Gestalt therapy

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Gestalt therapy is an existential/experiential form of psychotherapy that emphasizes personal responsibility, and that focuses upon the individual's experience in the present moment, the therapist–client relationship, the environmental and social contexts of a person's life, and the self-regulating adjustments people make as a result of their overall situation.

Gestalt therapy was developed by Fritz Perls, Laura Perls and Paul Goodman in the 1940s and 1950s, and was first described in the 1951 book Gestalt Therapy.

Overview

Edwin Nevis described Gestalt therapy as "a conceptual and methodological base from which helping professionals can craft their practice". In the same volume, Joel Latner stated that Gestalt therapy is built upon two central ideas: that the most helpful focus of psychotherapy is the experiential present moment, and that everyone is caught in webs of relationships; thus, it is only possible to know ourselves against the background of our relationships to others. The historical development of Gestalt therapy (described below) discloses the influences that generated these two ideas. Expanded, they support the four chief theoretical constructs (explained in the theory and practice section) that comprise Gestalt theory, and that guide the practice and application of Gestalt therapy. 

Gestalt therapy was forged from various influences upon the lives of its founders during the times in which they lived, including: the new physics, Eastern religion, existential phenomenology, Gestalt psychology, psychoanalysis, experimental theater, as well as systems theory and field theory. Gestalt therapy rose from its beginnings in the middle of the 20th century to rapid and widespread popularity during the decade of the 1960s and early 1970s. During the '70s and '80s Gestalt therapy training centers spread globally; but they were, for the most part, not aligned with formal academic settings. As the cognitive revolution eclipsed Gestalt theory in psychology, many came to believe Gestalt was an anachronism. Because Gestalt therapists disdained the positivism underlying what they perceived to be the concern of research, they largely ignored the need to use research to further develop Gestalt theory and Gestalt therapy practice (with a few exceptions like Les Greenberg, see the interview: "Validating Gestalt"). However, the new century has seen a sea of change in attitudes toward research and Gestalt practice. 

Gestalt therapy is not identical with Gestalt psychology but Gestalt psychology influenced the development of Gestalt therapy to a large extent.

Gestalt therapy focuses on process (what is actually happening) over content (what is being talked about). The emphasis is on what is being done, thought, and felt at the present moment (the phenomenality of both client and therapist), rather than on what was, might be, could be, or should have been. Gestalt therapy is a method of awareness practice (also called "mindfulness" in other clinical domains), by which perceiving, feeling, and acting are understood to be conducive to interpreting, explaining, and conceptualizing (the hermeneutics of experience). This distinction between direct experience versus indirect or secondary interpretation is developed in the process of therapy. The client learns to become aware of what he or she is doing and that triggers the ability to risk a shift or change.

The objective of Gestalt therapy is to enable the client to become more fully and creatively alive and to become free from the blocks and unfinished business that may diminish satisfaction, fulfillment, and growth, and to experiment with new ways of being. For this reason Gestalt therapy falls within the category of humanistic psychotherapies. As Gestalt therapy includes perception and the meaning-making processes by which experience forms, it can also be considered a cognitive approach. Also, because Gestalt therapy relies on the contact between therapist and client, and because a relationship can be considered to be contact over time, Gestalt therapy can be considered a relational or interpersonal approach. As it appreciates the larger picture which is the complex situation involving multiple influences in a complex situation, it can also be considered a multi-systemic approach. In addition, the processes of Gestalt therapy are experimental, involving action, Gestalt therapy can be considered both a paradoxical and an experiential/experimental approach.

When Gestalt therapy is compared to other clinical domains, a person can find many matches, or points of similarity. "Probably the clearest case of consilience is between gestalt therapy's field perspective and the various organismic and field theories that proliferated in neuroscience, medicine, and physics in the early and mid-20th century. Within social science there is a consilience between gestalt field theory and systems or ecological psychotherapy; between the concept of dialogical relationship and object relations, attachment theory, client-centered therapy and the transference-oriented approaches; between the existential, phenomenological, and hermeneutical aspects of gestalt therapy and the constructivist aspects of cognitive therapy; and between gestalt therapy's commitment to awareness and the natural processes of healing and mindfulness, acceptance and Buddhist techniques adopted by cognitive behavioral therapy."

Contemporary theory and practice

The theoretical foundations of Gestalt therapy essentially rests atop four "load-bearing walls": phenomenological method, dialogical relationship, field-theoretical strategies, and experimental freedom. Although all these tenets were present in the early formulation and practice of Gestalt therapy, as described in Ego, Hunger and Aggression (Perls, 1947) and in Gestalt Therapy, Excitement and Growth in the Human Personality (Perls, Hefferline, & Goodman, 1951), the early development of Gestalt therapy theory emphasized personal experience and the experiential episodes understood as "safe emergencies" or experiments. Indeed, half of the Perls, Hefferline, and Goodman book consists of such experiments. Later, through the influence of such people as Erving and Miriam Polster, a second theoretical emphasis emerged: namely, contact between self and other, and ultimately the dialogical relationship between therapist and client. Later still, field theory emerged as an emphasis. At various times over the decades, since Gestalt therapy first emerged, one or more of these tenets and the associated constructs that go with them have captured the imagination of those who have continued developing the contemporary theory of Gestalt therapy. Since 1990 the literature focused upon Gestalt therapy has flourished, including the development of several professional Gestalt journals. Along the way, Gestalt therapy theory has also been applied in Organizational Development and coaching work. And, more recently, Gestalt methods have been combined with meditation practices into a unified program of human development called Gestalt Practice, which is used by some practitioners.

Phenomenological method

The goal of a phenomenological exploration is awareness. This exploration works systematically to reduce the effects of bias through repeated observations and inquiry.

The phenomenological method comprises three steps: (1) the rule of epoché, (2) the rule of description, and (3) the rule of horizontalization. Applying the rule of epoché one sets aside one's initial biases and prejudices in order to suspend expectations and assumptions. Applying the rule of description, one occupies oneself with describing instead of explaining. Applying the rule of horizontalization one treats each item of description as having equal value or significance. 

The rule of epoché sets aside any initial theories with regard to what is presented in the meeting between therapist and client. The rule of description implies immediate and specific observations, abstaining from interpretations or explanations, especially those formed from the application of a clinical theory superimposed over the circumstances of experience. The rule of horizontalization avoids any hierarchical assignment of importance such that the data of experience become prioritized and categorized as they are received. A Gestalt therapist using the phenomenological method might say something like, “I notice a slight tension at the corners of your mouth when I say that, and I see you shifting on the couch and folding your arms across your chest ... and now I see you rolling your eyes back”. Of course, the therapist may make a clinically relevant evaluation, but when applying the phenomenological method, temporarily suspends the need to express it.

Dialogical relationship

To create the conditions under which a dialogic moment might occur, the therapist attends to his or her own presence, creates the space for the client to enter in and become present as well (called inclusion), and commits him or herself to the dialogic process, surrendering to what takes place, as opposed to attempting to control it. With presence, the therapist judiciously “shows up” as a whole and authentic person, instead of assuming a role, false self or persona. The word 'judicious' used above refers to the therapist's taking into account the specific strengths, weaknesses and values of the client. The only 'good' client is a 'live' client, so driving a client away by injudicious exposure of intolerable [to this client] experience of the therapist is obviously counter-productive. For example, for an atheistic therapist to tell a devout client that religion is myth would not be useful, especially in the early stages of the relationship. To practice inclusion is to accept however the client chooses to be present, whether in a defensive and obnoxious stance or a superficially cooperative one. To practice inclusion is to support the presence of the client, including his or her resistance, not as a gimmick but in full realization that this is how the client is actually present and is the best this client can do at this time. Finally, the Gestalt therapist is committed to the process, trusts in that process, and does not attempt to save him or herself from it (Brownell, in press, 2009, 2008)).

Field-theoretical strategies

Field theory is a concept borrowed from physics in which people and events are no longer considered discrete units but as parts of something larger, which are influenced by everything including the past, and observation itself. “The field” can be considered in two ways. There are ontological dimensions and there are phenomenological dimensions to one's field. The ontological dimensions are all those physical and environmental contexts in which we live and move. They might be the office in which one works, the house in which one lives, the city and country of which one is a citizen, and so forth. The ontological field is the objective reality that supports our physical existence. The phenomenological dimensions are all mental and physical dynamics that contribute to a person's sense of self, one's subjective experience—not merely elements of the environmental context. These might be the memory of an uncle's inappropriate affection, one's color blindness, one's sense of the social matrix in operation at the office in which one works, and so forth. The way that Gestalt therapists choose to work with field dynamics makes what they do strategic. Gestalt therapy focuses upon character structure; according to Gestalt theory, the character structure is dynamic rather than fixed in nature. To become aware of one's character structure, the focus is upon the phenomenological dimensions in the context of the ontological dimensions.

Experimental freedom

Gestalt therapy is distinct because it moves toward action, away from mere talk therapy, and for this reason is considered an experiential approach. Through experiments, the therapist supports the client's direct experience of something new, instead of merely talking about the possibility of something new. Indeed, the entire therapeutic relationship may be considered experimental, because at one level it is a corrective, relational experience for many clients, and it is a "safe emergency" that is free to turn out however it will. An experiment can also be conceived as a teaching method that creates an experience in which a client might learn something as part of their growth. Examples might include: (1) Rather than talking about the client's critical parent, a Gestalt therapist might ask the client to imagine the parent is present, or that the therapist is the parent, and talk to that parent directly; (2) If a client is struggling with how to be assertive, a Gestalt therapist could either (a) have the client say some assertive things to the therapist or members of a therapy group, or (b) give a talk about how one should never be assertive; (3) A Gestalt therapist might notice something about the non-verbal behavior or tone of voice of the client; then the therapist might have the client exaggerate the non-verbal behavior and pay attention to that experience; (4) A Gestalt therapist might work with the breathing or posture of the client, and direct awareness to changes that might happen when the client talks about different content. With all these experiments the Gestalt therapist is working with process rather than content, the How rather than the What.

Noteworthy issues

Self

In field theory, self is a phenomenological concept, existing in comparison with other. Without the other there is no self, and how one experiences the other is inseparable from how one experiences oneself. The continuity of selfhood (functioning personality) is something that is achieved in relationship, rather than something inherently "inside" the person. This can have its advantages and disadvantages. At one end of the spectrum, someone may not have enough self-continuity to be able to make meaningful relationships, or to have a workable sense of who she is. In the middle, her personality is a loose set of ways of being that work for her, including commitments to relationships, work, culture and outlook, always open to change where she needs to adapt to new circumstances or just want to try something new. At the other end, her personality is a rigid defensive denial of the new and spontaneous. She acts in stereotyped ways, and either induces other people to act in particular and fixed ways towards her, or she redefines their actions to fit with fixed stereotypes.

In Gestalt therapy, the process is not about the self of the client being helped or healed by the fixed self of the therapist; rather it is an exploration of the co-creation of self and other in the here-and-now of the therapy. There is no assumption that the client will act in all other circumstances as he or she does in the therapy situation. However, the areas that cause problems will be either the lack of self-definition leading to chaotic or psychotic behavior, or the rigid self-definition in some area of functioning that denies spontaneity and makes dealing with particular situations impossible. Both of these conditions show up very clearly in the therapy, and can be worked with in the relationship with the therapist. 

The experience of the therapist is also very much part of the therapy. Since we co-create our self-other experiences, the way a therapist experiences being with a client is significant information about how the client experiences themselves. The proviso here is that a therapist is not operating from their own fixed responses. This is why Gestalt therapists are required to undertake significant therapy of their own during training. 

From the perspective of this theory of self, neurosis can be seen as fixed predictability—a fixed Gestalt—and the process of therapy can be seen as facilitating the client to become unpredictable: more responsive to what is in the client's present environment, rather than responding in a stuck way to past introjects or other learning. If the therapist has expectations of how the client should end up, this defeats the aim of therapy.

Change

In what has now become a "classic" of Gestalt therapy literature, Arnold R. Beisser described Gestalt's paradoxical theory of change. The paradox is that the more one attempts to be who one is not, the more one remains the same. Conversely, when people identify with their current experience, the conditions of wholeness and growth support change. Put another way, change comes about as a result of "full acceptance of what is, rather than a striving to be different."

The empty chair technique

Empty chair technique or chairwork is typically used in Gestalt therapy when a patient might have deep-rooted emotional problems from someone or something in their life, such as relationships with themselves, with aspects of their personality, their concepts, ideas, feelings, etc., or other people in their lives. The purpose of this technique is to get the patient to think about their emotions and attitudes. Common things the patient addresses in the empty chair are another person, aspects of their own personality, a certain feeling, etc., as if that thing were in that chair. They may also move between chairs and act out two or more sides of a discussion, typically involving the patient and persons significant to them. It uses a passive approach to opening up the patient's emotions and pent-up feelings so they can let go of what they have been holding back. A form of role-playing, the technique focuses on exploration of self and is used by therapists to help patients self-adjust. Gestalt techniques were originally a form of psychotherapy, but are now often used in counseling, for instance, by encouraging clients to act out their feelings helping them prepare for a new job. The purpose of the technique is so the patient will become more in touch with their feelings and have an emotional conversation that clears up any long-held feelings or reaction to the person or object in the chair. When used effectively, it provides an emotional release and lets the client move forward in their life.

Historical development

Fritz Perls was a German-Jewish psychoanalyst who fled Europe with his wife Laura Perls to South Africa in order to escape Nazi oppression in 1933. After World War II, the couple emigrated to New York City, which had become a center of intellectual, artistic and political experimentation by the late 1940s and early 1950s.

Early influences

Perls grew up on the bohemian scene in Berlin, participated in Expressionism and Dadaism, and experienced the turning of the artistic avant-garde toward the revolutionary left. Deployment to the front line, the trauma of war, anti-Semitism, intimidation, escape, and the Holocaust are further key sources of biographical influence.

Perls served in the German Army during World War I, and was wounded in the conflict. After the war he was educated as a medical doctor. He became an assistant to Kurt Goldstein, who worked with brain-injured soldiers. Perls went through a psychoanalysis with Wilhelm Reich and became a psychiatrist. Perls assisted Goldstein at Frankfurt University where he met his wife Lore (Laura) Posner, who had earned a doctorate in Gestalt psychology. They fled Nazi Germany in 1933 and settled in South Africa. Perls established a psychoanalytic training institute and joined the South African armed forces, serving as a military psychiatrist. During these years in South Africa, Perls was influenced by Jan Smuts and his ideas about "holism". 

In 1936 Fritz Perls attended a psychoanalysts' conference in Marienbad, Czechoslovakia, where he presented a paper on oral resistances, mainly based on Laura Perls's notes on breastfeeding their children. Perls's paper was turned down. Perls did present his paper in 1936, but it met with "deep disapproval." Perls wrote his first book, Ego, Hunger and Aggression (1942, 1947), in South Africa, based in part on the rejected paper. It was later re-published in the United States. Laura Perls wrote two chapters of this book, but she was not given adequate recognition for her work.

The seminal book

Perls's seminal work was Gestalt Therapy: Excitement and Growth in the Human Personality, published in 1951, co-authored by Fritz Perls, Paul Goodman, and Ralph Hefferline (a university psychology professor and sometime patient of Fritz Perls). Most of Part II of the book was written by Paul Goodman from Perls's notes, and it contains the core of Gestalt theory. This part was supposed to appear first, but the publishers decided that Part I, written by Hefferline, fit into the nascent self-help ethos of the day, and they made it an introduction to the theory. Isadore From, a leading early theorist of Gestalt therapy, taught Goodman's Part II for an entire year to his students, going through it phrase by phrase.

First instances of Gestalt therapy

Fritz and Laura founded the first Gestalt Institute in 1952, running it out of their Manhattan apartment. Isadore From became a patient, first of Fritz, and then of Laura. Fritz soon made From a trainer, and also gave him some patients. From lived in New York until his death, at age seventy-five, in 1993. He was known worldwide for his philosophical and intellectually rigorous take on Gestalt therapy. Acknowledged as a supremely gifted clinician, he was indisposed to writing, so what remains of his work is merely transcripts of interviews.

Of great importance to understanding the development of Gestalt therapy is the early training which took place in experiential groups in the Perls's apartment, led by both Fritz and Laura before Fritz left for the West Coast, and after by Laura alone. These "trainings" were unstructured, with little didactic input from the leaders, although many of the principles were discussed in the monthly meetings of the institute, as well as at local bars after the sessions. Many notable Gestalt therapists emerged from these crucibles in addition to Isadore From, e.g., Richard Kitzler, Dan Bloom, Bud Feder, Carl Hodges, and Ruth Ronall. In these sessions, both Fritz and Laura used some variation of the "hot seat" method, in which the leader essentially works with one individual in front of an audience with little or no attention to group dynamics. In reaction to this omission emerged a more interactive approach in which Gestalt-therapy principles were blended with group dynamics; in 1980, the book Beyond the Hot Seat, edited by Feder and Ronall, was published, with contributions from members of both the New York and Cleveland Institutes, as well as others.

Fritz left Laura and New York in 1960, briefly lived in Miami, and ended up in California. Jim Simkin was a psychotherapist who became a client of Perls in New York and then a co-therapist with Perls in Los Angeles. Simkin was responsible for Perls's going to California, where Perls began a psychotherapy practice. Ultimately, the life of a peripatetic trainer and workshop leader was better suited to Fritz's personality—starting in 1963, Simkin and Perls co-led some of the early Gestalt workshops and training groups at Esalen Institute in Big Sur, California, where Perls eventually settled and built a home. Jim Simkin then purchased property next to Esalen and started his own training center, which he ran until his death in 1984. Simkin refined his precise version of Gestalt therapy, training psychologists, psychiatrists, counselors and social workers within a very rigorous, residential training model.

The schism

In the 1960s, Perls became infamous among the professional elite for his public workshops at Esalen Institute. Isadore From referred to some of Fritz's brief workshops as "hit-and-run" therapy, because of Perls's alleged emphasis on showmanship with little or no follow-through—but Perls never considered these workshops to be complete therapy; rather, he felt he was giving demonstrations of key points for a largely professional audience. Unfortunately, some films and tapes of his work were all that most graduate students were exposed to, along with the misperception that these represented the entirety of Perls's work. 

When Fritz Perls left New York for California, there began to be a split with those who saw Gestalt therapy as a therapeutic approach similar to psychoanalysis. This view was represented by Isadore From, who practiced and taught mainly in New York, as well as by the members of the Cleveland Institute, which was co-founded by From. An entirely different approach was taken, primarily in California, by those who saw Gestalt therapy not just as a therapeutic modality, but as a way of life. The East Coast, New York–Cleveland axis was often appalled by the notion of Gestalt therapy leaving the consulting room and becoming a way of life on the West Coast in the 1960s. 

An alternative view of this split saw Perls in his last years continuing to develop his a-theoretical and phenomenological methodology, while others, inspired by From, were inclined to theoretical rigor which verged on replacing experience with ideas.

The split continues between what has been called "East Coast Gestalt" and "West Coast Gestalt," at least from an Amerocentric point of view. While the communitarian form of Gestalt continues to flourish, Gestalt therapy was largely replaced in the United States by Cognitive Behavioral Therapy, and many Gestalt therapists in the U.S. drifted toward organizational management and coaching. At the same time, contemporary Gestalt Practice (to a large extent based upon Gestalt therapy theory and practice) was developed by Dick Price, the co-founder of Esalen Institute. Price was one of Perls's students at Esalen.

Post-Perls

In 1969, Fritz Perls left the United States to start a Gestalt community at Lake Cowichan on Vancouver Island, Canada. He died almost one year later, on 14 March 1970, in Chicago. One member of the Gestalt community was Barry Stevens. Her book about that phase of her life, Don't Push the River, became very popular. She developed her own form of Gestalt therapy body work, which is essentially a concentration on the awareness of body processes.

The Polsters

Erving and Miriam Polster started a training center in La Jolla, California, which also became very well known, as did their book, Gestalt Therapy Integrated, in the 1970s.

The Polsters played an influential role in advancing the concept of contact-boundary phenomena. The standard contact-boundary resistances in Gestalt theory were confluence, introjection, projection and retroflection. A disturbance described by Miriam and Erving Polster was deflection, which referred to a means of avoiding contact. Instances of boundary phenomena can have pathological or non-pathological aspects; for example, it is appropriate for an infant and mother to merge, or become "confluent," but inappropriate for a client and therapist to do so. If the latter do become confluent, there can be no growth, because there is no boundary at which one can contact the other: the client will not be able to learn anything new, because the therapist essentially becomes an extension of the client.

Influences upon Gestalt therapy

Some examples

There were a variety of psychological and philosophical influences upon the development of Gestalt therapy, not the least of which were the social forces at the time and place of its inception. Gestalt therapy is an approach that is holistic (including mind, body, and culture). It is present-centered and related to existential therapy in its emphasis on personal responsibility for action, and on the value of "I–thou" relationship in therapy. In fact, Perls considered calling Gestalt therapy existential-phenomenological therapy. "The I and thou in the Here and Now" was a semi-humorous shorthand mantra for Gestalt therapy, referring to the substantial influence of the work of Martin Buber—in particular his notion of the I–Thou relationship—on Perls and Gestalt. Buber's work emphasized immediacy, and required that any method or theory answer to the therapeutic situation, seen as a meeting between two people. Any process or method that turns the patient into an object (the I–It) must be strictly secondary to the intimate, and spontaneous, I–Thou relation. This concept became important in much of Gestalt theory and practice.

Both Fritz and Laura Perls were students and admirers of the neuropsychiatrist Kurt Goldstein. Gestalt therapy was based in part on Goldstein's concept called Organismic theory. Goldstein viewed a person in terms of a holistic and unified experience; he encouraged a "big picture" perspective, taking into account the whole context of a person's experience. The word Gestalt means whole, or configuration. Laura Perls, in an interview, denotes the Organismic theory as the base of Gestalt therapy.

There were additional influences on Gestalt therapy from existentialism, particularly the emphasis upon personal choice and responsibility.

The late 1950s–1960s movement toward personal growth and the human potential movement in California fed into, and was itself influenced by, Gestalt therapy. In this process Gestalt therapy somehow became a coherent Gestalt, which is the Gestalt psychology term for a perceptual unit that holds together and forms a unified whole.

Psychoanalysis

Fritz Perls trained as a neurologist at major medical institutions and as a Freudian psychoanalyst in Berlin and Vienna, the most important international centers of the discipline in his day. He worked as a training analyst for several years with the official recognition of the International Psychoanalytic Association (IPA), and must be considered an experienced clinician. Gestalt therapy was influenced by psychoanalysis: it was part of a continuum moving from the early work of Freud, to the later Freudian ego analysis, to Wilhelm Reich and his character analysis and notion of character armor, with attention to nonverbal behavior; this was consonant with Laura Perls's background in dance and movement therapy. To this was added the insights of academic Gestalt psychology, including perception, Gestalt formation, and the tendency of organisms to complete an incomplete Gestalt and to form "wholes" in experience. 

Central to Fritz and Laura Perls's modifications of psychoanalysis was the concept of dental or oral aggression. In Ego, Hunger and Aggression (1947), Fritz Perls's first book, to which Laura Perls contributed (ultimately without recognition), Perls suggested that when the infant develops teeth, he or she has the capacity to chew, to break food apart, and, by analogy, to experience, taste, accept, reject, or assimilate. This was opposed to Freud's notion that only introjection takes place in early experience. Thus Perls made assimilation, as opposed to introjection, a focal theme in his work, and the prime means by which growth occurs in therapy.

In contrast to the psychoanalytic stance, in which the "patient" introjects the (presumably more healthy) interpretations of the analyst, in Gestalt therapy the client must "taste" his or her own experience and either accept or reject it—but not introject or "swallow whole." Hence, the emphasis is on avoiding interpretation, and instead encouraging discovery. This is the key point in the divergence of Gestalt therapy from traditional psychoanalysis: growth occurs through gradual assimilation of experience in a natural way, rather than by accepting the interpretations of the analyst; thus, the therapist should not interpret, but lead the client to discover for him- or herself.

The Gestalt therapist contrives experiments that lead the client to greater awareness and fuller experience of his or her possibilities. Experiments can be focused on undoing projections or retroflections. The therapist can work to help the client with closure of unfinished Gestalts ("unfinished business" such as unexpressed emotions towards somebody in the client's life). There are many kinds of experiments that might be therapeutic, but the essence of the work is that it is experiential rather than interpretive, and in this way, Gestalt therapy distinguishes itself from psychoanalysis.

Principal influences: a summary list

• Otto Rank's invention of "here-and-now" therapy and Rank's post-Freudian book Art and Artist (1932), both of which strongly influenced Paul Goodman.
• Wilhelm Reich's psychoanalytic developments, especially his early character analysis, and the later concept of character armor and its focus on the body.
• Jacob Moreno's psychodrama, principally the development of enactment techniques for the resolution of psychological conflicts.
• Kurt Goldstein's holistic theory of the organism, based on Gestalt theory.
• Martin Buber's philosophy of relationship and dialogue ("I–Thou").
• Kurt Lewin's field theory as applied to the social sciences and group dynamics.
• European phenomenology of Franz Brentano, Edmund Husserl, Martin Heidegger, and Maurice Merleau-Ponty.
• The existentialism of Kierkegaard over that of Sartre, rejecting nihilism.
• Carl Jung's psychology, particularly the polarities concept.
• Some elements from Zen Buddhism.
• Differentiation between thing and concept from Zen and the works of Alfred Korzybski.
• The American pragmatism of William James, George Herbert Mead, and John Dewey.

Current status

Gestalt therapy reached a zenith in the United States in the late 1970s and early 1980s. Since then, it has influenced other fields like organizational development, coaching, and teaching. Many of its contributions have become assimilated into other current schools of therapy. In recent years, it has seen a resurgence in popularity as an active, psychodynamic form of therapy which has also incorporated some elements of recent developments in attachment theory. There are, for example, four Gestalt training institutes in the New York City metropolitan area alone, not to mention dozens of others worldwide. 

Gestalt therapy continues to thrive as a widespread form of psychotherapy, especially throughout Europe, where there are many practitioners and training institutions. Dan Rosenblatt led Gestalt therapy training groups and public workshops at the Tokyo Psychotherapy Academy for seven years. Stewart Kiritz continued in this role from 1997 to 2006. 

The form of Gestalt Practice initially developed at Esalen Institute by Dick Price has spawned numerous offshoots.

Training of Gestalt therapists

Pedagogical approach

Many Gestalt therapy training organizations exist worldwide. Ansel Woldt asserted that Gestalt teaching and training are built upon the belief that people are, by nature, health-seeking. Thus, such commitments as authenticity, optimism, holism, health, and trust become important principles to consider when engaged in the activity of teaching and learning—especially Gestalt therapy theory and practice.

Associations

The Association for the Advancement of Gestalt Therapy (AAGT) holds a biennial international conference in various locations—the first was in New Orleans, in 1995. Subsequent conferences have been held in San Francisco, Cleveland, New York, Dallas, St. Pete's Beach, Vancouver (British Columbia), Manchester (England), and Philadelphia. In addition, the AAGT holds regional conferences, and its regional network has spawned regional conferences in Amsterdam, the Southwest and the Southeast of the United States, England, and Australia. Its Research Task Force generates and nurtures active research projects and an international conference on research.

The European Association for Gestalt Therapy (EAGT), founded in 1985 to gather European individual Gestalt therapists, training institutes, and national associations from more than twenty European nations.

Gestalt Australia and New Zealand (GANZ) was formally established at the first "Down Under" Gestalt Therapy Conference held in Perth in September 1998.

Emotionally focused therapy

From Wikipedia, the free encyclopedia

Emotionally focused therapy and emotion-focused therapy (EFT) are a family of related approaches to psychotherapy with individuals, couples, or families. EFT approaches include elements of experiential therapy (such as person-centered therapy and Gestalt therapy), systemic therapy, and attachment theory. EFT is usually a short-term treatment (8–20 sessions). EFT approaches are based on the premise that human emotions are connected to human needs, and therefore emotions have an innately adaptive potential that, if activated and worked through, can help people change problematic emotional states and interpersonal relationships. Emotion-focused therapy for individuals was originally known as process-experiential therapy, and it is still sometimes called by that name.

EFT should not be confused with emotion-focused coping, a category of coping proposed by some psychologists, although clinicians have used EFT to help improve clients' emotion-focused coping.

History

EFT began in the mid-1980s as an approach to helping couples. EFT was originally formulated and tested by Sue Johnson and Les Greenberg in 1985, and the first manual for emotionally focused couples therapy was published in 1988.

To develop the approach, Johnson and Greenberg began reviewing videos of sessions of couples therapy to identify, through observation and task analysis, the elements that lead to positive change. They were influenced in their observations by the humanistic experiential psychotherapies of Carl Rogers and Fritz Perls, both of whom valued (in different ways) present-moment emotional experience for its power to create meaning and guide behavior. Johnson and Greenberg saw the need to combine experiential therapy with the systems theoretical view that meaning-making and behavior cannot be considered outside of the whole situation in which they occur. In this "experiential–systemic" approach to couples therapy, as in other approaches to systemic therapy, the problem is viewed as belonging not to one partner, but rather to the cyclical reinforcing patterns of interactions between partners. Emotion is viewed not only as a within-individual phenomena, but also as part of the whole system that organizes the interactions between partners.

In 1986, Greenberg chose "to refocus his efforts on developing and studying an experiential approach to individual therapy". Greenberg and colleagues shifted their attention away from couples therapy toward individual psychotherapy. They attended to emotional experiencing and its role in individual self-organization. Building on the experiential theories of Rogers and Perls and others such as Eugene Gendlin, as well as on their own extensive work on information processing and the adaptive role of emotion in human functioning, Greenberg, Rice & Elliott (1993) created a treatment manual with numerous clearly outlined principles for what they called a process-experiential approach to psychological change. Elliott et al. (2004) and Goldman & Greenberg (2015) have further expanded the process-experiential approach, with detailed manuals of specific methods of therapeutic intervention. Goldman & Greenberg (2015) presents case formulation maps for this approach.

Johnson continued to develop EFT for couples, integrating attachment theory with systemic and humanistic approaches, and explicitly expanding attachment theory's understanding of love relationships. Johnson's model retained the original three stages and nine steps and two sets of interventions that aim to reshape the attachment bond: one set of interventions to track and restructure patterns of interaction and one to access and reprocess emotion. Johnson's goal is the creation of positive cycles of interpersonal interaction wherein individuals are able to ask for and offer comfort and support to safe others, facilitating interpersonal emotion regulation.

Greenberg & Goldman (2008) developed a variation of EFT for couples that contains some elements from Greenberg and Johnson's original formulation but adds several steps and stages. Greenberg and Goldman posit three motivational dimensions—(1) attachment, (2) identity or power, and (3) attraction or liking—that impact emotion regulation in intimate relationships.

Similar terminology, different meanings

The terms emotion-focused therapy and emotionally focused therapy have different meanings for different therapists. 

In Les Greenberg's approach the term emotion-focused is sometimes used to refer to psychotherapy approaches in general that emphasize emotion. Greenberg "decided that on the basis of the development in emotion theory that treatments such as the process experiential approach, as well as some other approaches that emphasized emotion as the target of change, were sufficiently similar to each other and different from existing approaches to merit being grouped under the general title of emotion-focused approaches." He and colleague Rhonda Goldman noted their choice to "use the more American phrasing of emotion-focused to refer to therapeutic approaches that focused on emotion, rather than the original, possibly more English term (reflecting both Greenberg's and Johnson's backgrounds) emotionally focused." Greenberg uses the term emotion-focused to suggest assimilative integration of an emotional focus into any approach to psychotherapy. He considers the focus on emotions to be a common factor among various systems of psychotherapy: "The term emotion-focused therapy will, I believe, be used in the future, in its integrative sense, to characterize all therapies that are emotion-focused, be they psychodynamic, cognitive-behavioral, systemic, or humanistic." Greenberg co-authored a chapter on the importance of research by clinicians and integration of psychotherapy approaches that stated:

In addition to these empirical findings, leaders of major orientations have voiced serious criticisms of their preferred theoretical approaches, while encouraging an open-minded attitude toward other orientations.... Furthermore, clinicians of different orientations recognized that their approaches did not provide them with the clinical repertoire sufficient to address the diversity of clients and their presenting problems.

Sue Johnson's use of the term emotionally focused therapy refers to a specific model of relationship therapy that explicitly integrates systems and experiential approaches and places prominence upon attachment theory as a theory of emotion regulation. Johnson views attachment needs as a primary motivational system for mammalian survival; her approach to EFT focuses on attachment theory as a theory of adult love wherein attachment, care giving, and sex are intertwined. Attachment theory is seen to subsume the search for personal autonomy, dependability of the other and a sense of personal and interpersonal attractiveness, lovability and desire. Johnson's approach to EFT aims to reshape attachment strategies towards optimal interdependency and emotion regulation, for resilience and physical, emotional, and relational health.

Features

Experiential focus

All EFT approaches have retained emphasis on the importance of Rogerian empathic attunement and communicated understanding. They all focus upon the value of engaging clients in emotional experiencing moment-to-moment in session. Thus, an experiential focus is prominent in all EFT approaches. All EFT theorists have expressed the view that individuals engage with others on the basis of their emotions, and construct a sense of self from the drama of repeated emotionally laden interactions.

The information-processing theory of emotion and emotional appraisal (in accordance with emotion theorists such as Magda B. Arnold, Paul Ekman, Nico Frijda, and James Gross) and the humanistic, experiential emphasis on moment-to-moment emotional expression (developing the earlier psychotherapy approaches of Carl Rogers, Fritz Perls, and Eugene Gendlin) have been strong components of all EFT approaches since their inception. EFT approaches value emotion as the target and agent of change, honoring the intersection of emotion, cognition, and behavior. EFT approaches posit that emotion is the first, often subconscious response to experience. All EFT approaches also use the framework of primary and secondary (reactive) emotion responses.

Maladaptive emotion responses and negative patterns of interaction

Greenberg and some other EFT theorists have categorized emotion responses into four types (see § Emotion response types below) to help therapists decide how to respond to a client at a particular time: primary adaptive, primary maladaptive, secondary reactive, and instrumental. Greenberg has posited six principles of emotion processing: (1) awareness of emotion or naming what one feels, (2) emotional expression, (3) regulation of emotion, (4) reflection on experience, (5) transformation of emotion by emotion, and (6) corrective experience of emotion through new lived experiences in therapy and in the world. While primary adaptive emotion responses are seen as a reliable guide for behavior in the present situation, primary maladaptive emotion responses are seen as an unreliable guide for behavior in the present situation (alongside other possible emotional difficulties such as lack of emotional awareness, emotion dysregulation, and problems in meaning-making).

Johnson rarely distinguishes between adaptive and maladaptive primary emotion responses, and rarely distinguishes emotion responses as dysfunctional or functional. Instead, primary emotional responses are usually construed as normal survival reactions in the face of what John Bowlby called "separation distress". EFT for couples, like other systemic therapies that emphasize interpersonal relationships, presumes that the patterns of interpersonal interaction are the problematic or dysfunctional element. The patterns of interaction are amenable to change after accessing the underlying primary emotion responses that are subconsciously driving the ineffective, negative reinforcing cycles of interaction. Validating reactive emotion responses and reprocessing newly accessed primary emotion responses is part of the change process.

Individual therapy

Individual therapy

Goldman & Greenberg 2015 proposed a 14-step case formulation process that regards emotion-related problems as stemming from at least four different possible causes: lack of awareness or avoidance of emotion, dysregulation of emotion, maladaptive emotion response, or a problem with making meaning of experiences. The theory features four types of emotion response, categorizes needs under "attachment" and "identity", specifies four types of emotional processing difficulties, delineates different types of empathy, has at least a dozen different task markers, relies on two interactive tracks of emotion and narrative processes as sources of information about a client, and presumes a dialectical-constructivist model of psychological development and an emotion schematic system.

The emotion schematic system is seen as the central catalyst of self-organization, often at the base of dysfunction and ultimately the road to cure. For simplicity, we use the term emotion schematic process to refer to the complex synthesis process in which a number of coactivated emotion schemes coapply, to produce a unified sense of self in relation to the world.

Techniques used in "coaching clients to work through their feelings" may include the Gestalt therapy empty chair technique, frequently used for resolving "unfinished business", and the two-chair technique, frequently used for self-critical splits.

Emotion response types

Sadness

 

Anger

 

Fear

 

Emotion-focused theorists have posited that each person's emotions are organized into idiosyncratic emotion schemes that are highly variable both between people and within the same person over time, but for practical purposes emotional responses can be classified into four broad types: primary adaptive, primary maladaptive, secondary reactive, and instrumental.

1. Primary adaptive emotion responses are initial emotional responses to a given stimulus that have a clear beneficial value in the present situation—for example, sadness at loss, anger at violation, and fear at threat. Sadness is an adaptive response when it motivates people to reconnect with someone or something important that is missing. Anger is an adaptive response when it motivates people to take assertive action to end the violation. Fear is an adaptive response when it motivates people to avoid or escape an overwhelming threat. In addition to emotions that indicate action tendencies (such as the three just mentioned), primary adaptive emotion responses include the feeling of being certain and in control or uncertain and out of control, and/or a general felt sense of emotional pain—these feelings and emotional pain do not provide immediate action tendencies but do provide adaptive information that can be symbolized and worked through in therapy. Primary adaptive emotion responses "are attended to and expressed in therapy in order to access the adaptive information and action tendency to guide problem solving."
2. Primary maladaptive emotion responses are also initial emotional responses to a given stimulus; however, they are based on emotion schemes that are no longer useful (and that may or may not have been useful in the person's past) and that were often formed through previous traumatic experiences. Examples include sadness at the joy of others, anger at the genuine caring or concern of others, fear at harmless situations, and chronic feelings of insecurity/fear or worthlessness/shame. For example, a person may respond with anger at the genuine caring or concern of others because as a child he or she was offered caring or concern that was usually followed by a violation; as a result, he or she learned to respond to caring or concern with anger even when there is no violation. The person's angry response is understandable, and needs to be met with empathy and compassion even though his or her angry response is not helpful. Primary maladaptive emotion responses are accessed in therapy with the aim of transforming the emotion scheme through new experiences.
3. Secondary reactive emotion responses are complex chain reactions where a person reacts to his or her primary adaptive or maladaptive emotional response and then replaces it with another, secondary emotional response. In other words, they are emotional responses to prior emotional responses. ("Secondary" means that a different emotion response occurred first.) They can include secondary reactions of hopelessness, helplessness, rage, or despair that occur in response to primary emotion responses that are experienced (secondarily) as painful, uncontrollable, or violating. They may be escalations of a primary emotion response, as when people are angry about being angry, afraid of their fear, or sad about their sadness. They may be defenses against a primary emotion response, such as feeling anger to avoid sadness or fear to avoid anger; this can include gender role-stereotypical responses such as expressing anger when feeling primarily afraid (stereotypical of men's gender role), or expressing sadness when primarily angry (stereotypical of women's gender role). "These are all complex, self-reflexive processes of reacting to one's emotions and transforming one emotion into another. Crying, for example, is not always true grieving that leads to relief, but rather can be the crying of secondary helplessness or frustration that results in feeling worse." Secondary reactive emotion responses are accessed and explored in therapy in order to increase awareness of them and to arrive at more primary and adaptive emotion responses.
4. Instrumental emotion responses are experienced and expressed by a person because the person has learned that the response has an effect on others, "such as getting them to pay attention to us, to go along with something we want them to do for us, to approve of us, or perhaps most often just not to disapprove of us." Instrumental emotion responses can be consciously intended or unconsciously learned (i.e., through operant conditioning). Examples include crocodile tears (instrumental sadness), bullying (instrumental anger), crying wolf (instrumental fear), and feigned embarrassment (instrumental shame). When a client responds in therapy with instrumental emotion responses, it may feel manipulative or superficial to the therapist. Instrumental emotion responses are explored in therapy in order to increase awareness of their interpersonal function and/or the associated primary and secondary gain.

The therapeutic process with different emotion responses

Emotion-focused theorists have proposed that each type of emotion response calls for a different intervention process by the therapist. Primary adaptive emotion responses need be more fully allowed and accessed for their adaptive information. Primary maladaptive emotion responses need to be accessed and explored to help the client identify core unmet needs (e.g., for validation, safety, or connection), and then regulated and transformed with new experiences and new adaptive emotions. Secondary reactive emotion responses need empathic exploration in order to discover the sequence of emotions that preceded them. Instrumental emotion responses need to be explored interpersonally in the therapeutic relationship to increase awareness of them and address how they are functioning in the client's situation. 

It is important to note that primary emotion responses are not called "primary" because they are somehow more real than the other responses; all of the responses feel real to a person, but therapists can classify them into these four types in order to help clarify the functions of the response in the client's situation and how to intervene appropriately.

Therapeutic tasks

A therapeutic task is an immediate problem that a client needs to resolve in a psychotherapy session. In the 1970s and 1980s, researchers such as Laura North Rice (a former colleague of Carl Rogers) applied task analysis to transcripts of psychotherapy sessions in an attempt to describe in more detail the process of clients' cognitive and emotional change, so that therapists might more reliably provide optimal conditions for change. This kind of psychotherapy process research eventually led to a standardized (and evolving) set of therapeutic tasks in emotion-focused therapy for individuals.

The following table summarizes the standard set of these therapeutic tasks as of 2012. The tasks are classified into five broad groups: empathy-based, relational, experiencing, reprocessing, and action. The task marker is an observable sign that a client may be ready to work on the associated task. The intervention process is a sequence of actions carried out by therapist and client in working on the task. The end state is the desired resolution of the immediate problem.

In addition to the task markers listed below, other markers and intervention processes for working with emotion and narrative have been specified: same old stories, empty stories, unstoried emotions, and broken stories.

Therapeutic tasks in emotion-focused therapy for individuals

	Task marker	Intervention process	End state
Empathy-based tasks	Problem-relevant experience (e.g., interesting, troubling, intense, puzzling)	Empathic exploration	Clear marker, or new meaning explicated
	Vulnerability (painful emotion related to self)	Empathic affirmation	Self-affirmation (feels understood, hopeful, stronger)
Relational tasks	Beginning of therapy	Alliance formation	Productive working environment
	Therapy complaint or withdrawal difficulty (questioning goals or tasks; persistent avoidance of relationship or work)	Alliance dialogue (each explores own role in difficulty)	Alliance repair (stronger therapeutic bond or investment in therapy; greater self-understanding)
Experiencing tasks	Attentional focus difficulty (e.g., confused, overwhelmed, blank)	Clearing a space	Therapeutic focus; ability to work productively with experiencing (working distance)
	Unclear feeling (vague, external or abstract)	Experiential focusing	Symbolization of felt sense; sense of easing (feeling shift); readiness to apply outside of therapy (carrying forward)
	Difficulty expressing feelings (avoiding feelings, difficulty answering feeling questions)	Allowing and expressing emotion (also experiential focusing, systematic evocative unfolding, chairwork)	Successful, appropriate expression of emotion to therapist and others
Reprocessing tasks [situational-perceptual]	Difficult/traumatic experiences (narrative pressure to tell painful life stories)	Trauma retelling	Relief, validation, restoration of narrative gaps, understanding of broader meaning
	Problematic reaction point (puzzling over-reaction to specific situation)	Systematic evocative unfolding	New view of self in-the-world-functioning
	Meaning protest (life event violates cherished belief)	Meaning creation work	Revision of cherished belief
Action tasks [action tendency]	Self-evaluative split (self-criticism, tornness)	Two-chair dialogue	Self-acceptance, integration
	Self-interruption split (blocked feelings, resignation)	Two-chair enactment	Self-expression, empowerment
	Unfinished business (lingering bad feeling regarding significant other)	Empty-chair work	Let go of resentments, unmet needs regarding other; affirm self; understand or hold other accountable
	Stuck, disregulated anguish	Compassionate self-soothing	Emotional/bodily relief, self-empowerment

Emotion-focused therapy for trauma

The interventions and the structure of emotion-focused therapy have been adapted for the specific needs of psychological trauma survivors. A manual of emotion-focused therapy for individuals with complex trauma (EFTT) has been published. For example, modifications of the traditional Gestalt empty chair technique have been developed.

Other versions of EFT for individuals

Brubacher (2017) proposed an emotionally focused approach to individual therapy that focuses on attachment, while integrating the experiential focus of empathic attunement for engaging and reprocessing emotional experience and tracking and restructuring the systemic aspects and patterns of emotion regulation. The therapist follows the attachment model by addressing deactivating and hyperactivating strategies. Individual therapy is seen as a process of developing secure connections between therapist and client, between client and past and present relationships, and within the client. Attachment principles guide therapy in the following ways: forming the collaborative therapeutic relationship, shaping the overall goal for therapy to be that of "effective dependency" (following John Bowlby) upon one or two safe others, depathologizing emotion by normalizing separation distress responses, and shaping change processes. The change processes are: identifying and strengthening patterns of emotion regulation, and creating corrective emotional experiences to transform negative patterns into secure bonds.

Couples therapy

A couple

 

A systemic perspective is important in all approaches to EFT for couples. Tracking conflictual patterns of interaction, often referred to as a "dance" in Johnson's popular literature, has been a hallmark of the first stage of Johnson and Greenberg's approach since its inception in 1985. In Goldman and Greenberg's newer approach, therapists help clients "also work toward self-change and the resolution of pain stemming from unmet childhood needs that affect the couple interaction, in addition to working on interactional change." Goldman and Greenberg justify their added emphasis on self-change by noting that not all problems in a relationship can be solved only by tracking and changing patterns of interaction:

In addition, in our observations of psychotherapeutic work with couples, we have found that problems or difficulties that can be traced to core identity concerns such as needs for validation or a sense of worth are often best healed through therapeutic methods directed toward the self rather than to the interactions. For example, if a person's core emotion is one of shame and they feel "rotten at the core" or "simply fundamentally flawed," soothing or reassuring from one's partner, while helpful, will not ultimately solve the problem, lead to structural emotional change, or alter the view of oneself.

In Greenberg and Goldman's approach to EFT for couples, although they "fully endorse" the importance of attachment, attachment is not considered to be the only interpersonal motivation of couples; instead, attachment is considered to be one of three aspects of relational functioning, along with issues of identity/power and attraction/liking. In Johnson's approach, attachment theory is considered to be the defining theory of adult love, subsuming other motivations, and it guides the therapist in processing and reprocessing emotion.

In Greenberg and Goldman's approach, the emphasis is on working with core issues related to identity (working models of self and other) and promoting both self-soothing and other-soothing for a better relationship, in addition to interactional change. In Johnson's approach, the primary goal is to reshape attachment bonds and create "effective dependency" (including secure attachment).

Stages and steps

EFT for couples features a nine-step model of restructuring the attachment bond between partners. In this approach, the aim is to reshape the attachment bond and create more effective co-regulation and "effective dependency", increasing individuals' self-regulation and resilience. In good-outcome cases, the couple is helped to respond and thereby meet each other's unmet needs and injuries from childhood. The newly shaped secure attachment bond may become the best antidote to traumatic experience from within and outside of the relationship. 

Adding to the original three-stage, nine-step EFT framework developed by Johnson and Greenberg, Greenberg and Goldman's emotion-focused therapy for couples has five stages and 14 steps. It is structured to work on identity issues and self-regulation prior to changing negative interactions. It is considered necessary, in this approach, to help partners experience and reveal their own underlying vulnerable feelings first, so they are better equipped to do the intense work of attuning to the other partner and to be open to restructuring interactions and the attachment bond.

Johnson (2008) summarizes the nine treatment steps in Johnson's model of EFT for couples: "The therapist leads the couple through these steps in a spiral fashion, as one step incorporates and leads into the other. In mildly distressed couples, partners usually work quickly through the steps at a parallel rate. In more distressed couples, the more passive or withdrawn partner is usually invited to go through the steps slightly ahead of the other."

Stage 1. Stabilization (assessment and de-escalation phase)

• Step 1: Identify the relational conflict issues between the partners
• Step 2: Identify the negative interaction cycle where these issues are expressed
• Step 3: Access attachment emotions underlying the position each partner takes in this cycle
• Step 4: Reframe the problem in terms of the cycle, unacknowledged emotions, and attachment needs

During this stage the therapist creates a comfortable and stable environment for the couple to have an open discussion about any hesitations the couples may have about the therapy, including the trustworthiness of the therapist. The therapist also gets a sense of the couple's positive and negative interactions from past and present and is able to summarize and present the negative patterns for them. Partners soon no longer view themselves as victims of their negative interaction cycle; they are now allies against it.

Stage 2. Restructuring the bond (changing interactional positions phase)

• Step 5: Access disowned or implicit needs (e.g., need for reassurance), emotions (e.g., shame), and models of self
• Step 6: Promote each partner's acceptance of the other's experience
• Step 7: Facilitate each partner's expression of needs and wants to restructure the interaction based on new understandings and create bonding events

This stage involves restructuring and widening the emotional experiences of the couple. This is done through couples recognizing their attachment needs, and then changing their interactions based on those needs. At first their new way of interacting may be strange and hard to accept, but as they become more aware and in control of their interactions they are able to stop old patterns of behavior from reemerging.

Stage 3. Integration and consolidation

• Step 8: Facilitate the formulation of new stories and new solutions to old problems
• Step 9: Consolidate new cycles of behavior

This stage focuses on reflection of new emotional experiences and self-concepts. It integrates the couple's new ways of dealing with problems within themselves and in the relationship.

Styles of attachment

Johnson & Sims (2000) described four attachment styles that affect the therapy process:

1. People who are secure and trusting perceive themselves as lovable, able to trust others and themselves within a relationship. They give clear emotional signals, and are engaged, resourceful and flexible in unclear relationships. Secure partners express feelings, articulate needs, and allow their own vulnerability to show.
2. People who have a diminished ability to articulate feelings, tend not to acknowledge their need for attachment, and struggle to name their needs in a relationship. They tend to adopt a safe position and solve problems dispassionately without understanding the effect that their safe distance has on their partners.
3. People who are psychologically reactive and who exhibit anxious attachment. They tend to demand reassurance in an aggressive way, demand their partner's attachment and tend to use blame strategies (including emotional blackmail) in order to engage their partner.
4. People who have been traumatized and have experienced little to no recovery from it vacillate between attachment and hostility.

Family therapy

A family

The emotionally focused family therapy (EFFT) of Johnson and her colleagues aims to promote secure bonds among distressed family members. It is a therapy approach consistent with the attachment-oriented experiential–systemic emotionally focused model in three stages: (1) de-escalating negative cycles of interaction that amplify conflict and insecure connections between parents and children; (2) restructuring interactions to shape positive cycles of parental accessibility and responsiveness to offer the child or adolescent a safe haven and a secure base; (3) consolidation of the new responsive cycles and secure bonds. Its primary focus is on strengthening parental responsiveness and care giving, to meet children and adolescents' attachment needs. It aims to "build stronger families through (1) recruiting and strengthening parental emotional responsiveness to children, (2) accessing and clarifying children's attachment needs, and (3) facilitating and shaping care giving interactions from parent to child". Some clinicians have integrated EFFT with play therapy.

One group of clinicians, inspired in part by Greenberg's approach to EFT, developed a treatment protocol specifically for families of individuals struggling with an eating disorder. The treatment is based on the principles and techniques of four different approaches: emotion-focused therapy, behavioral family therapy, motivational enhancement therapy, and the New Maudsley family skills-based approach. It aims to help parents "support their child in the processing of emotions, increasing their emotional self-efficacy, deepening the parent–child relationships and thereby making ED [eating disorder] symptoms unnecessary to cope with painful emotional experiences". The treatment has three main domains of intervention, four core principles, and five steps derived from Greenberg's emotion-focused approach and influenced by John Gottman: (1) attending to the child's emotional experience, (2) naming the emotions, (3) validating the emotional experience, (4) meeting the emotional need, and (5) helping the child to move through the emotional experience, problem solving if necessary.

Efficacy

Johnson, Greenberg, and many of their colleagues have spent their long careers as academic researchers publishing the results of empirical studies of various forms of EFT.

The American Psychological Association considers emotion-focused therapy for individuals to be an empirically supported treatment for depression. Studies have suggested that it is effective in the treatment of depression, interpersonal problems, trauma, and avoidant personality disorder.

Practitioners of EFT have claimed that studies have consistently shown clinically significant improvement post therapy. Studies, again mostly by EFT practitioners, have suggested that emotionally focused therapy for couples is an effective way to restructure distressed couple relationships into safe and secure bonds with long-lasting results. Johnson et al. (1999) conducted a meta-analysis of the four most rigorous outcome studies before 2000 and concluded that the original nine-step, three-stage emotionally focused therapy approach to couples therapy had a larger effect size than any other couple intervention had achieved to date, but this meta-analysis was later harshly criticized by psychologist James C. Coyne, who called it "a poor quality meta-analysis of what should have been left as pilot studies conducted by promoters of a therapy in their own lab". A study with an fMRI component suggested that emotionally focused couples therapy reduces the brain's response to threat in the presence of a romantic partner, but this study too was later harshly criticized by Coyne.

Strengths

Some of the strengths of EFT approaches can be summarized as follows:

• EFT aims to be collaborative and respectful of clients, combining experiential person-centered therapy techniques with systemic therapy interventions.
• Change strategies and interventions are specified through intensive analysis of psychotherapy process.
• EFT has been validated by 30 years of empirical research. There is also research on the change processes and predictors of success.
• EFT has been applied to different kinds of problems and populations, although more research on different populations and cultural adaptations is needed.
• EFT for couples is based on conceptualizations of marital distress and adult love that are supported by empirical research on the nature of adult interpersonal attachment.

Criticism

Psychotherapist Campbell Purton, in his 2014 book The Trouble with Psychotherapy, criticized a variety of approaches to psychotherapy, including behavior therapy, person-centered therapy, psychodynamic therapy, cognitive behavioral therapy, emotion-focused therapy, and existential therapy; he argued that these psychotherapies have accumulated excessive and/or flawed theoretical baggage that deviates too much from an everyday common-sense understanding of personal troubles. With regard to emotion-focused therapy, Purton argued that "the effectiveness of each of the 'therapeutic tasks' can be understood without the theory" and that what clients say "is not well explained in terms of the interaction of emotion schemes; it is better explained in terms of the person's situation, their response to it, and their having learned the particular language in which they articulate their response."

In 2014, psychologist James C. Coyne criticized some EFT research for lack of rigor (for example, being underpowered and having high risk of bias), but he also noted that such problems are common in the field of psychotherapy research.

In a 2015 article in Behavioral and Brain Sciences on "memory reconsolidation, emotional arousal and the process of change in psychotherapy", Richard D. Lane and colleagues summarized a common claim in the literature on emotion-focused therapy that "emotional arousal is a key ingredient in therapeutic change" and that "emotional arousal is critical to psychotherapeutic success". In a response accompanying the article, Bruce Ecker and colleagues (creators of coherence therapy) disagreed with this claim and argued that the key ingredient in therapeutic change involving memory reconsolidation is not emotional arousal but instead a perceived mismatch between an expected pattern and an experienced pattern; they wrote:

The brain clearly does not require emotional arousal per se for inducing deconsolidation. That is a fundamental point. If the target learning happens to be emotional, then its reactivation (the first of the two required elements) of course entails an experience of that emotion, but the emotion itself does not inherently play a role in the mismatch that then deconsolidates the target learning, or in the new learning that then rewrites and erases the target learning (discussed at greater length in Ecker 2015). [...] The same considerations imply that "changing emotion with emotion" (stated three times by Lane et al.) inaccurately characterizes how learned responses change through reconsolidation. Mismatch consists most fundamentally of a direct, unmistakable perception that the world functions differently from one's learned model. "Changing model with mismatch" is the core phenomenology.

Other responses to Lane et al. (2015) argued that their emotion-focused approach "would be strengthened by the inclusion of predictions regarding additional factors that might influence treatment response, predictions for improving outcomes for non-responsive patients, and a discussion of how the proposed model might explain individual differences in vulnerability for mental health problems", and that their model needed further development to account for the diversity of states called "psychopathology" and the relevant maintaining and worsening processes.