Transforming Generalized Anxiety

An emotion-focused approach

Ladislav Timulak, James McElvaney

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781315527239
• Edition: 1
• Topic: Psicología
• Subtopic: Psicología anormal

Transforming Generalized Anxiety: An Emotion Focused Approach examines an approach to treating generalized anxiety disorder (GAD) which attempts to uncover the deeper, underlying emotional experiences that clients are afraid of. It also demonstrates how these painful experiences can be transformed in therapy into a form of emotional resilience by generating experiences of self-compassion and healthy, boundary setting, protective anger.

Though most of the literature on treating GAD is dominated by Cognitive Behavior Therapy, this book presents emotion-focused therapy as an alternative treatment of this condition. The emotional resilience this particular approach instils serves as a resource when encountering triggers of emotional vulnerability, but also decreases the client's need to avoid hitherto feared triggers and the emotional experiences they bring. Developed in a series of research studies, and illustrated with reference to case examples, this book offers a practical, theoretically informed, evidence based guide, to conducting therapy with clients.

Using clinical material, and applying the outcome of a series of research studies, Transforming Generalized Anxiety will equip psychotherapists and counsellors with the means to help GAD clients transform core painful experiences into a sense of empowerment and inner confidence.

Chapter 1

Introduction

Emotion-focused therapy (EFT; Greenberg et al., 1993; Greenberg, 2002; Greenberg & Johnson, 1988) is a research-informed, psychological therapy, which derives from a tradition of humanistic therapies such as person-centered and Gestalt therapy. To date, EFT has mainly been studied in the context of depression, trauma, and couples distress (Elliott, Greenberg, Watson, Timulak, & Freire, 2013). This form of therapy is supported by a solid body of research evidence (cf. Angus, Watson, Elliott, Schneider, & Timulak, 2015; Elliott et al., 2013). The approach is also very popular among clinicians and many EFT-related books have been published (e.g., Elliott, Watson, Goldman, & Greenberg, 2004; Goldman & Greenberg, 2015; Greenberg, 2002; 2011; 2015; 2016; Greenberg & Johnson, 1988; Greenberg & Paivio, 1997; Greenberg, Rice, & Elliott, 1993; Greenberg & Watson, 2006; Johnson, 2004; Paivio & Pascual-Leone, 2010; Timulak, 2015; Watson, Goldman, & Greenberg, 2007; Watson & Greenberg, 2017). More recently, this approach has been applied to anxiety difficulties, such as social anxiety (Elliott, 2013; Shahar, 2014; Shahar, Bar-Kalifa, & Alon, 2017) and generalized anxiety (Timulak & McElvaney, 2016; Watson & Greenberg, 2017).

Generalized Anxiety Disorder (GAD), as currently conceptualized (see the next chapter, where we discuss diagnostic issues), is a debilitating condition characterized by excessive anxiety and worry, and other symptoms such as restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance (American Psychiatric Association, 2013). Cognitivebehavioral therapy (CBT) is the most widely recognized psychological treatment of GAD, but not all clients benefit from it (Hanrahan et al., 2013). Some authors have recommended that more psychological therapies be developed to offer a broader range of treatment options (Hunot, Churchill, Teixeira, & Silva de Lima, 2007). This book reports on learnings from a project which aimed to develop emotion-focused therapy for generalized anxiety disorder (GAD) difficulties, carried out by a research group based in Dublin under the lead of the first author, Ladislav (Laco) Timulak (LT). The project was conceived in 2006 (Timulak, 2006a; 2006b) and further developed in subsequent years (e.g., Timulak, 2008), driven by the first author’s interest in contributing to the development of EFT and a particular personal interest in anxiety as an area requiring further development in experiential psychotherapies (cf. Elliott, Greenberg, & Lietaer, 2004).

Funding for the project was sought in 2009. The second author, James McElvaney (JMcE), became the project manager in 2010 (the project was finalized under the management of our colleague Daragh Keogh to whom we are indebted for all the support he provided). The project was sponsored by the Irish Health Research Board, and its first phase focused on the development of EFT for GAD on the basis of a series of case studies, reported in the form of an open trial (Timulak, McElvaney, Keogh, Martin, Clare, Chepukova, & Greenberg, 2017). The project also involved several doctoral dissertations. Several publications have already been published, focusing on different aspects of the project (e.g., Murphy et al., 2017; O’Brien et al., 2017; Timulak, 2015; Timulak & McElvaney, 2016; Timulak & Pascual-Leone, 2015). The project has now entered a new phase, in which the developed approach is being tested against an established treatment in an RCT (again the project is sponsored by the Irish Health Research Board).

This book presents an EFT model, which we refer to as an emotion-­transformation model of conceptualizing GAD, as well as practical guidelines for conducting EFT with clients meeting criteria for GAD, based on our learning and experience from the project as clinicians, as well as researchers and theoreticians. To date, we have presented the model and interventions in a published paper (Timulak & McElvaney, 2016). Concurrently, Watson and Greenberg (2017) have made a distinct contribution to the development of EFT for GAD, and this is also described below.

Our approach

Most current psychotherapeutic treatments of GAD (see Chapter 2) focus on working with the experience of anxiety and pervasive worry. This book, on the contrary, describes an approach which focuses primarily on the underlying emotional experiences and their triggers, which clients worry about, are afraid of, and want to avoid. While the approach highlighted in this book also focuses on working with worry (through increasing clients’ awareness of their own agency, and by highlighting the cost of worry) and apprehensive anxiety, and the avoidance that worry feeds into, its primary focus is on working with the underlying feared experiences. These experiences appear to center on felt loneliness/sadness, shame and primary terror/fear and respective unmet needs for closeness (love), acknowledgment, and safety (Timulak, 2015). These core painful experiences are transformed in therapy by the generation of experiences of (self-) compassion and healthy, boundary-setting, protective anger. These experiences of compassion and protective anger lead to natural grieving (as a natural follow on from compassionate experience) and the building of a sense of empowerment and inner confidence (see Pascual-Leone & Greenberg, 2007; Pascual-Leone, 2009; Timulak, 2015; Timulak & Pascual-Leone, 2015). Transformation of underlying vulnerabilities, and the corresponding self–self and self–other relating processes that contributed to those vulnerabilities, increases clients’ sense of emotional resilience and their confidence in being able to bear painful emotional experiences and handle the (interpersonal and intrapersonal) processes that trigger them. The client’s emotional resilience can then serve as a resource when encountering triggers of emotional vulnerability. Furthermore, the gradual building of emotional resilience decreases clients’ need to avoid the feared triggers and the emotional experiences they bring (Timulak & McElvaney, 2016).

Watson and Greenberg’s EFT for GAD model

As we were finishing our work on the book, a new book by Jeanne Watson and Les Greenberg (2017) was published that described their conceptualization of generalized anxiety and an emotion-focused treatment of it. Given that our book was practically finished by that time, we decided not to comment on Watson and Greenberg’s work throughout our book, as it would delay our contractual deadline. Instead, we decided to read through it and see whether we might offer a more global statement on the similarities and potential differences. In general, we do not see any major differences between the contents of their book and what we are outlining in the pages that follow. One of us (LT), had an opportunity to work on a chapter with Jeanne and Les (Watson, Timulak, & Greenberg, in press) a few months before their book was published, and it was apparent that there were no major theoretical or clinical differences in their thinking about EFT for GAD to ours. Indeed, we suspect that if the readers saw EFT for GAD in practice, based on either of the two books, they would not be certain on which of the writings the observed treatment was based. It is more likely that there may be individual differences due to the idiosyncratic styles of the therapists, rather than because of adherence to any particular, written account of working with clients with GAD from an EFT perspective.

If we were to comment on some of the differences, they would mainly concern the language used, and various differences in emphasis regarding certain conceptualizations and descriptions. This, however, is not surprising in a process where thoughts and observations have developed independently between two groups (although we would have been in professional contact with Jeanne and Les during the period when we were working on our project). We see our book as building on previous work described in Timulak (2015), that was influenced by the research on sequential emotional processing by Pascual-Leone and Greenberg (Pascual-Leone & Greenberg, 2007; Pascual-Leone, 2009) and of course on other classical EFT writings (the works of Greenberg, Elliott, Watson, Goldman, Paivio, etc.). Furthermore, almost all examples of the actual work in Timulak’s (2015) book were based on work with clients who met criteria for GAD.

In comparison, we see Watson and Greenberg’s book (2017) as being more in line with the conceptualizations presented in their previous book on working with depression (Greenberg & Watson, 2006) and other traditional EFT writing. For instance, if we were to pick some examples of difference, we do not use the language of “resolution”, as we do not see the goal of therapy as necessarily resolving worry, negative self-treatment, or emotional injuries. We rather ­emphasize the importance of increased emotional flexibility and resilience (cf. Pascual-Leone, 2009) without postulating that there is a particular end point, at which painful emotions or problematic self–self or self–other processes are resolved. Another point of difference arises in our discussion of our difficulties with the GAD diagnosis, which is not such a prominent issue with Watson and Greenberg. Furthermore, we do not think in terms of the vulnerable self, when conceptualizing core chronic painful feelings and corresponding self-organizations, although we see that term as useful. We simply refer to chronic painful feelings (and corresponding self-organizations), perhaps capturing the fluidity of the process. We can, of course, clearly recognize that fluidity in Watson and Greenberg’s account.

On a more clinical level, we can see that at times there may be some different emphases or variations. These could be attributed to different creative ways of using emotion-focused strategies and tasks, while following the same goals. At times, however, we had a sense that a self-soothing (self-compassion) process could be seen as somewhat more central than protective anger, in Watson and Greenberg’s account. In line with our previous writing (e.g., Timulak, 2015) we see both processes as equally important, although for a particular client one or other of these processes may be more important at a certain point in time. For example, if the client has difficulty accessing self-compassion, this may become a more central focus of therapy. Conversely, if the client has difficulty accessing anger, this may become targeted more in therapy. If we see any shared feature with regard to compassion and anger, when working with clients with anxiety difficulties, we see the importance of being able to access protective anger as particularly important, as it supports the person in feeling confident, expansive, and powerful, in other words, the opposite of scared and avoidant.

While we have attempted to point out some potential differences, we have not had an opportunity to discuss them with our esteemed colleagues. It may well be that they mainly represent language-influenced differences, which may become very small differences in actual EFT practice. We warmly recommend the expertly presented conceptualization of generalized anxiety and its emotion-focused treatment by Watson and Greenberg (2017). We found their account inspiring. It offered a great deal of opportunity for fruitful and stimulating reflection.

The book outline

After this introduction, the book will consist of four parts. The first part will outline the theoretical background, comprising three chapters. Chapter 2 will cover essential information on GAD such as definitions (including historical conceptualizations), prevalence, course, comorbidity, and the overall burden it imposes. The chapter will also present current psychological conceptualizations of GAD, particularly those stemming from a CBT theoretical framework. An outline of treatments based on these theoretical models will also be provided, together with information on their effectiveness.

Chapter 3 will present a brief overview of EFT theory. It will briefly ­summarize research evidence supporting the approach and will present the main theoretical concepts. It will also present the basic principles of clinical practice such as case conceptualization, use of the therapeutic relationship, and the use of a variety of treatment tasks.

Chapter 4 will present our Emotion Transformation model of GAD, based on the research projects run in the first author’s lab. The model assumes that there are particular, painful triggers in the client’s life that are difficult for the client to process emotionally. The client is afraid of these triggers and of the emotional experiences they bring, and attempts either to avoid the triggers, or manage them, by toughening up or by preparing him or herself for them through worry. This leads to an undifferentiated state of distress combined with anxiety and avoidance. The underlying feared core emotional pain characterized by feelings of loneliness, shame, and primary fear is then obscured, and unmet needs linked with those core experiences are unarticulated. A brief outline of therapy will also be offered here.

The second part of the book will focus on the initial building blocks of working with clients who suffer with generalized anxiety disorder in an emotion-focused way. Chapter 5 will present research-informed propositions about the qualities of the therapeutic relationship offered by the therapist that contribute to the client’s sense of safety, emotion regulation, and corrective emotional experiences. Attention will be paid to interpersonal sensitivities, which clients may bring to therapy and how they may impact on the development of safe, corrective relationships. Space will be devoted to showing how the therapist strives to build an authentic, compassionate, and validating relationship with the client.

Chapter 6 will follow on from Chapter 4 and will introduce our case conceptualization model in therapy. The model presents a conceptual framework consisting of: triggers of emotional pain; problematic self-treatment in the context of the triggers; apprehensive anxiety of the triggers, leading to emotional avoidance of the painful feelings and behavioral avoidance of painful triggers; global distress; the underlying feared core emotional pain; and related unmet needs. The model also refers to a strategy for therapy, which aims towards bringing in therapeutic experiences that respond to the underlying pain and unmet needs (e.g., compassion and healthy anger). The cost of avoidance is also highlighted, as is the way it can be used to contribute to the mobilization of determination to overcome anxiety. The chapter will also discuss how the therapist uses case conceptualization in therapy.

Chapter 7 will introduce some EFT tasks and strategies that can be used in therapy to help clients overcome their avoidance of the core emotional pain that needs to be transformed in therapy. The chapter will particularly focus on working with self-interruption and self-worry tasks. There will be an original description of working with worry, which was developed in our lab. The model assumes that worry is enacted in the two-chair task. The anxiety that the worry produces is amplified, the need and vulnerability (exhaustion) in the anxiety is articulated, and protective anger and self-compassion are generated.

The third part of the book presents Chapter 8, which focuses on accessing and transforming core, feared painful feelings. This chapter will focus on the strategies employed to access and differentiate the core emotional pain in the context of working with clients with GAD difficulties. The parts of the experiential tasks that allow access to the underlying painful emotions will be presented, with a specific focus on how the primary maladaptive emotions are accessed. The chapter will also focus on how the unmet needs present in the core painful feelings can be articulated in therapy. It also examines ways of generating experiences of self-compassion and healthy protective anger that serve as antidotes to the core painful feelings and as responses to the unmet needs.

The final part of the book presents a chapter which discusses adaptions of therapeutic strategy to various stages in therapy, and a chapter focusing on learning EFT for GAD. Chapter 9 will discuss the stages of therapy (beginning, middle, and end). It will also focus on issues of timing and the strategic use of therapy in specific circumstances such as time-limited therapy, work with comorbid conditions, personality characteristics of clients, problems in therapy, et cetera. It will also discuss the use of homework and various psychoeducational formats that can be applied, based on the formulations presented in the book. Chapter 10 will provide information on how to incorporate the therapeutic strategies highlighted in the book into one’s existing therapeutic repertoire (e.g., other therapeutic orientations...

Table of contents

• Cover
• Series
• Half-Title
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• 1 Introduction
• PART I Theoretical underpinnings
• PART II Building blocks of delivering EFT for GAD
• PART III Transformative work
• PART IV Practicalities of delivering EFT for GAD
• References
• Index