Emotion Focused Therapy for Generalized Anxiety
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Library of Congress Cataloging-in-Publication Data
Names: Watson, Jeanne C., author. | Greenberg, Leslie S., author. | American
Psychological Association, publisher.
Title: Emotion-focused therapy for generalized anxiety / Jeanne C. Watson and
Leslie S. Greenberg.
Description: First edition. | Washington, DC : American Psychological
Association, [2017] | Includes bibliographical references and index.
Identifiers: LCCN 2016034042| ISBN 9781433826788 | ISBN 143382678X
Subjects: | MESH: Anxiety Disorders—therapy | Psychotherapy—methods | Emotions
Classification: LCC RC531 | NLM WM 172 | DDC 616.85/22—dc23 LC record available
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To all those with generalized anxiety disorder—
may they find relief from their pain.
CONTENTS
Acknowledgments........................................................................................ ix
Introduction.................................................................................................. 3
Chapter 1. Emotion-Focused Therapy Formulation
of Generalized Anxiety Disorder.................................... 17
Chapter 2. The Role of Emotion in Generalized
Anxiety Disorder............................................................. 41
Chapter 3. Treatment Framework..................................................... 65
Chapter 4. The Therapeutic Relationship........................................ 93
Chapter 5. Strengthening the Vulnerable Self............................... 115
Chapter 6. Working With Worry: Anxiety Splits........................... 135
Chapter 7. Changing Negative Treatment of the Self:
Two-Chair Dialogues..................................................... 165
vii
Chapter 8. Transforming Pain: Working With Empty-Chair
Dialogues in Generalized Anxiety Disorder.................. 183
Chapter 9. Emotional Transformation and Compassionate
Self-Soothing in Generalized Anxiety Disorder........... 209
References................................................................................................. 235
Index......................................................................................................... 255
About the Authors................................................................................... 265
viii contents
ACKNOWLEDGMENTS
This book would not have been written without the support of many
individuals. In particular, we would like to acknowledge our mentors, teachers,
and colleagues who shared their knowledge and expertise and contributed
to the development of emotion-focused therapy (EFT) as a distinctive and
robust treatment approach. This book has emerged from hours of intensive
observation and practice to accurately describe and understand the process of
change in generalized anxiety disorder. Our students, as always, have provided
inspiration and support, contributing their time and efforts to learning the
approach and analyzing transcripts to inform us further about change processes
in psychotherapy in general and EFT in particular. A special note of thanks is
due to our clients, without whom this book could not have been written. They
were courageous in seeking relief from generalized anxiety disorder and were
willing to work with us to overcome their condition, so that they could look
forward to living life with confidence and trust in themselves and their future.
This work requires a strong editorial team. We would like to acknowledge
and thank Susan Reynolds at the American Psychological Association for her
enduring patience and encouragement. Without her faith and belief in EFT, this
book would not have been produced. Thanks also go to David Becker, for his
ix
input and guidance, and the team at the American Psychological Association,
as well as the reviews from two anonymous colleagues whose input we drew on
to strengthen this book. Their generosity of time and spirit is very much appre-
ciated. We trust that they will be pleased with the final product.
As always, we thank our families, our partners, and our sons and daugh-
ters for their enduring support, love, and commitment as they cheered from the
sidelines and provided relief from domestic chores so that we might concen-
trate on writing. We would like to make special mention of Brenda Greenberg,
who passed away during the period that this book was being developed. We
believe that she would be proud and pleased with this volume and know that
our time was well spent. To all of you, please know that your love has been
sustaining and invaluable during the arduous and demanding process of writ-
ing this book for publication. We trust that it will be well received and that
you will agree your contributions were worth it.
x acknowledgments
EMOTION-FOCUSED
THERAPY FOR
GENERALIZED
ANXIETY
Emotion-Focused Titlepp.indd 1 11/3/16 2:13 PM
INTRODUCTION
Generalized anxiety disorder (GAD) is a serious disorder that impairs
functioning and has high social and economic costs (American Psychiatric
Association, 2013; World Health Organization, 2016). Hoffman, Dukes, and
Wittchen (2008) observed that GAD contributes to significant impairments
in role functioning as well as decrements in quality of life. The impairment
of persons with comorbid disorders is even more severe. For people with
GAD, the condition negatively impacts their general health, including their
physical and mental health, vitality, and social functioning, which leads to
increased use of health care resources and loss of productivity due to absen-
teeism (Porensky et al., 2009; Revicki et al., 2012). It has been noted that the
costs from health care and lost productivity exceed those of other patients.
Moreover, there is the impact of intergenerational transmission, as people
with GAD communicate and share their anxious worrying behavior with
their offspring and other family members.
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Emotion-Focused Therapy for Generalized Anxiety, by J. C. Watson and L. S. Greenberg
Copyright © 2017 by the American Psychological Association. All rights reserved.
3
GAD is the most common anxiety disorder and is underrecognized, with
only 20% to 32% of patients receiving adequate treatment (Porensky et al.,
2009; Revicki et al., 2012). To make matters worse, studies have found that
GAD can be treatment resistant. Although approximately 50% of patients
respond to short-term treatment, a large percentage either do not respond
at all or relapse after treatment (Borkovec, Newman, Pincus, & Lytle, 2002;
Hanrahan, Field, Jones, & Davey, 2013). As a result, numerous researchers and
clinicians have called for improved and different treatments for the condition
(Craske & Waters, 2005; Hofmann & Smits, 2008; Roemer & Orsillo, 2002).
In this book, we provide an understanding of GAD from an emotion-focused
therapy (EFT) perspective and present alternative treatment strategies that
mental health practitioners can use to help clients with GAD maintain posi-
tive, long-term changes.
Until recently, EFT has focused on depression (Greenberg & Watson,
2006), trauma (Greenberg & Paivio, 1997; Paivio & Pascual-Leone, 2010),
and couples therapy (Greenberg & Goldman, 2008; Greenberg & Johnson,
1988; Johnson, 2004), with no theory of anxiety or, more specifically, no theory
of GAD. In EFT in general, dysfunction is seen as arising from the activation
of core painful maladaptive emotion schemes of fear, sadness, and shame and
the associated vulnerable self-organizations resulting from the synthesis of
these schemes together with the inability to symbolize and regulate the
ensuing painful affect (Greenberg, 2002, 2011; Kennedy-Moore & Watson,
1999, 2001; J. Watson, 2011). In EFT, when people experience anxiety, the
self is organized as scared and vulnerable because of the activation of emo-
tion schematic memories of harmful and painful experiences in the absence
of protection and support. As a result, people do not internalize self-soothing
strategies and instead develop negative ways of relating to the self and modu-
lating emotions.
Developmentally, the experience of intense distress combined with the
absence of soothing, care, protection, and support results in the inability to
adequately regulate and symbolize emotional experience, leading to painful
experiences being interrupted and blocked to protect the self from feared
dissolution and disintegration. Without adequate protection, soothing, and
succor, negative ways of regulating emotional experience and coping with
challenging and distressing life circumstances are internalized. These negative
ways of relating to one’s experience include dismissing the experience, invali-
dating it, silencing the self, blaming the self for the negative experience, and
rejecting the self as unworthy of being loved and supported. Thus, as a result of
an intensely painful experience and in an attempt to manage feelings, there
is a constriction of awareness such that individuals have difficulty represent-
ing and symbolizing their experience in consciousness. Instead, people with
GAD experience a sense of undifferentiated distress—a vague feeling in the
4 emotion-focused therapy for generalized anxiety
body at the edge of awareness. The combination of the inability to symbolize
painful emotions and experiences, negative ways of treating the self, and
an inability to soothe the resulting overwhelming emotions leads to a fear
of dissolution and compromises the individual’s affect regulation capacities.
People end up worrying in an effort to protect the self from falling apart
because of an inability to cope with the underlying painful feelings of fear,
sadness, and shame.
GENERALIZED ANXIETY DISORDER
Estimates of the lifetime prevalence of GAD in the general population
range from 1.9% to 5.4%. GAD is more common in women than in men
by a ratio of 2 to 1 (Andlin-Sobocki & Wittchen, 2005; Brown, O’Leary,
& Barlow, 2001). Among the elderly, estimates are even higher, with some
researchers suggesting that 17% of elderly men and 21.5% of elderly woman
require treatment for the disorder (Brown et al., 2001; Salzman & Lebowitz,
1991). More than half of those individuals diagnosed with GAD experience
onset during childhood and adolescence, although later onset does occur after
the age of 20 (Andlin-Sobocki & Wittchen, 2005).
Symptoms are often worse during periods of stress. Most people with
GAD report that they have felt anxious and nervous all their lives, which
underscores the important role of early life experiences in its etiology and
development. Anxiety disorders, and specifically GAD, have been found to
be comorbid with other Axis I disorders from the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (American Psychiatric Association,
2013), including other anxiety disorders (e.g., social anxiety disorder, post-
traumatic stress disorder, panic disorder), mood disorders, addictions, and eat-
ing disorders (Carter, Wittchen, Pfister, & Kessler, 2001; Craske & Waters,
2005; Kessler, Ruscio, Shear, & Wittchen, 2009). Unipolar depression is
4 times more common in GAD than is bipolar depression, with incidence
being 67% and 17%, respectively (Judd et al., 1998). Overlap has also been
found with Axis II disorders, including avoidant and dependent personality
disorders (Mauri et al., 1992). Some researchers have suggested that given
its early onset, anxiety should be viewed as temporally primary among the
other disorders with which there is high comorbidity. They have suggested
that early detection and treatment of anxiety might have implications for the
onset of other disorders (Kessler et al., 2009).
Unlike some of the other anxiety disorders (e.g., social anxiety, phobias),
GAD has no clear precipitants. It is not associated with a particular stimulus
(e.g., heights, snakes) but is activated by a variety of different situations and
stimuli (American Psychiatric Association, 2013; World Health Organization,
introduction 5
2016). The early onset of GAD suggests that it is a condition that develops
early in development and may be consolidated during core developmental
years. Studies looking at early childhood factors associated with GAD point to
a negative early climate characterized by parental rejection and criticism, lack
of parental warmth and acceptance, and a sense that family dynamics were
unfair. This may be compounded by other negative life experiences and events
for which people may have had insufficient protection, support, and care.
The research literature shows that not all clients respond to short-term
treatments, although some clients clearly progress and their symptoms remit
after several weeks (Borkovec et al., 2002; Elliott & Freire, 2010; Hanrahan
et al., 2013); other individuals may require a longer length of treatment. The
exact length will vary in terms of the severity of clients’ early life conditions,
as well as the individual capacities that clients bring to therapy (see Chapter 5,
this volume). Some individuals may need time to build greater confidence in
themselves and to develop an adequate understanding of what has transpired
in their lives that has made them feel so vulnerable, reject their experience,
and unable to regulate their emotions. As they gain a better understanding
and acknowledge their experiences, they can begin to see what was so chal-
lenging and negative for them and appreciate what was lost and not received.
This enables them to symbolize previously disclaimed painful experiences
and identify the negative behaviors and ways of processing their experi-
ences that were internalized as they tried to cope with intensely distressing
events. This understanding points to aspects of their experience that they can
change. Clients with GAD come to recognize that they do not adequately
process their emotions and bodily experience, fearing that they will “disinte-
grate” because of the intensity of the pain. There is a recognition that they
need to become more aware of their bodily experiences and emotions, experi-
ence their painful emotions, learn how to accept them, symbolize them and
put them into words, and finally, with the help of the therapist, access new,
more empowering emotions to transform their painful maladaptive feelings.
Feeling stronger and more resilient, they are better able to modulate their
distress, soothe their painful feelings, and express their emotions and needs
to others.
MAIN PROCESSES IN EMOTION-FOCUSED THERAPY
EFT emphasizes the important role of the therapeutic relationship and
provides suggestions and ways of working with clients to resolve how they
relate to the self and others. Although therapy is a complex, multilayered
interaction, we have distilled five main processes and tasks that are woven
sequentially and in parallel throughout the treatment. These processes include
6 emotion-focused therapy for generalized anxiety
the following: (a) providing clients with an empathic, accepting, and prizing
relationship to build a stronger sense of self so that they feel more trusting of
their emotional experience and perceptions, become more confident in their
interactions with others, become more self-compassionate and self-nurturing,
are able to tolerate and soothe their emotional experience, and modulate the
expression of their emotions and needs to others; (b) working with clients
to experience disclaimed painful emotions and develop an understanding
of their life story or narrative to make sense of life events and their impact;
(c) working with clients on identifying and changing the negative ways in
which they relate to the self using two-chair tasks; (d) working with clients
to transform painful maladaptive emotions by healing past emotional injuries
experienced in interaction with significant others using empty-chair tasks to
resolve unfinished business; and (e) working with clients to develop capaci-
ties to self-soothe using imaginal transformation and two-chair dialogues to
resolve emotional suffering.
Although these processes and tasks are described as following a sequential
order in treatment, they generally occur in parallel and are woven through-
out the treatment process after the therapist has begun to build a positive
therapeutic relationship and a positive alliance with the client in the first
few sessions. So, although the therapist may focus on one of the these tasks
more than the others at different times in therapy, or on additional tasks such
as initially building a therapeutic alliance, developing a case formulation, or
building a stronger sense of self, the process remains fluid.
Once the EFT therapist introduces chair dialogues, she or he continues
to work on the relationship by providing empathic attunement, acceptance,
and prizing in a sincere and congruent manner to continue to strengthen
clients’ sense of self and to facilitate awareness of clients’ emotional experi-
ence and help clients represent it in words. Labeling their emotions, learning
to regulate and modulate their intense feelings of distress, and transforming
core painful maladaptive emotions enable clients to acquire the capacities to
regulate and express their emotional experiences more optimally and develop
more positive ways of caring for the self. Throughout therapy, as clients work
to change their core painful emotions, undo their negative self-treatment,
as well as to resolve their attachment injuries, they cycle in and out of tasks
that focus on how they relate to the self using two-chair dialogues and how
they address emotional injuries with an imagined other using empty-chair
dialogues. Although working on self–self and working on self–other relation-
ships are conceptualized as two parallel tracks, it is highly likely that to fully
resolve emotional injuries with an imagined other, clients may need to have
consolidated changes in how they relate to the self and their emotions so that
they feel deserving and entitled to assert their needs and receive loving care
and protection from others.
introduction 7
