken by a group member), and dialoguing with absent individuals represented by an empty chair (Moreno, 2014). These methods proved highly influential: as Eric Berne notes, “nearly all ‘active’ techniques were first tried out by Moreno in psychodrama so that it is difficult to come up with an original idea in this regard” (Berne, 1970, p. 164).

George Kelly and ‘personal-construct therapy’

American psychologist George Kelly (1905–1967) was influenced by Moreno’s work. Like Moreno, Kelly rejected much of psychoanalysis and contended that clients’ actions were more paramount to emotional distress than their history (Fransella & Neimeyer, 2005). In 1955, Kelly outlined personal construct therapy (PCT) – described by some as a convergence of behaviourism and psychodrama (Griffith, 2003) – which embraced a constructivist view of personality. In essence, Kelly believed that people created themselves and their worlds and could therefore recreate themselves when these usual ‘roles’ became problematic.

A quintessential intervention in PCT, ‘fixed role therapy’ (Kelly, 1955) involved an examination of the client’s current identity or ‘construct’ alongside the creation of a new persona (a ‘role sketch’). This new character would then be rehearsed through role-play and enacted in daily life for a specified period. Kelly (1955) hoped that immersion in this novel role would provide clients with a “construct shaking experience” (p. 412), demonstrating that change was possible and entrapment in one’s autobiography could be overcome (Neimeyer & Winter, 2007). Kelly’s work would later influence technical and conceptual elements of Beck’s cognitive therapy including behavioural rehearsal, role-play, and experimentation (Beck, 1976).

Frederick “Fritz” Perls and ‘gestalt therapy’

Outspoken, irreverent, and confrontational, Fritz Perls (1893–1970) remains a controversial figure in psychotherapy. Initially trained as a psychoanalyst, Perls later established gestalt therapy in the 1950s. Prior to this, Perls trained with Moreno and regularly attended psychodrama sessions in New York. It was here that he was introduced to chairwork (Kellogg, 2015), techniques which were later centralised in his gestalt approach.

Whilst Perls’s relationship with Moreno was at times strained, both individuals shared similar conceptualisations of therapeutic change. For Perls, emotional conflicts could only be resolved if their manifestations were made apparent in the ‘here-and-now’. These ideas spurred his rejection of intellectualisation and ‘aboutism’ in psychotherapy; rather than ‘talking about’ their problems, Perls believed that clients needed to ‘talk to’ these issues (Perls, 1969). “It is insufficient to recall a past incident”, Perls (1973, p. 65) states, “one has to psychodramatically return to it”.

Like Moreno, Perls was also a consummate performer. Throughout the 1960s, he provided demonstrations of gestalt chairwork in well-attended workshops. Many chairwork techniques were popularised by these performances including two-chair dialogues between clients’ polarised ‘top-dog’ and ‘under-dog’ (i.e. the critical and criticised parts of the self) and empty-chair dialogues with other individuals (‘unfinished situations’). However, Perls’s use of the chair deviated from psychodrama in one crucial aspect: rather than inviting other individuals into chairwork, clients would be asked to enact all roles in the ‘hot-seat’ (Perls, 1969). In proposing this, chairwork shifted from being a principally group-focused intervention to one which could be applied in individual therapies.

Leslie S. Greenberg and ‘process-experiential/emotion-focused therapy’

Whilst Moreno, Kelly, and Perls elegantly demonstrated the ‘art’ of chairwork, Leslie Greenberg has clarified the ‘science’ of these techniques. Greenberg first trained in person-centred therapy before studying gestalt therapy with Perls’s wife, Laura. Greenberg was impressed by the transformative power of chairwork but frustrated by a lack of guidance regarding its implementation, rendering it “unteachable in any systemic way” (Greenberg, 1979, p. 316).

Seeking to demystify these techniques, Greenberg began conducting chairwork-related research in the 1970s. This has continued into the 21st century and has helped establish the clinical effectiveness of these techniques and their mechanisms of change (see Chapter 15). Greenberg’s research has also informed the development of process-experiential therapy (Greenberg et al., 1993) and emotion-focused therapy (Elliott, Watson, Goldman, & Greenberg, 2004), both of which combine chairwork with Rogers’ (1951) therapeutic conditions for growth: ingredients which early gestalt approaches sometimes lacked (Leslie Greenberg, personal communication). As we shall see, Greenberg’s contributions have also influenced applications of chairwork in CBT and ‘integrative’ forms of cognitive psychotherapy.

2
Chairwork in cognitive and behavioural therapies

Despite its rich history of applications, many CBT therapists are unfamiliar with chairwork. To contextualise the inclusion of these techniques in clinicians’ technical repertoires, this chapter charts the development of chairwork in cognitive therapy and allied psychotherapeutic approaches.

Behaviour therapy

Behavioural therapy (BT) emerged in the 1950s with the intention of modifying maladaptive behaviour. One of the first behavioural interventions widely applied by clinicians, assertiveness skills training sought to alleviate clients’ social and emotional inhibitions by encouraging a “return to excitation” (Salter, 1949, p. 39). These ideas were extended by Wolpe (1958) who theorised that assertiveness generated therapeutic effects through the “reciprocal inhibition of anxiety” (p. 115). To help clients develop their assertiveness skills, Wolpe regularly employed in-session ‘psychodramas’. This precedent would prompt widespread use of behavioural rehearsal in BT (Lazarus, 1963) – a term behaviourists seem to have favoured more than psychodrama. Informed by theories of social learning (Bandura, 1969), these experiential methods were later broadened to include modelling, coaching, ‘contrasted’ role-plays, and ‘exaggerated’ behaviour rehearsal (McFall & Twentyman, 1973; McNeilage & Adams, 1979).

Rational emotive behaviour therapy

Often considered a forerunner to CBT, Albert Ellis’s ‘rational therapy’ (now rational emotive behaviour therapy [REBT]) proposed that psychological disturbance originated from underlying irrational beliefs. Developing a rational perspective on one’s problems, Ellis argued, could alleviate distress and encourage behaviour change (Ellis, 1962). Whilst disputing irrational beliefs often proved effective, Ellis observed that some remained resistant to change. In these circumstances, he recommended that ‘forceful’ chairwork techniques be used to bring irrational beliefs into sharper focus and ensure their disputation was memorable (Ellis, 2004). Interestingly, it was the adoption of these evocative interventions that partly inspired Ellis to rename his approach ‘rational-emotive therapy’ (Ellis, 2001). Several influential chairwork techniques have since emerged from REBT including role-reversal and rational-emotive dialogues (Dryden, 1995).

Cognitive therapy

Beck’s cognitive model, which aimed to generate symptomatic relief through cognitive modification, represented a radical departure from BT (Clark, 1995). Over time, Beck’s cognitive therapy (CT) was gradually adopted by many behaviourists, leading to an assimilation of first-wave BT and second-wave CT (‘cognitive behavioural therapy’) (Hayes, 2004). Whilst cognitive interventions where centralised in CT, Beck (1991) believed these “by no means [defined] the limits of cognitive therapy” (p. 195). Assuming that other techniques remained compatible with its underlying principles, technical eclecticism was welcomed in CT. Experiential interventions such as chairwork, which exposed the client to transformational experiences, were regarded as a particularly effective means to accelerate cognitive modification (Beck, 1976). Second only to behavioural interventions, gestalt and psychodrama techniques appeared to be the chief integrations in early CT (Beck, Emery, & Greenberg, 1985; Beck, Rush, Shaw, & Emery, 1979). Indeed, Beck has since acknowledged that his use of “enactive, emotive strategies was influenced, no doubt, by psychodrama and gestalt therapy” (Beck, 1991, p. 196).

Cognitive treatments for complex presentations were elaborated throughout the 1990s (e.g. Beck et al., 1990; Young, 1990). These longer-term therapies advocated the use of active and evocative schema-level interventions in difficult-to-treat disorders, including chairwork. Emerging theories of cognition and affect also provided sophisticated rationales for the inclusion of these techniques, including a need to work with ‘hot’ cognitive material, the limits of analytic interventions when applied to primitive schematic structures, and the importance of emotional arousal in enabling cognitive modification (Arntz & Weertman, 1999; Safran & Greenberg, 1982; Teasdale & Barnard, 1993). Consequently, chairwork was often recommended when ‘traditional’ cognitive interventions proved ineffective (Beck, 1995).

The emergence of allied approaches

The 1990s also saw a new generation of allied psychotherapies emerge (previously referred to as a ‘third-wave’ of cognitive therapy; Hayes, 2004). These included acceptance and commitment therapy (ACT), compassion focused therapy (CFT), and dialectical behaviour therapy (DBT). Whilst markedly different in many aspects, these approaches shared certain principles in common including the therapeutic role of acceptance, non-judgemental awareness, and metacognitive processes (Gilbert, 2010; Hayes, Strosahl, & Wilson, 2012; Linehan, 2015). Also defining of this new generation of therapies was growing appreciation for the role of ‘self-multiplicity’. Whilst CBT had previously referred to the existence of multiple ‘mindsets’ and ‘modes’ of information processing (Beck, 1996; Teasdale,...