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Evidence-Based Principles from Psychodynamic and

Process-Experiential Psychotherapies

Keith J. Edwards and Edward B. Davis

Psychotherapy commonly centers on treating clients with emotional, relational and identity difficulties. Psychodynamic and process-experiential (PE) psychotherapies are frequently used for treating such problems, but among scientists and practitioners alike, there is a pervasive and popularized notion that these psychotherapies lack empirical support (Elliott, 2002; Shedler, 2010). Such a notion may in part emanate from what Shedler (2010) described as “lingering distaste” for the psychoanalytic community, based on that community’s “past arrogance and authority” (p. 98). It may also reflect a response to the historically dismissive stance that the psychodynamic and PE communities have taken toward research. Nonetheless, the growing demand for time-efficient and evidence-based treatments has resulted in the development of psychodynamic and PE approaches that are both short-term and evidence-based (Elliott, Watson, Goldman & Greenberg, 2004; Shedler, 2010).

Addressing Problematic Worldview Assumptions

Many Christian counselors and psychotherapists have worldview-related reservations about psychodynamic and PE approaches based on inconsistencies between these traditions’ underlying worldview assumptions and those of traditional Christian theology. For example, both psychodynamic and PE psychotherapies emphasize ideals of autonomy, self-determination and personal fulfillment, whereas traditional Christian theology emphasizes ideals of depending on God, being led by the Holy Spirit and finding fulfillment through Christlike service.

Indeed, for Christian mental-health professionals, there are myriad worldview-conflicts between psychodynamic/PE models and orthodox Christian doctrine. We do not have the space to address all such conflicts. Instead, we will briefly comment on why it makes sense for Christian counselors and psychotherapists to appropriate some principles from psychodynamic and PE treatments in the service of Christ, his church and his kingdom.

Appropriating Principles from Psychodynamic and Process-Experiential Psychotherapies

There are several reasons for Christian counselors and psychotherapists to appropriate principles from psychodynamic and PE psychotherapies. For instance, Christianity is an experientially focused religion in which positive transformation occurs primarily through loving relationships with God and others. Similarly, psychodynamic/PE treatments are chiefly dedicated to providing clients with corrective emotional experiences in the therapy relationship (Moriarty & Davis, 2012; cf. Norcross, 2011). For this reason, a Christian counselor or psychotherapist can use these techniques to facilitate deep-level, sanctifying transformation in clients’ relationships with God, others and themselves.

In this chapter, we discuss evidence-based psychodynamic and PE strategies that can be used in Christian counseling and psychotherapy. Toward that end, we argue that the worldview-conflicts

Edwards, Keith J., and Edward B. Davis. Evidence-Based Principles from Psychodynamic and Process-Experiential Psychotherapies : Chapter 7, Evidence-Based Practices for Christian Counseling and Psychotherapy, InterVarsity Press, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/liberty/detail.action?docID=5389502. Created from liberty on 2025-05-27 03:40:38.

between psychodynamic/PE models and Christian theology can be reconciled by distinguishing between content and process. For example, one can use emotionally evocative communication strategies (same process) to either preach the gospel of Jesus or propagate the philosophy of Marxism (different contents). Similarly, despite the worldview conflicts between psychodynamic/PE models and Christian theology, Christian counselors and psychotherapists can use psychodynamic/PE strategies to promote the positive growth of Christian clients.

In fact, psychodynamic/PE treatments actually process—particularly emotionally richprivilege experiential processing. Therapists skilled in using psychodynamic/PE techniques must be process experts who are able to facilitate the client’s deep emotional engagement and experiencing, because these processes are the presumed mechanisms of change. It is this type of processing that can reveal the rich layers of client’s experiences, opening up possibilities for increased insight and for growth- promoting meaning making (Greenberg, 2011).

When using psychodynamic/PE techniques, the task of meaning making is where process and content are integrated. Within the context of Christian counseling and psychotherapy, because the clinician and the client share a common meaning-making framework (i.e., a Christian worldview), theologically informed transformation is perhaps especially possible.

Unfortunately, there are as of yet no randomized controlled trials examining the efficacy of Christian- accommodated psychodynamic or PE treatments. However, we hypothesize that Christian counselorsall and psychotherapists can benefit from appropriating the evidence-based principles of psychotherapeutic change that are emphasized within the psychodynamic and PE traditions—namely the adept tracking and directing of therapeutic process. In other words, we believe all Christian clinicians can become more effective if they cultivate process expertise (e.g., through becoming competent in using psychodynamic and PE interventions).

The remainder of this chapter is divided into two parts. First, we review the empirical evidence supporting the efficacy of psychodynamic and PE psychotherapies. Next, we describe a three-phase model of experiential therapy, integrating psychodynamic and PE approaches (Greenberg & Watson, 2006). At various places, we discuss ways that Christian counselors and psychotherapists can use these types of interventions in their work with Christian clients.

Empirical Support for Treatment Efficacy

The efficacy of psychodynamic psychotherapy. Perhaps the best available research on the efficacy of psychodynamic psychotherapy is Gerber et al.’s (2011) review-article, the culminating report of their ad hoc subcommittee for evaluation of the evidence base for psychodynamic psychotherapy. This committee was comprised of five expert psychotherapy researchers—three who espoused a psychodynamic theoretical orientation and two who espoused a nonpsychodynamic one. They examined fifty-four randomized controlled trials (RCTs) that were deemed to be of at least adequate methodological quality. The RCTs included a total of sixty-three comparisons between psychodynamic psychotherapy and either an comparison group ( = 39 comparisons; i.e., a group who received anactive n evidence-based treatment or a specific/presumed-effective treatment) or an comparison group (inactive n = 24 comparisons; i.e., a group that received no treatment, treatment as usual, or a minimal/presumed- ineffective treatment). Relative to comparators ( = 39), psychodynamic treatments evidencedactive n better outcomes in six comparisons (15%), poorer outcomes in five comparisons (13%), and statistically equivalent outcomes in twenty-eight comparisons (72%). In contrast, relative to comparators (inactive n = 24), psychodynamic treatments evidenced better outcomes in eighteen comparisons (75%) and statistically equivalent outcomes in six comparisons (25%; Gerber et al., 2011). In sum, Gerber et al.

(2011) concluded that the empirical support for psychodynamic psychotherapy is but mainlypromising suggests that psychodynamic psychotherapy is more efficacious than an inactive comparator. Relative to other active treatments (e.g., CBT), the evidence suggests statistically equivalent efficacy.

At the time of writing this chapter (May 2013), no psychodynamic treatments have received enough empirical support to be consensually deemed as per Chambless et al.’s (1998) gold-well-established standard criteria for classifying evidence-based treatments. Only two have received enough to be considered (a) short-term psychodynamic psychotherapy for depression and (b)probably efficacious: psychodynamic treatment for panic disorder (for a regularly updated list of evidence-based treatments, see ).www.psycho logicaltreatments.org

Before proceeding, it is important to summarize Shedler’s (2010) controversial review of meta- analytic research on the efficacy of psychodynamic psychotherapy. Of the meta-analyses Shedler (2010) reviewed, the two most methodologically rigorous were (a) Abbass et al. (2006) and (b) Leichsenring, Rabung and Leibing (2004). Both meta-analyses examined only the highest-quality RCTs ( = 23 and 17n RCTs, respectively, with eight overlapping) of short-term psychodynamic psychotherapy (i.e., forty hours or less; = 15 and 21 sessions, respectively), relative to inactive comparators. These meta-M analyses synthesized the RCT findings into a quantifiable common metric: an (ES)—that is,effect size the standardized mean difference between comparison groups (i.e., the group-mean difference, expressed in standard-deviation units). (Conventional interpretive guidelines suggest that an ES of 0.8 indicates a large effect, 0.5 indicates a moderate effect, and 0.2 indicates a small effect.)

Abbass et al. (2006) found that, for general psychiatric symptoms, short-term psychodynamic psychotherapy evidenced a between-groups, control-referenced ES of 0.97 at therapy termination and of 1.51 at long-term follow-up (>9 months post-therapy). Leichsenring et al. (2004) found that for general

short-term psychodynamic psychotherapy ( = 15 RCTs) demonstrated a between-psychiatric symptoms n groups, control-referenced ES of 0.90 ( = 0.48) at therapy termination and of 0.95 at follow-up ( =SD M 14 months); for ( = 17 RCTs), 1.39 ( = 0.83) and 1.57 ( = 0.88),presenting problems n SD SD respectively. Notably, when the outcomes of short-term psychodynamic psychotherapy and active comparators (e.g., CBT) were compared, the respective therapy-termination and follow-up data were statistically equivalent, both for general psychiatric symptoms ( = 14 RCTs at therapy-termination andn 12 at follow-up) and for target problems ( = 15 and 14 RCTs, respectively; Abbass et al., 2006),n supporting Gerber et al.’s (2011) conclusions. Importantly, these data Shedler’s (2010) claimscontradict that (a) psychodynamic psychotherapy uniquely leads to benefits that increase over time and (b) the benefits of nonpsychodynamic treatments tend to decay. Indeed, Shedler’s article has received a number of worthy criticisms (e.g., Anestis, Anestis & Lilienfeld, 2011).

The efficacy of Christian-accommodated psychodynamic treatments. Only two outcome studies have examined the efficacy of Christian-accommodated psychodynamic treatments: Tisdale et al. (1997) and Thomas, Moriarty, Davis and Anderson (2011). However, these studies offer only pilot data, because each study lacked a control group and included other types of treatment (e.g., pharmacotherapy, psychoeducation). Tisdale et al. (1997) examined the change experienced by clients who participated in an object-relations oriented, multimodal program for adult psychiatric inpatients. The treatment program involved an integration of object relations theory with theological principles, as described in books by Cloud and Townsend (e.g., 2004). Relative to admission scores, participants’ discharge scores evidenced statistically significant improvements in god images (i.e., the mental/neural representations that underlie a person’s embodied, emotional relationship with God; Davis, 2010) and self-images (i.e., the mental /neural representations that underlie a person’s thoughts and feelings about themselves). However, only the latter were large enough to be considered clinically meaningful. Of note, the evidenced changes in self-images over the twelve-month follow-up period, while the changes in god images enduredincreased but did not improve further.

In another pilot study, Thomas et al. (2011) used a Christian-accommodated, psychotherapy- integrationist oriented, eight-week, manualized protocol to treat adult outpatients in a group-

psychotherapy format. This protocol was designed for use with individuals seeking treatment for god- image difficulties. At admission and termination, a variety of self-report outcome measures were administered, and scores on these measures evidenced statistically significant improvements on all nine god-image variables; all but one of these improvements were large-sized and thus clinically meaningful. Specifically, participants reported experiencing God emotionally as distant (within-subjects, pre-less post change ES = 1.73), disapproving (ES = 1.39) and harsh (ES = 0.88), and as accepting (ES =more 1.23), intimate (ES = 1.13) and supportive (ES = 0.79). Furthermore, they reported experiencing less god-attachment anxiety (ES = 0.70) and god-attachment avoidance (ES = 0.43), as well as more congruence (ES = 1.30) between their emotional experience of God (god images) and their theological beliefs about God (god concepts; Davis, 2010). When asked to specify the change mechanisms that led to their psychotherapeutic benefits, participants most commonly mentioned (a) two mechanisms of group-member influence (interpersonal input and output [ = 13] and universality [ = 10]) and (b) threen n psychotherapeutic interventions (allegorical-bibliotherapy, a cognitive-restructuring exercise and a psychodynamic exercise [ s = 9 for all three]).n

The efficacy of process-experiential psychotherapy. Unfortunately, there are as of yet no studies examining the efficacy of Christian-accommodated PE treatments, although some authors have hypothesized that narrative-experiential interventions may be particularly potent in effecting positive god-image change (Davis & Badenoch, 2010; Moriarty & Davis, 2012). In contrast, within the secular psychotherapy-research literature, there are dozens of studies on the efficacy of PE psychotherapy, relative to both inactive and active comparators (Elliott, 2002).

Perhaps the best available research in this area is Elliott’s (2002) review chapter, a meta-analysis of eighty-six published outcome studies of PE psychotherapies. This meta-analysis evaluated comparisons between PE psychotherapy and either an inactive comparator (no treatment or waitlist control; = 36n comparisons) or an active comparator (a non-PE treatment; = 48 comparisons). Relative to n inactive comparators, PE treatments evidenced a between-groups, control-referenced ES of 0.72 ( = 0.53). TheSD within-subjects, pre-post change ES was 1.03 ( = 0.59) at termination, 1.26 ( = 0.71) at earlySD SD follow-up (i.e., one to eleven months), and 1.15 ( = 0.55) at late follow-up (i.e., ≥ twelve months). InSD contrast, relative to comparators, PE treatments evidenced statistically equivalent outcomes toactive those of non-PE treatments, with a between-groups, comparative ES (i.e., differences between the pre- post change ESs of the two treatment groups) of 0.0 ( = 0.44; Elliott, 2002). Of note, at this time noSD PE treatments have received enough empirical support to be deemed , and only two havewell-established received enough to be considered (a) emotion-focused therapy for depression andprobably efficacious: (b) emotion-focused therapy for moderately distressed couples (Greenberg, 2011).

Shared Assumptions of Psychodynamic and Process-Experiential Psychotherapies

Psychodynamic and PE therapies have very different historical origins, and they each have distinctive ideas about human personality, psychopathology and psychotherapy. However, there have been increasing efforts to integrate these and other approaches into a common theoretical and psychotherapeutic framework (e.g., ). As it relates specifically towww.unifiedpsychotherapyproject.org integrating psychodynamic and PE therapies, such efforts are largely based on consilient advancements in the fields of attachment and interpersonal neurobiology. The integration of these two therapies is based on shared assumptions that (a) relationships are the crucible of human development, (b) emotions are the primary motivational system, and (c) implicit (nonconscious) mental processes matter (Cozolino, 2010; Siegel, 2012).

Relationships are the crucible of human development. It is now well-established that, across the lifespan, close relationships impact and modify humans’ mental models of self and others. In attachment

relationships, our embodied mind can be transformed in positive ways, through experiential engagement with another embodied mind that is experienced as safe, attuned, empathic and responsive (Cozolino, 2010; Siegel, 2012).

Emotions are the primary motivational system. Psychodynamic and PE psychotherapies also emphasize the primacy of affect. The human brain-body system is viewed as genetically predisposed to be goal-seeking, adaptational and self-organizing. Emotions are seen as the primary motivational system that guides humans’ adaptation to the environment, because emotions are the main mechanism by which experiential memories are stored and the chief lens through which subjective experiences are appraised. In addition, emotions guide humans’ coping and adaptation efforts, and they provide the self with feedback regarding the status of one’s goals and relationships. Furthermore, emotions are the primary mechanism of interpersonal communication and attachment bonding (Greenberg, 2011).

Implicit (nonconscious) mental processes matter. Last, there is now widespread recognition that a substantial amount of energy and information is processed at an implicit level (i.e., outside of conscious awareness). For instance, nonconscious mental processes help explain why our head and heart knowledge are not always congruent (e.g., god images and god concepts, respectively; Davis, 2010). Psychodynamic and PE approaches affirm that the brain largely processes energy and information at a nonconscious level, implicitly shaping our perceptions, feelings and thoughts (Cozolino, 2010; Siegel, 2012).

An Integrative Model of Experiential Therapy

Next, we describe a three-phase model of experiential therapy based on the work of Greenberg and Watson (2006) that integrates psychodynamic and PE approaches. Within this model, the goals of therapy are (a) to co-construct reflective awareness of deeper emotional dynamics, (b) to overcome defensive avoidance of these dynamics, and (c) to facilitate transformative experiencing of new emotional dynamics. These goals are pursued as the therapist establishes emotional engagement through attunement, resonance and empathy; fosters awareness through active, reflective exploration; overcomes avoidance through sensitive exploration of client vulnerabilities; builds clients’ self-efficacy through confirmation of client strengths; and facilitates transformative experiences through the use of certain process-skills, none of which is unique to experiential therapy. Here we describe a few of these skills.

Crucial process skills. Developing and maintaining a good working alliance. In the psychotherapist’ s toolbox, perhaps the most important process skill is developing and maintaining a good working alliance. Indeed, it is now well-established that, across all psychotherapy formats (individual, family and group), the working alliance is demonstrably effective in promoting positive psychotherapeutic outcomes (Norcross, 2011). The working alliance is especially emphasized within the context of psychodynamic and PE psychotherapies, because it is the basis for everything else that happens in therapy (Greenberg, Rice & Elliott, 1993; Norcross, 2011).

Empathic attunement and resonance. Another important process skill is empathic attunement and resonance with the client’s immediate and unfolding emotional experience. Throughout all phases of treatment, experiential therapists are guided by their moment-to-moment “process assessment” of the client’s current emotional state (Elliott et al., 2004). Siegel (2010) has described the psychotherapist’s in- session practice of mindfulness (i.e., purposeful awareness of here-and-now experiences, with an attitude of curiosity, openness, acceptance and lovingkindness) as one effective way to be fully present, attuning and resonating with the client’s experiences as they unfold. This type of empathic attunement and resonance is the soil within which secure attachment and positive transformation occur (Cozolino, 2010; Greenberg, 2011).

Empathic understanding and validation. Communicating empathic understanding of the client’s emotional experience is another key component of fostering secure attachment and transformation. Here again the goal is to help the client experience the therapist’s attunement and resonance. For example, the

therapist might say: “You feel so overwhelmed by your own feelings that you find it hard to even make sense of your husband’s response. Everything seems confusing and overwhelming. Is that it?” This final question indicates tentativeness, thereby communicating the therapist’s collaborative intent (described below; Greenberg, 2011).

Empathic validation is the complement to understanding. In a validation statement, the therapist implicitly communicates: “You make sense to me.” With such an intervention, the goal is to support clients’ sense of coherence and to promote continued exploration of their experiences and behavior. An example is: “You feel so alarmed that you can’t focus. It makes sense that when you’re terrified, you can’ t even concentrate.” Empathic validations are especially effective when helping clients confront emotions they find confusing or disorienting. At such times, a therapist’s validation can strengthen the client’s ability to tolerate emotional engagement and to become more open to exploring their experiences (Greenberg, 2011).

In attachment terminology, the collective goal of empathic attunement, resonance, understanding and validation is to help clients “feel felt.” For example, Christian clients who present with significant spiritual struggles (e.g., questions about how things “should” be for believers) often benefit from having their spiritual struggles empathized with and validated. Thus, a Christian client who is dealing with unresolved anger toward an abusive parent may believe that expressing anger toward that parent is “sinful.” It can be effective to empathize with and validate both the client’s anger and the spiritual struggle over expressing that anger.

Collaborative intent. Another important process-skill is communicating collaborative intent. That is, it is crucial to routinely invite clients’ input and to facilitate clients’ mutual involvement in therapy’s overarching goals (i.e., aims) and tasks (i.e., the global and specific strategies for achieving those aims; Norcross, 2011). Also, it is important to communicate tentativeness when offering an empathic understanding or validation. Communicating tentatively fosters a sense of safety, which is critical to supporting client exploration and maintaining a good working alliance (Greenberg et al., 1993). Collaboratively inviting client feedback is also a demonstrably effective element of the therapy relationship (Norcross, 2011).

Phase 1: Accessing and allowing emotional experience. In the three-phase model described here, clients are guided to seek answers to four questions about their subjective experiences: “What are my feelings?” “What are my feelings telling me?” “What needs underlie these feelings?” “What do I need to do?” (Greenberg & Watson, 2006). (Note that experiential therapy proceeds according to the principle that all feelings should be attended to, but not all feelings should be acted on.) In the first phase, clients are encouraged to explore, discuss and express the full range of their emotional experiences, especially feelings that are contradictory, threatening or distressing (Shedler, 2010). Several interventions can help clients access and allow their emotions (Greenberg, 2011).

Clarification. In experiential therapy, the first task is to facilitate experiential awareness, and clarification is one way to evoke clients’ emotional experience. Clarification involves asking for specific examples of the problem the client is describing; the goal is to seek details. For example, when a college- student client reports she is having a lot of conflict with her mother because her mother is so controlling, you might use clarification by asking, “What’s an example of a recent situation when your mom was being controlling and it really upset you?” As the client searches her memory and recounts the event, the experiential therapist attends to the client’s emotional states. The more detailed the description, the more likely the client will relive the emotions of the event. Client defenses are often manifested in the form of vagueness or lack of details, or they are reflected in the client’s minimization or avoidance of vulnerable feelings. Persistent, sensitive and empathically attuned clarification is a gentle but effective way to access clients’ emotions, bypass their defenses and overcome their avoidance (Frankland, 2010).

Evocative question/experiential focus. Evocative questions are also effective. These open questions are designed to evoke clients’ attention to and exploration of their internal experience. Evocative questions help clients differentiate between external events and their internal responses to those events. For example, the therapist may probe for the client’s subjective experience: “What’s happening right

now, as you say that?” Or the therapist can use Siegel’s (2010) SIFT-the-mind question: “As you reflect on your own internal experience, what sensations, images, feelings and thoughts come to mind?” Two other examples are “What did you feel when you heard your husband say that he care?” or “Wheredoes in your do you feel the fear?” Evocative questions are also useful for probing the client’sbody experience of the therapist and for making the relationship experientially salient. For instance, the therapist can ask: “What is it like for you to tell me about your struggle with masturbation?” In short, evocative questions increase clients’ internal attending, which deepens and helps them put words to their embodied, emotional experiences. Indeed, Lieberman et al. (2007) have shown that putting feelings into words (i.e., affect labeling) helps down-regulate negative emotions.

Empathic conjecture. Empathic conjecture is another experiential intervention. Here the goal is to offer a tentative understanding of the tacit meaning embedded within the client’s experience, by probing for feelings that are as-yet unacknowledged or that are at the edge of the client’s awareness. An example is: “You say you are frustrated with the way things have gone, and I can understand that. It also seems you’re feeling sad and alone. Does that fit?” Empathic conjectures can help clients symbolize experiences they are having difficulty putting into words, especially when those experiences involve contradictory, threatening or distressing feelings. These conjectures must be offered tentatively, with collaborative intent, because the therapist is essentially speaking for the client, verbalizing as-yet unarticulated experience (Greenberg, 2011).

Slowing the narrative pace and heightening client experience. In addition, it is helpful to slow down the client’s narration of experiences (e.g., through probing for clarifying details). Doing so fosters increased self-awareness and deeper experiential processing. Furthermore, the therapist can heighten the client’s emotional experience by using repetition, images, metaphors or enactments. For example, during an empty-chair dialogue (discussed below), the therapist might say: “So could you say that again, directly to her . . . that you shut her out?” “Slow down a minute and describe what happened inside you as she said ‘I never love you.’ ” “Can you say that again, ‘I feel so abandoned by God . . . sodid alone’?” Because experiential exercises can make clients feel self-conscious and uncomfortable, the therapist needs to be willing and able to empathically and courageously enter the client’s subjective world. One way to navigate this sacred space is to use sensitive language that invites the client’s feedback and collaboration (e.g., “I wonder if . . . ,” “I’m sensing that . . .” or “Does that fit for you?” Greenberg, 2011).

Overcoming avoidance of emotion. The primary way clients cope with problematic emotions is through avoidance. McCullough et al. (2003) has conceptualized such avoidance as reflecting an affect

. Experiential therapists actively but sensitively explore and challenge clients’ attempts to avoidphobia distressing feelings and thoughts. The clinician guides the client toward and deeper into difficult-to-face feelings and thoughts. In the context of a safe, empathic, trusting therapy relationship, the client is exposed to previously avoided feelings and thoughts. Using graded exposure (to avoid flooding), the therapist seeks to promote coregulatory expansion of the client’s window of affect tolerance (Cozolino, 2010; Siegel, 2012).

The process of overcoming avoidance progresses in three steps. First, clients become aware theythat are avoiding. Next, they become aware of they are avoiding. Finally, they become aware of how what they are avoiding. For example, a fictitious Christian client named Omar idealized his father (a minister) but described long periods of being alone, without his father’s presence. The therapist noted that Omar’s narration was oddly devoid of emotion. In particular, Omar rationalized his experiences, offering the excuse that his father was a minister who had extensive godly responsibilities. By using a story about a son’s longing for contact and closeness with his father, the therapist empathically validated Omar’s perspective but also confronted his rationalization. The therapist then made an empathic conjecture about Omar possibly feeling lonely and abandoned. Omar was able to enter into his feelings of sadness and longing, opening the door for exploring how his father’s absence has vastly impacted his adult functioning.

With Christian clients, it is especially important to explore their attempts to avoid distressing feelings and thoughts that manifest in their embodied, emotional relationship with God. For instance, there often is a large discrepancy between Christians’ head and heart knowledge of God, with a need to overcome the defense mechanisms blocking the integration of these two modes of knowledge (Davis, 2010).

Phase 2: Relational processing and making sense of emotional experience. Coregulating the client’ s emotional arousal. Clients avoid painful and difficult emotions for a reason: they are distressing and hard to regulate. There are a variety of ways that therapists can help clients approach and regulate these types of emotions. For example, therapists can help clients build their capacity to experience and tolerate difficult emotions by learning and practicing affect-regulation skills (e.g., deep breathing, muscle relaxation, Christian contemplative prayer/meditation), both during and in between therapy sessions. Therapists also can encourage clients to adopt a safe, “working-distant” stance, separating themselves from the emotion’s intensity by reflectively exploring its meaning and implications. Another way the therapist can coregulate the client’s emotional arousal is to maintain an experientially mindful presence through a warm and gentle vocal tone, a kind and empathic facial expression, and a calming and respectful silence (Greenberg, 2011; Siegel, 2010). Also, it is helpful for the therapist to validate the difficulty of experiencing painful emotions and to affirm clients’ efforts to regulate their affect and self- soothe (regardless of whether such efforts are successful).

In experiential therapy, clients who have experienced trauma and abuse are especially at risk for becoming affectively dysregulated. It is now well established that, for traumatic memories to be transformed, they need to be activated and experientially accessed. However, for this processing of traumatic emotions to be effective, the level of emotional arousal needs to be at a moderate and manageable level, until distress subsides. This processing of difficult or avoided emotions is the experiential version of gradual desensitization to feared stimuli (Cozolino, 2010; Harwood, Beutler, Williams & Stegman, 2011; McCullough et al., 2003).

Using confrontation. Another way to help clients process and make sense of their emotional experience is to use confrontation, which involves the therapist reflecting back to a client something the therapist observes, thereby raising awareness of it and directing attention toward it. Confrontation may involve raising awareness of an aspect of the client’s behavior or emotional state, in an effort to enhance the client’s experience (e.g., “You seem to be really enjoying telling me about your son’s award”). It may involve directing clients’ attention toward something of which they are already aware (e.g., “I notice you have been ten minutes late for the last two sessions”). Or it may raise awareness of something that clients are avoiding or of which they are not consciously aware. Indeed, clients often communicate far more meaning implicitly than explicitly, and confrontation can be used to focus the client’s attention on tacit nonverbal cues that are pregnant with meaning (e.g., changes in vocal tone, body posture or physiological state). For instance, confrontations can be used to highlight inconsistencies between clients’ verbal report and affective display (e.g., smiling while describing a painful experience). Even so, when therapists offer confrontations, they must conjointly communicate collaborative intent, through such means as inviting client feedback (Frankland, 2010).

Exploring problematic reactions. Clients often report experiencing upsetting or puzzling reactions to events or people. Exploring problematic reactions can help clients make sense of their experiences and gain self-understanding (e.g., about the ways they habitually experience and interpret life events). Here the therapist invites the client to re-enter and systematically re-experience the situation. The overarching goal is for clients to become aware of the deeper meanings embedded within their experience, especially the ways their problematic reaction may reflect a recurring theme in their lives or a typical way they construe situations or people. Elliott et al. (2004) have called this intervention systematic evocative

.unfolding Note that systematic evocative unfolding is not a conceptual analysis of the situation; it is an

experiential re-entry, involving clients systematically describing what they are experiencing (or rather, re-experiencing) as the problematic episode unfolds in their narrative. For example, Greenberg and Watson (2006) described a female client who reported a disturbing experience of depression following

an important exam at school. During the exploration of the experience, the client realized she was angry at the teacher because he included questions about material that was never covered in class. As a child, this client experienced recurrent emotional and physical abuse from her father; now, as an adult, whenever she encountered unfair treatment from an authority figure, she withdrew into depression. Through experiential therapy, the client was able to change this pattern, largely via empty-chair dialogue (discussed below).

Identifying and exploring recurring themes and patterns. One of the goals of experiential therapy is to provide the client with new self-understanding. This goal can largely be accomplished by helping clients identify and explore themes and patterns that recur across their feelings, thoughts, behaviors and relationships (Shedler, 2010). Such an enterprise often involves co-constructing coherent, textured, growth-promoting life narratives (Cozolino, 2010).

A well-recognized feature of experiential therapy is the discussion of past relational experiences with a developmental focus. This developmental focus needs to center on exploring early-childhood experiences of caregivers and how those experiences are related to and reflected in the client’s current emotional and relational life. The goal here is to assist clients in freeing themselves from internalized past experiences, so they can more fully and flexibly live in and enjoy the present (Shedler, 2010).

Clients often resist exploring the past for a number of reasons. With Christian clients, two of the most commonly cited reasons are the biblical principles that Christians should (a) forget the past and move on (e.g., Phil 3:13) and (b) refrain from blaming their parents for their current problems. The therapist can counter such objections by highlighting that, in experiential therapy, the focus is on one’s own experiences—how subjective experiences in the past impact subjective experiences in the present. Exploring significant childhood memories is thus a way to activate emotionally salient but nonintegrated parts of oneself, toward the goal of transforming one’s self-functioning. For instance, my (Edwards) father was an alcoholic, and when he was drunk he violently physically abused my mother. I frequently witnessed this explosive violence, and my traumatic experiential memories needed integration and transformation. Indeed, through psychotherapy and personal reflection, I have spent a lot of time understanding and resolving the impact my father’s drinking and violence has had on my self- functioning.

Experiential therapists also focus on current interpersonal relationships and attachment dynamics. In- session experiential processing is used to explore the clients’ self- and other-representations, attachment tendencies and interpersonal patterns of behavior (Davis, 2010; Siegel, 2012). In addition, clients are encouraged to cultivate and draw on their social support network, partly as a way to enhance the likelihood of a positive psychotherapeutic outcome (Harwood et al., 2011).

With Christian clients, explorations of emotional experience of God may also help illuminate any transference/countertransference dynamics that are emerging. Such explorations can include discussions of how God may desire to bring healing and sanctification in the client’s mind, brain and relationships, via experiences in psychotherapy (Moriarty & Davis, 2012).

Furthermore, the client’s general patterns of relating will manifest in the therapy relationship. Thus it is important for the therapist to use confrontation to point out these patterns and to use interpretation to elucidate their connection to past relationships (Frankland, 2010; Shedler, 2010). However, such explorations may evoke client shame, self-consciousness, resistance or defensiveness, and it can be a challenge to collaboratively and safely process these dynamics. Sometimes it is possible to empathically reflect, confront or process these dynamics in real time, but at other times it may be necessary to wait until the events have passed and can be explored in retrospect. For example, Levenson (2010) described a male client who could not answer a direct question regarding his feelings about lending money to his daughter. Several sessions later, the client disclosed that his therapist’s request for more information had irritated him. Because he had previously experienced his therapist as safe and understanding, the client assertively verbalized his anger, without fearing he would be rejected. Gradually, the client’s recurrent positive experiences in the therapy relationship empowered him to assert himself in other relationships (i. e., outside therapy).

Facilitate optimal levels of experiential processing. In experiential therapy, a centrally important activity is clients’ active processing of their emotional experiences, while relating with the therapist. The therapist facilitates active processing by evoking clients’ verbal description of their internal, subjective experience. In other words, it is not enough for clients to merely have a deep emotional experience; for the experience to be therapeutically beneficial, clients must also put words to that experience (i.e., it must be symbolized; Greenberg, 2011; Siegel, 2010).

Here the therapist must focus on keeping clients’ arousal level in an optimal window (i.e., mild-to- moderate arousal)—neither so high that clients are overwhelmed nor so low that they are languishing. Stated differently, the therapist needs to facilitate optimal levels of experiential processing (vs. conceptual processing), thereby (a) expanding the client’s window of affect tolerance and regulation and (b) fostering integration of different aspects of the client’s emerging experience (Cozolino, 2010). Indeed, facilitating clients’ verbal articulation of their subjective state is one way to coregulate their level of arousal, keeping it at an optimal level. Thus, when an intense emotional experience emerges in the session, the therapist should shift the focus to experiential, verbal processing of that upsetting reaction. Initially, affect-regulation techniques (e.g., deep breathing) may need to be used, but the goal is to help clients verbalize their internal experiences, thereby helping them integrate and regulate their affect (cf. Lieberman et al., 2007).

Freely explore fantasies, dreams and wishes. Much of human experiential processing occurs outside of conscious awareness, especially when it comes to affective and relational experiences (Cozolino, 2010). Hence, when using experiential techniques, the psychotherapist needs to provide ample time and space for implicit (nonconscious) aspects of the client’s experience to emerge. Free association should be encouraged, especially the exploration of fantasies, dreams and wishes. Here the goal is facilitating insight into what underlies the client’s emotional and relational difficulties (Shedler, 2010). For example, to fully access the underlying meaning of an emotional experience, have the client explore the unacceptable behaviors (e.g., fantasies and wishes) they might like to enact in the situation. A client struggling with anger toward an abusive boss can be asked: “I know that actually confronting your boss might put your job at risk, but what do you wish you could say to him?” Exploring fantasies or wishes is very effective with Christian clients who consider angry thoughts or impulses morally unacceptable.

Phase 3: Transformation and restructuring of emotional experience. The first two phases of experiential therapy are focused on accessing and making meaning of clients’ subjective self-states. The interventions we have described in these prior phases are largely designed to promote enhanced awareness, relational processing and self-integration (at conscious and nonconscious levels). This last phase of experiential therapy—emotional transformation—actually takes place over the entire course of therapy, especially during the middle phase. This transformation also happens outside therapy, as clients act on the emotional-awareness and regulation-skills they have developed in therapy sessions. Experiential therapists actively track and guide clients’ extra-therapy enactments, to support more complete, generalized transformation (Greenberg, 2011). Nonetheless, transformation is of course facilitated in therapy as well, and here we describe two techniques for accomplishing that task.

Interpretations and narrative integration. Again, new self-understanding is one important outcome of experiential therapy, and interpretations are an effective way to promote such understanding. Frankland (2010) has defined an interpretation as “a statement or question (often involving information gathered from clarifications and confrontations) that is designed to help the patient understand and appreciate an internal issue or struggle that is outside of her awareness” (p. 56). Interpretations link current functioning with significant developmental experiences that the client has described previously. For example, a fictitious client named Tanya presented with distress about her romantic relationship with a man who often ignored her and was unresponsive to her legitimate needs. Tanya was afraid to be assertive regarding her needs, because she feared losing the relationship. The therapist sensitively commented that, earlier in therapy, Tanya alluded that a similar pattern of fearful nonassertion

characterized her reverse-caretaking role with her alcoholic mother. This interpretation led to deeper exploration of Tanya’s pattern of nonassertion—a pattern that often left her with unmet needs. With the support of her therapist, Tanya began to risk being more assertive with her friends and boyfriend.

The interpretations employed in phase 3 seek to promote deeper processing of emotional meaning, with a goal of integrating that meaning into the client’s life narrative. During this phase, the emotional significance of clients’ beliefs and assumptions are made more explicit, and the developmental roots of their difficulties are identified and integrated with their current experiences. Cognitive and emotional restructuring occurs largely via the process of narrative integration, which involves linking various components of the client’s life into a coherent story (Cozolino, 2010). For example, Davis and Badenoch (2010) have suggested that narrative integration is an important treatment goal when working with religious/spiritual individuals who espouse a relationship with God. God-image narrative therapy (see Davis, 2009, for a treatment manual) is one experiential treatment that can be used to explore the connections among these clients’ experiences in relationship with God and others. Here the goal of narrative integration is threefold: (a) the integration of clients’ spiritual narrative, (b) the integration of clients’ life narrative and (c) the integration of clients’ spiritual narrative with their life narrative.

The following fictitious case illustrates this transformation process. Sally, a Christian missionary nurse, habitually overworked herself. If she took time off, she was afraid her fellow missionaries would criticize her and the locals would think less of her faith. In fact, Sally’s fellow missionaries praised her for her tireless dedication, and the locals expressed admiration and gratitude. As a result, she felt like a failure whenever she could not help her constituents in all the ways they needed help. Sally habitually redoubled her nursing efforts, to avoid feelings of failure. In short, her maladaptive pattern was self- defeating and gradually led her to the point of burnout. Through psychotherapy, Sally came to recognize how her critical and demanding father had been internalized in the form of her harsh introject, which drove her to compulsively achieve. She was able to experience and express anger at her father’s harsh treatment. She was also able to mourn the loss of a more loving and grace-filled childhood. Through experiencing her psychotherapist’s compassion, kindness and grace, Sally was able to experience God, others and herself in similar ways. She developed a more self-compassionate introject and restructured her life in ways that were more healthy and life-giving for her.

Facilitation of task resolution. Experiential therapy involves adeptly facilitating the client’s completion of therapy tasks, while maintaining a relationship-focus (see Elliott et al., 2004; Greenberg, 2011, for reviews). Here we describe one application of a popular, well-researched task for promoting emotional transformation—the empty chair technique.

The empty-chair task is usually proposed when a client accesses and explores unresolved negative feelings toward a significant other person (usually a parent). The goal of this task is to facilitate experiential processing and resolution of the client’s negative feelings. The therapist first clarifies the nature of the unresolved feelings, proposes the task, sets an empty chair across from the client and invites the client to visualize the person as seated in that chair. The chair in which the client is currently sitting is dubbed the “self-chair.” The therapist typically has clients start by staying in the self-chair and expressing their feelings and thoughts to the imagined other person. When clients have expressed sufficient emotions (i.e., evidencing optimal experiential processing), they are asked to switch to the empty chair and experience these complaints in the role of the “other.” At that point, the client may say something such as “I don’t know how he would feel or what he would say.” The therapist then offers the process directive (e.g., “Be the father in your head”), to facilitate emotional identification with the client’ s introject of the other person. The end of the empty-chair dialogue task is usually marked by a sequence of two adaptive emotions: first anger (e.g., holding the other person responsible) and then sadness (e.g., for the loss that the unresolved negative feelings represent). This sequence is prototypically activated by asking clients (seated in the self-chair) to express their adaptive, underlying, unfulfilled needs (e.g., “Tell your father what you needed from him”). Then these needs become experientially associated with adaptive emotions and action tendencies. Full resolution may result if the other person takes responsibility and apologizes, or if the self forgives the other person; partial resolution may result from setting a boundary, distancing or letting go.

Summary and Conclusion

In this chapter, we have summarized the psychodynamic and PE outcome research, which has revealed that each of these psychotherapies is more efficacious than inactive comparison groups (e.g., control groups) and is as efficacious as other active treatments (e.g., evidence-based treatments). We also have described a three-phase model of experiential therapy (Greenberg & Watson, 2006) and have discussed interventions that can be employed in each phase, including examples of how to use experiential interventions in Christian counseling and psychotherapy.

As we conclude this chapter, we want to make it clear that we are not suggesting that experiential interventions are more effective than other interventions or are uniformly effective with all clients. In fact, we recommend that psychotherapists routinely practice informed theoretical/technical pluralism and . That is, we recommend that psychotherapists cultivate a habit ofpatient-treatment matching thoughtfully drawing on a broad range of theories and techniques, with an attitude of flexibility, openness and humility (informed theoretical/technical pluralism; Moriarty & Davis, 2012) and of making strategic, research-informed clinical decisions that integrate client, relationship and technique factors (patient-treatment matching; Harwood et al., 2011). With regard to the latter, the evidence-based principles of systematic treatment selection prescribe that insight-oriented, relationship-focused interventions (e.g., the interventions we describe in this chapter) are most likely to be effective with individuals who have an internalizing coping style (i.e., tend to internalize blame, be introverted and cope by turning inwardly). In contrast, skill-building and symptom-removal interventions (e.g., CBT) are more likely to be effective with individuals who have an externalizing coping style (i.e., tend to externalize blame, to be extroverted and to cope by acting outwardly; Norcross, 2011).

In conclusion, the take-home evidence-based practice recommendation of this chapter is that, within Christian counseling and psychotherapy, psychodynamic and PE interventions are most likely to be effective with Christian clients who have an internalizing coping style. With such clients, use the interventions we have described, accommodating them by incorporating religion/spirituality into therapy goals and tasks and by emphasizing experiential processing not only of clients’ human relationships but also their emotional relationship with God. In time, we hope that Christian-accommodated psychodynamic and PE techniques will be thoughtfully developed and empirically examined, so that such interventions can be selected and utilized with confidence, in the context of evidence-based Christian counseling and psychotherapy.

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