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Introduction
The evolution of psychotherapy over time has come from grim days for the psychologically disturbed to the modern age where efficient systems of therapy have arisen. Functional assessment was the method of therapy previously. Eminent psychoanalysts have studied and evaluated their findings and found the emotional factor to be an essential component of psychotherapy. I have attempted to trace the various concepts that have slowly but surely led us to the functional assessment and emotion focussed theory and their integration. To help in my attempt, I have been able to quote findings from scholarly articles, practice based and research literature. I am convinced of the advantages of integrating functional assessment with emotion focussed psychotherapy.
The History of Psychological Therapy
Travelling from the grim, intolerant attitude of the Stone ages through the centuries to the modern days of efficient psychoanalysis and therapy, mankind has of late accepted the mentally ill as unfortunate fellow humans who need help and can be guided into leading normal lives. At different stages of our evolution, these people were considered subhuman, tortured or locked away.. During the French Revolution, for the first time, these unfortunate beings were released from chains at the instance of Philippe Pinel.. A major breakthrough came for the psychologically disturbed in the United States in the early twentieth century. Clifford W. Beers founded the National Committee for Mental Hygiene. Deinstitutionaling of these patients and getting them back into society have become the trend. (Historical treatment of Psychological Disorders.
Psychoanalysis
Psychoanalysis has become an inseparable part of human behaviour and experience. The role of psychoanalysis has brought a change in the study of biological sciences, social sciences, group behaviour and developmental theory in child psychiatry. It improves our understanding of the role of emotions in health and medical illness. The framework of psychoanalysis stresses that the human being is a unique individual and he faces factors outside of his awareness (unconscious thoughts) which influence his thoughts and actions. His past affects his present. As individuals are often unaware of the factors that influence their actions, they express them as unhappiness or some recognisable symptoms or exhibit some traits which others can recognise as abnormal. The psychoanalyst helps the patient elucidate his symptoms and trace them back into his past life. Psychoanalysis is a tool for discovering the factors causing the problems and is a mode of therapy at the same time. It furthers our understanding of the role of emotions in health and medical illness. (About Psychoanalysis, American Psychoanalytical Association )
Functional Assessment
The functional assessment philosophy is an assessment-based approach to psychological therapy and has been linked to the behaviourist tradition.
Functional analysis, behavioural assessment , antecedent consequent assessment, contextual assessment are terms used in it. Practitioners have been using assessment- based therapies relying on sequences. Cognitive behavioural assessment, systems focussed models, emotion focussed therapy and psychodynamic therapy are the various forms of therapy used to help the psychologically disturbed.
The presenting problem, precipitating factors, predisposing factors, perpetuating factors and protective factors are taken into consideration for functional assessment. In the sequence of events, the client may be faced with a predisposing factor which can preciptate his psychological distress and create the presenting problem. The therapist sees the client with the problem, studies the case and comes up with an idea about the perpetuating factors and the protective factors. Emotions are not given much consideration here.
Emotion Focussed Theory
The emotion focussed approach to assessment and therapy is a modernised synthesis of the humanistic or experiential schools of thought. For years now we have been following the Gestalt theory, Client-centred theory and the existential theory. The belief that psychological or emotional growth is a natural process forms the basis. Emotions are an adaptive resource. From birth, emotions are part of our signalling system. They help us to communicate our intentions and regulate interactions. Negative emotions help us to express discontent and stimulate others to comply accordingly.
The forefathers of Gestalt who were familiar with Eastern mysticism and philosophies viewed emotion as a vital regulator of action.. It was considered to energise action and provide awareness to an organism of its needs. The person is not considered in parts but as an integrated whole. The interplay between biological maturation, environmental influences, interaction of the individual and the environment and creative adjustment are crucial features. The goal of this therapy is to allow the natural evolution of emotion so that it provided a guidance to behaviour. Gestalt therapy is seen as a form of training in emotional awareness (Greenberg and Safran, 1987).
This theory further states that emotions were often blocked from awareness and from organising action by self-concept, conflicts or unfinished business. The aim of blocking was to avoid painful or unwanted emotion. Gestalt therapy has four major concepts; biological field theory, entity of the organism, the need for contact and relationship and the capacity for making wholes. Gestalt therapy lacks a distinct well-defined and elaborate theory of human development.
The client-centered approach defined feeling as the union of emotion and cognition. The concept of experiencing and everything that is occurring within an organism at any given moment that is available to awareness are important. (Gendlin,1962; Rogers ,1959)
Existential therapy takes the human condition seriously. It has four major themes: death, freedom and resposibility, isolation and meaninglessness. These are believed to be at the roots of most psychological problems.
In this theory, therapists studied the emotional arousal caused in a problem. In normal people, these emotions are processed and interpreted correctly. The emergence of an emotion, awareness of the arousal, apt interpretation and appropriate expressive action completes the sequence normally. However this is not the case in a psychologically disturbed person. Blocks or obstacles prevent the normal completion of the sequence. If the client were to avoid or ignore the emotional arousal, he is in a problem. This is when the therapist steps in. He places an importance to interpersonal processes and then emotion focussed processes. The therapist shows empathy towards the client. Then he tries to build a therapeutic bond with the client who begins to trust and follow instructions without any qualms. They agree on many points and set up collaborative goals and tasks of therapy. This summarises the principles of emotion focussed therapy as emotional or experiential processing, focussing on client choice and then focussing on getting closure or achieving benefits.
Assessment of Emotion
Differentiation has to be made between primary and secondary emotions and between adaptive and maladaptive emotional experiences (Greenberg, 2002). Primary are the essential and direct initial reactions to a situation. Secondary emotions are those occurring due to earlier primary responses and include defences (Fosha, 2000). These have to be explored before arriving at the primary responses. Adaptive emotions help us to access information whereas maladaptive emotional experiences are difficult to penetrate. The maladaptive ones are loneliness, sadness, feeling abandoned, feeling wretched and worthless and explosive anger which destroys relationships. The maladaptive emotions makes a person appear irredeemable. Transformation of these maladaptive emotions must be the aim of therapy. Distinguishing among the emotions would help in the choice of intervention required. The primary adaptive emotions help to elicit vital information. The maladaptive emotions must be evoked and transformed into making the patient amenable to change.
Differential Change Process
Awareness of emotions and being able to express them in language is an essential component of therapy. This awareness and expression are signs of change. The principle of change is an important therapeutic goal (Rogers, 1959). When a person is able to express his emotion, he has undergone 2 changes: that of overcoming avoidance and promoting emotional processing (Greenberg and Safran, 1987). He becomes better controlled when he survives a problem and is able to acknowledge his emotions.
This makes him better equipped to narrate the concerned event and his problems.
Emotional arousal and its regulation is the next principle change. Emotion can be regulated in various ways. Regulation helps him distance himself from the distressed state and develop self-soothing capacities. Meditation is one manner to achieve the self soothing ability. Emotion coaching should promote the clients abilities to receive and be compassionate to his emerging painful experience. The client should be able to turn off the affective alarm signal and accept the situation by empathising and providing cognitive, affective and physiological soothing. He can achieve this by diaphragmatic breathing, relaxation, compassion, calming self-talk and self-acceptance.
The therapist can soothen the client by helping him recognise the wounded child, finding an inner voice of strength and wisdom or finding a safe place to go to when he is distressed.
The third change principle involves the changing of emotion with emotion (Greenberg, 2002). A maladaptive emotional state can be changed with another maladaptive emotion. Reason is seldom enough to change the maladaptive state. Another feeling may be the only technique to undo the first emotion.
The maladaptive emotion leaves the client worthless, unloved and unable to go on.
The therapist has to expose the client to alternate healthy adaptive emotions like pride, joy and humour. Maladaptive fear can be overcome by anger or disgust or by softer emotions of compassion and forgiveness. Maladaptive shame can create an emotion of shrinking into the ground. This can be changed by encouraging anger at violation, self-comforting feelings and regaining pride and worth. Maladaptive anger can be changed to adaptive sadness. Positive emotions are known to overcome lingering negative ones.
(Frederikson, 2001). It has been found that resilient people cope by using positive emotions to overcome negative emotional experiences. This helps them bounce back to normal level and get the comfort they need.
FA and EFT
An integrated therapy is now advocated. Treatment needs to combine methods of working with affect, cognition and behaviour (Greenberg, 2002).
3 principle emotional changes that are recognised are emotional awareness, regulation and transformation. Therapeutic intervention should be guided by the region of the brain affected in the clients distress like the amygdala or prefrontal cortex, the type of dysregulation that has occurred (too little or too much emotion), and the type of process that is needed to bring about the change(whether short term or long term therapy).
An integrated therapeutic approach would probably affect the system at a chosen level like the cognitive, emotional, behavioural and interactional. Any specific effect would benefit the whole body system. This comparable change caused by the new approach would improve the patient cognitively, emotionally and behaviourally.
Emotional responses through two pathways Le Douxs (1993,1996) studies show that the fear response occurs unawares.
He claims that there are 2 different paths, the lower when the amygdala sends the distress signal to the brain and body and the higher when the same message is carried through the thalamus to the cortex. The shorter lower path is speedy and thereby the emotional response is faster than the thinking brain in the higher path which is slower to react and thereby cannot stop the initial response. Beck (1996) has suggested that the contents of a danger mode like fear, anxiety and an impulse to run away are experienced as reflex reactions. The fight flight mode has a perception of threat (cognitive system), feelings of anxiety or anger (affective system) that initiate the person to act (motivation), and the action itself (behavioural system) and the physical mobilisation (physiological system).
The 2 pathway-system points to the possibility of 2 learning techniques in case of impairment following an illness: one a conceptual and logical form and the other a perceptual associative one (Pascual Leone, 1987). Van de Kolk (1994) speaks of 2 types of memory, one factual and the other emotional. The conceptual form of learning and memory that involve facts and reasoning are produced in the cortex while the more automatic associative kind of learning and memory that involve immediate experience and perception are produced with the aid of the emotional brain (Greenberg, 2002). We can assume that there are 2 kinds of knowledge: knowledge by description(conceptual) and knowledge by acquaintance (experiential)
Emotions as excess energies.
Modern psychoanalysts have discarded the idea that emotions are excess energy as claimed by Freud. They recognise emotion as having a primacy of its own (Basch, 1992). They believe that dynamic unconsciousness is not suppressed instinctive drives but are affect states that have been defensively walled off because they failed to evoke attuned responsiveness (Stolorow, 1994)
Therapy
Treatment now consists of helping clients approach and tolerate emotional experiences so that emotions transform by connecting to self and situation (Stein, 1991).
Behavioural and cognitive theories visualise emotion in 2 ways. Emotion especially negative thoughts led to negative emotions which are a state of disturbance and disorganisation. These negative emotions are seen as clinical symptoms which need to be reduced through therapy. Another psychoanalyst suggested that a stimulus activated a cognitive schema where motivation, affect and behaviour (Beck, 1976) prevail. As depressed feelings result from maladaptive thinking, a cognitive therapist has the job of making the clients identify and re-evaluate those incidents which have resulted in the present situation and thereby reduce their depression. Recent evidence suggests that the behavioral component of Cognitive Behavioural Therapy maybe the effective ingredient of change in the treatment of depression. Behaviourists and cognitive behaviourists appear to be increasing their focus on automatic-unconscious cognitive-affective structures in theory and treatment.
Dysfunctional modes can be therefore treated in three ways; by deactivating them, by constructing adaptive modes to neutralise them or by changing their structure and content. Beck (1996) believes in the third method. Though Becks theory is changing, cognitive theory has retained its combination of behavioural and rationale intervention.
Exposure is used to treat trauma and emotion is used to unearth false beliefs.
Experiential Process
In recent developments of the human experiential theory, emotion is seen as a biologically adaptive, rapidly acting and meaningful system that gives the feedback on the states of the body and mind. Awareness of emotions informs people about what concerns them and provides them with speedy evaluation of the significance of events to their well-being. Simple dimensions of a stimulus like size, movements, whether pleasant or unpleasant or congruent to needs may produce primary responses which are combined with memorial information to form emotion schemes (Greenberg and Safran, 1987).
The experiential process brings about symbolisation which is influenced by the process and influences it in turn. Emotion schemes are the basis of experiential consciousness whereas cognitive conceptual schemes are the basis of a second element involving conceptual conscious thought. Greenberg has identified 3 types of emotions: primary adaptive, maladaptive and secondary emotionality. Primary adaptive feelings provide information; maladaptive need to be evoked and modified and the secondary ones need to be explored to get at the primary causes.
Factors that guide Intervention.
3 factors guide intervention. They are the source of the affect involved in the clients distress, the type of affect dysregulation and the type of change process to be used. The source of the affect is explained by the 2 pathway system mentioned earlier. There are also two types of affect dysregulation. One is the underregulation of intense negative effect and the other is the overregulation of affect. There are two types of therapeutic change advocated to develop an integrated, affective, cognitive, behavioural treatment. A first order type of change involves symptom reduction and improved adjustment. Here we provide support and help clients think in a new way or train them in distress reduction skills. A second order change involves a change in the clients affective orienting schemes. This form of psychotherapy is slower.
Functional Assessment of Schoolchildren Study Findings
A team studied the effects of functional assessment and positive behaviour support on classroom behaviours of young children. FACET, a programme, was implemented in pre-kindergarten through first grade classrooms. School-based teams conducted the research. Child behaviours were compared between experimental and control classes. The children in the experimental classes had significant gains, exhibited a higher level of positive behaviours and fewer negative behaviours compared to the control children. The intervention that incorporates functional assessment, collaboration and evidence-based treatment in the therapy of children with challenging behaviours has been proved effective in this study (Gettinger and Stoiber, 2006)
Functional assessment has been more tied to behaviour problems than academic problems. The method has been used in academic assessment too. 5 reasonable hypotheses for poor academic performance have been discussed a) the student does not want to do work b)the student has not spent enough time on the work c) the student has not had enough help to successfully complete the work d) the student has not had previously to do the work in the requested manner. e) the work is too hard for the student. If the function of the difficulty is identified, matching interventions can be developed. If the child does not want to do the work, incentives may be offerred to stimulate him to work.
Combining FA with EFT in School Studies
CBA (Child Behavioural Analysis) techniques are a part of the process as the assessor has to make repeated assessments. Functional approaches are useful but time consuming. It is the trend lately to combine functional assessment with emotion focussed therapy in order to deal with the problem of performance of a child which can be academic or behavioural. School Psychology has considered intellectual ability and academic achievement as important in the school life of a child. The socio-emotional and behavioural problems have been neglected (Merrell, Guilford Press) so far but attention is now being paid to the emotional aspect.
EFT -Study
Research on couples therapy also shows the role of emotional awareness and expression in a satisfying relationship. Emotional focussed couples therapy where there is expression of underlying attachment-oriented emotions leads to a satisfying marital life.
(Johnson and Greenberg, 1985). Couples that show more emotional experience in the therapy along with softening of blaming partners ended up being more satisfied than couples who showed lesser experiencing (Greenberg, Ford, Alden and Johnson, 1993).
This kind of expression of emotion is useful for terminating family conflicts too (Diamond and Liddle, 1996). One study demonstrated that an emotional cycle in the relaxation treatment, increase in arousal, arousal with reflection, more abstract reflection and then relaxation, following one upon the other finally results in a good outcome Mergenthaler, 1996). Disturbances of affect regulation has been spoken about in all personality disorders in the Diagnostic and Statistical Manula of Mental Disorders (4th ed., American Psychiatric Association, 1994). Descriptions have been included about borderline personality disorder where difficulty to control anger is the problem and schizoid disorder where extreme coldness is the problem.
Conclusion
Psychoanalysts agree to certain specific points of modern theories. First, the emergence of emotion focussed therapy is a signal that the material being discussed is significant to a patients well-being. Secondly, the awareness of emotion and attention to it in therapy play a significant role in accessing the information in emotion. Thirdly, incongruence between cognition, emotion and physiology can occur and is pathogenic.
Fourthly, emotion often needs to be aroused and processed as therapy to promote change.
Finally, it is important to promote emotion regulation and emotional experience. There is a great deal of research evidence that the first four points of emotional arousal, depth of experience and emotion focus relate to the outcome of therapy. Some psychoanalysts have found that session emotional intensity was a strong predictor of outcome (Beutler, Clarkin and Bongar, 2000). Recently studies have shown that successful dynamic theories involve more of an emotion focus. We find that there are points of agreement among several psychoanalysts that at unconscious levels, emotive and cognitive structures are highly integrated. Methods that increase arousal have been found to be useful in treating panic. Emotional processing of trauma facilitates recovery (Foa and Jaycox, 1999).. Therapeutic emotional arousal and awareness along with conscious cognitive processing of the aroused emotional experience can result in a beneficial change in certain groups of people. We either make sense of the cognitive processing of emotion or regulate it. Principles of working with emotions involve distinguishing different types of emotional expression (primary, secondary, adaptive and maladaptive) and the application of 3 major change processes (awareness of emotion, regulation of emotional arousal and changing emotion with emotion). With these principles in place, psychoanalysts would be better equipped to form an integration of the affective, behavioural and cognitive elements of psychotherapy (Greenberg, 2002)
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