Transforming Emotional Pain in Psychotherapy

An emotion-focused approach

Ladislav Timulak

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317642817
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychotherapeutische Beratung

Emotion-focused therapy is a research-informed psychological therapy that to date has mainly been studied in the context of depression, trauma and couple distress. The evidence suggests that this therapy has a lasting and transformative effect. Ladislav Timulak presents EFT as a particular therapeutic approach that addresses psychological human suffering, offering a view that puts more emphasis on attending to the distress, rather than avoiding or suppressing it.

Focusing on the latest developments in EFT, Transforming Emotional Pain in Psychotherapy presents a theory of human suffering and a model of therapy that addresses that suffering. The model of suffering assumes that the experienced emotional pain is a response to an injury that prevents or violates the fulfilment of the basic human needs of being loved, safe, and acknowledged. This book focuses on a particular way of transforming emotional pain in psychotherapy through: helping the client to tolerate the pain; assisting the client to identify the core of the difficult emotional experiences; identifying the needs connected to the core pain which are unmet or being violated, and responding (with compassion and protective anger) to the underlying needs of the client that transforms the original pain.

Transforming Emotional Pain in Psychotherapy provides an account of how emotional pain can be conceptualised and how it can be addressed in therapy. It provides practical tips for therapists working with emotional pain and shows how it can then be made more bearable and transformed allowing the client to be more sensitive to the pain of others, and to seek support when needed. This book will be essential reading for clinical and counselling psychologists, psychotherapists and counsellors in practice and training, as well as for fully qualified professionals undergoing further training in EFT.

1 Introduction

DOI: 10.4324/9781315760650-1

This book focuses on emotional pain and its transformation in psychotherapy from the theoretical framework represented by emotion-focused therapy (EFT; Elliott, Watson, Goldman, and Greenberg, 2004; Greenberg, 2002; Greenberg and Johnson, 1988; Greenberg, Rice, and Elliott, 1993). While there are a number of books, chapters, and papers written on the use of emotion-focused therapy with a variety of client presenting issues, this book provides a unique framework that builds on the model of emotional transformation first presented by Pascual-Leone and Greenberg (2007; Pascual-Leone, 2009; see also work of Pascual-Leone and his colleagues: Pascual-Leone, 2005; Kramer, Pascual-Leone, Despland & de Roten, in press; Paivio and Pascual-Leone, 2010) and then further developed in the research group I run in Trinity College Dublin (e.g., Crowley, Timulak, and McElvaney, 2013; Dillon, Timulak, and Greenberg, 2014; Keogh, Timulak, and McElvaney, 2013; Keogh, O’Brien, Timulak, and McElvaney, 2011; McNally, Timulak, and Greenberg, 2014; O’Brien, Timulak, McElvaney and Greenberg, 2012; Timulak, Dillon, McNally, and Greenberg, 2012), and finally in the collaborative work of Timulak and Pascual-Leone (2014). The emotion transformation model is used as a framework, organising a theory of psychopathology and theory of psychotherapy (i.e., case conceptualisation and strategy for therapy).

Emotion-focused therapy (EFT; Greenberg et al., 1993; Greenberg, 2002; Greenberg and Johnson, 1988) is a research-informed psychological therapy that to date has mainly been studied in the context of depression, trauma, and couple distress (Elliott, Greenberg, Watson, Timulak, and Freire, 2013). There are also new developments in this therapy for a variety of client difficulties such as eating disorders (Lafrance Robinson, Dolhanty, and Greenberg, 2013), social anxiety (Elliott, 2013, Shahar, 2013), or generalised anxiety disorder (Timulak, McElvaney, Martin, and Greenberg, 2014). The evidence suggests that this therapy has a lasting and transformative effect (Elliott et al., 2013), and its popularity is growing apace, particularly in North America. This is evidenced, for instance, by the huge growth in published books on EFT such as Elliott et al. (2004), Greenberg (2002; 2011), Greenberg et al. (1993), Greenberg and Goldman (2008), Greenberg and Johnson (1988), Greenberg and Paivio (1997), Greenberg and Watson (2006), Johnson (2004), Paivio and Pascual-Leone (2010), and Watson, Goldman, and Greenberg (2007). The approach has a strong research base, some of which will be presented in this book.

This book presents a theory of human suffering (psychopathology in more traditional terms) and a model of therapy that addresses that suffering. The model of suffering assumes that the experienced emotional pain is a response to an injury that prevents or violates the fulfilment of the basic human needs of being loved, safe, and acknowledged. The book is written for trainees in professional training programmes (clinical and counselling psychology, counselling and psychotherapy) as well as for fully qualified professionals undergoing further training in EFT or having an interest in this approach. This book is most helpful for those people who already have some background in EFT.

Human Suffering—Emotional Pain

As will be postulated later in the book, some psychotherapy research suggests that the motivation which underlies the psychological world of clients is characterised by a longing for safety, belonging, and creative actualisation. One can easily see the parallels to the arguments suggested by a neuroscientist Damasio (2011), who argues that motivational force in all living creatures is to flourish and to live to its full potential and argues that this principle can be seen on a biological as well as cultural and societal level.

On a psychological level, it has been shown that there is a correlation between a fulfilment of internal needs and personal well-being, fulfilment, and contribution to society (cf. also Deci and Ryan, 2000 on fulfilment of inner needs). However, human experience is full of real and potential adversities that do not allow fulfilment of our core fundamental needs and strivings and thus bring experiences of psychological (emotional) pain. The human experience can bring both joy and suffering. Joy comes when our fundamental needs are fulfilled, and suffering comes when they are violated or not fulfilled. Some of us are luckier and encounter less pain and suffering than others, but to encounter pain is inevitable. This book will focus on psychological pain, often described as emotional (Greenberg, 2002), or more recently, social pain (MacDonald and Jensen-Campbell, 2011) and its transformation in psychotherapy. It will focus on how psychological pain develops, how it is experienced, and how it can be transformed, leading to a fuller and more mature living.

The psychological (emotional) pain can be defined as an unpleasant, overwhelming, upsetting internal experience. It often presents itself in the form of general distress, physiological tension in the middle part of the body (e.g., head, throat, neck, shoulders, solar plexus, stomach), and a mixture of upsetting emotions and thoughts. Psychological pain also shows itself in the form of symptoms of anxiety and depression. People can be tormented by worries or obsessions that do not allow them to sleep or tense and tire them during the day. They may have panic attacks with unpleasant bodily symptoms, or they can feel hopelessness and helplessness that shut them off from others and stop their joy in living.

It seems likely that both emotional and physical pain share a neural circuitry, which is why we use the same word to describe the unpleasant consequences of distress in either the psychological or physical aspects of our being (Eisenberg, 2011). For instance, Eisenberg, in a review of her own and her colleagues’ studies, suggests that individuals who are more sensitive to physical pain are also more sensitive to social rejection. Additionally, she points out that pharmacological studies have shown that regulating physical pain also regulates social pain.

Emotional pain also has physiological aspects that are uncomfortable and bring a tangible, bodily experienced pain. The emotional pain impacts our breathing, our muscular tensions, our digestion, our thinking (which may be narrower and ruminative), our sleep, levels of tiredness, appetite, and physical aches (probably linked to the muscle tension). The emotional pain also expresses itself through changes in the cardiovascular, neuroendocrine, and immune systems that initially mobilise and alert the organism, but from a longer-term perspective have negative effect on our overall health (e.g., levels of cortisol) (Dickerson, 2011). In its more extreme form, the emotional pain can be characterised by a strong emotion dysregulation (Bradley et al., 2011).

On the other hand, there are some significant dissimilarities between emotional and physical pain. For example, the memories of emotional pain are more upsetting than the memories of physical pain, and the anticipation of emotional pain is more easily pre-lived than the anticipation of physical pain (Chen & Williams, 2011). For instance, if we experienced humiliation, the memory of it will make us cringe. Similarly, if I am to deliver a talk in a hostile environment, I will be nervous and anxious, expecting rejection and fearing humiliation. My body will make me feel this anxiety, and I will be able to imagine felt experience of shame in the face of being criticised or ridiculed.

The scientific disciplines of medicine (psychiatry) and psychology often do not speak about the emotional pain. When trying to capture psychological suffering, these disciplines focus on the description of common symptoms such as anxiety, behavioural avoidance, negative thinking, sleeplessness, irritation, muscular tension, negative view of the future, obsessive thoughts, compulsory behaviour, and so on. They classify people according to the clusters of symptoms, and the presence of some symptoms in the absence of some other symptoms serves as a basis for a particular diagnosis. At the same time many of those symptoms such as depression and apprehensive anxiety (focusing on potential triggers that may bring or worsen the experienced pain) are often secondary to more primary feelings (Greenberg, 2002), which can be present in the form of discreet emotions such as loneliness and loss, shame, and a sense of being judged (Dickerson, 2011; Greenberg and Watson, 2006; MacDonald, Borsook, and Spielman, 2011) and as upsetting trauma, dread, and terror (Ford, 2009).

The mainstream diagnostic classifications, such as the DSM (American Psychiatric Association, 2013), take very little account of the impact on these symptoms of the individual’s response to ‘stressors’ that may be involved in either the present life situation or have historically been implicated in the formation of specific symptoms. These classifications lack an emphasis for understanding the presenting symptoms in the context of the suffering person’s life situation, life history, and biological and developmentally shaped predispositions. Rather, the DSM-5 focuses on answering the question of whether the psychological presentation of the person is more or less normative and whether it causes impairment in everyday functioning. The classification systems do not try to understand how the suffering relates to the person’s overall sense of the self (including the biological level of functioning such as tiredness, irritability, bodily pain expression, and tolerance), the person’s sense of the self in the community, and the sense of self in the context of close family or intimate relationships. The mainstream classifications do not try to understand the psychological suffering in the context of the person’s life project, in the context of the person’s life history, or in the context of the person’s needs and wishes.

To understand human suffering fully, however, we need to understand what people strive for in their life. Along with psychology, many of the philosophical, scientific, and theological theories and approaches have attempted to provide answers to this question. The question of what people strive for thus becomes metaphysical, and various conceptualisations are provided. These conceptualisations are often shaped by personal persuasions, worldviews, and the preferences of scientists, psychologists, and so on.. As a result, there has been much disagreement both within and between the various disciplines as they are loaded with values and their consequences. Most of the concepts are set a priori, on the basis of the theoretician’s persuasions.

Each therapist is a theoretician, trying to understand what needs are not being met when people are suffering and experiencing psychological and emotional pain. Thus, considering what needs are unmet is a crucial part of the therapist’s work. Whilst it is not possible to know fully what people strive for in their lives, we can observe the principles that appear to capture the directions of these strivings.

Responding to Emotional Pain

For centuries people have sought and offered both informal and formal help in responding to emotional pain. Family members or caretakers in childhood, friends and acquaintances, as well as formally trained doctors, priests, teachers, elders, and more recently psychologists, counsellors, and psychotherapists were or are the ones who offer this help. Caring others provided attentive presence and listening as well as more active guidance. However, during the twentieth century, with the development of psychology along with counselling and psychotherapy research, we have developed a more scientific understanding of various forms of help through psychological means. For instance, the recent neuroscientific evidence suggests that the caring and empathic presence of the other has an analgesic impact on the pain centres in the brain (Panksepp, 2011). A further line of research suggests that providing social support increases the threshold of physical pain (Eisenberg, 2011; Master et al., 2009) or decreases the experience of threat as detected on a neural basis (Coan et al., 2006). Much research evidence exists which documents the positive role of social support (in its various forms) in increasing the capacity to bear physical as well as emotional pain (see e.g., Brown, Sheffield, Leary, and Robinson, 2003; Eisenberger, Taylor, Gable, Hilmert, and Lieberman, 2007).

Nevertheless, despite the positive role of social support and our advancing understanding of how this social support alleviates (and sometimes transforms) emotional pain, there are clear limitations to our capability of addressing emotional pain. Although a lot of emotional suffering is transformed through informal social help or through formal counselling or psychotherapy into safer, more sensitive, connected, and more creative lives, it is also the case that a lot of suffering is not transformed due to its complexity, the personal history of the suffering person, the level of adversity the person experienced, along with possible genetic and biological predispositions that may influence the biological resilience of the organism, and so on.

Psychotherapy research is attempting to distil and nuance the processes responsible for transformation of emotional pain. We know quite a lot about what is helpful, but we want to know more about which actual psychological processes may optimally respond to emotional processing. We want to understand what type of emotional pain can be transformed through what kind of intervention processes (Castonguay and Beutler, 2006). There are an infinite number of helping approaches to emotional human suffering. These approaches are often similar or complementary, although occasionally they are following exactly the opposite steps.

This book is another contribution to the debate on how to address psychological human suffering. It offers a view that places more emphasis on attending to the distress, rather than avoiding or suppressing it. It focuses on the underlying pain that informs the person about their unfulfilled needs. It focuses on responding to those needs by generating an emotional response from the self as well as from the other(s). This approach does not assume that people have irrational thoughts as some approaches suggest, nor does it focus on an interpretation of how unresolved conflicts are unconsciously and unsuccessfully played out in everyday functioning. Nonetheless, this approach agrees that people may not always fully understand their own experiences and the resulting action tendencies.

The approach presented here assumes that there are strong genetic and environmentally caused biological vulnerabilities (e.g., influencing neural substrate reactivity; Caspi and Moffitt, 2006) that influence the level of human psychological sufferi...