Interview – Leslie Greenberg

Interview with Leslie Greenberg

The future is in the hands of the students

Laura Mikkelsen, 4. semester

Emotion is one of the main topics in the first courses we undertake as psychology students at Aarhus University. We discuss its evolutionary roots, the physiological changes, the cognitive appraisals, and especially, whether emotions are universal or not. The last debate is used to question the importance of emotions and their role in psychology, but according to the founder of emotion-focused therapy (EFT), Leslie Greenberg, the centrality of emotion in human experience, human change, and therefore psychotherapy, is unambiguous. Zoom lets us call him up on a spring morning in Canada to talk about his decades of work with research in psychotherapy, humanistic therapies, and the current dogmas in the field of psychology.

Since Leslie Greenberg’s first studies in the 1970’s he has been interested in the processes of psychotherapy as he studied several humanistic approaches to psychotherapy including gestalt therapy, client-centered therapy, and existential therapy. In the following decades, he integrated these different approaches in the context of emotion theory when he developed and refined EFT. The approach evolved as a result of Leslie Greenberg’s research which led him to see emotion as the most fundamental human process:

There are many levels of human change. You can get a cognitive change or a conceptual narrative change, but the real change has to come at the level of automatic emotional processing, and you need to change emotions–but you need to feel an emotion to change an emotion. It has been remarkable that psychology and psychotherapy have existed for more than a hundred years, but the problem has never been defined as being emotional processing. You have unconscious motivation, you have behavior, you have interaction, you have cognition, but it is really emotion. Emotions underlie behavior, cognition, and interaction, so we want to change emotion. We are helping people processing their emotions–that is the important thing, and we believe that emotions are the most fundamental human process. So, whereas Descartes said: “I think, therefore I am” we say: “I feel, therefore I am”.

Immediately, Barrett and the rest of the curriculum from cognitive psychology starts running through my mind. Emotions, feelings, affect – how do they differ from one another? And more importantly, what aspect does EFT refers to? Luckily, Leslie Greenberg is ready with a great answer:

There is no clear definition of any of these words, so when I lecture and write, I use them interchangeably to fit the context just to what sounds better or seems better. When you are working with clients you often talk about “What are your feelings?”, not “What are your emotion?” And you certainly do not say: “What’s your affect?”

The example makes Leslie Greenberg’s point clear: It does not matter in practice. And further he adds:

I did a search once of these words and found that ever since the 17th or 18th hundred they have been used interchangeably to mean different things by different philosophers and then by different psychologists.

However, if you are a first-year student and want a formal theoretical perspective, Leslie Greenberg presents a comprehensible image by DeMasio:

Imagine a tree and the tree has roots. Affects are the roots and the main stem, of this affective system. Then emotions are the main branches; the categorical emotions anger, sadness, fear, and shame are like the branches. And then feelings are the more differentiated twigs and leaves. So, the feelings are like: “I feel surprised” or “I feel fragile”. Emotion is fear. And affect is high arousal.

Leslie Greenberg emphasizes that it is not that important a distinction in practice and that EFT works with all kinds of emotions, feelings, and affects:

It also includes feeling surprised, feeling on top of the world, feeling under the weather–these are large metaphors, but they still describe a feeling state. But you can also talk about feeling shaky. Feeling covers both sensory experience and complex meaning, sensed meaning, so they mean many things. Especially when you are working with another human being; this is not writing an academic paper.

With the understanding of the term emotion, the next question arises. How does one change an emotion?

I have been proposing that because we have studied for many, many years, how do people change, the best way to change an amygdala-based painful emotion is with another emotion. So, a core principle is changing emotion with emotion.

Changing emotion with emotion is one of the six core principles formulated by Leslie Greenberg about working with emotion. The remaining five are awareness of emotion, emotional expression, regulation of emotion, reflection on experience, and corrective experience of emotion through newly lived interpersonal experiences. The last principle plus changing emotion with emotion from within are central in EFT according to Leslie Greenberg’s short description of the therapy:

It is a humanistic experiential therapy. So, a key aspect of it is, we believe, that people have to feel something in order to change something. You have to experience what you are talking about, not just talk about it.

That the focus of the therapy is present emotions is not the only thing that separates EFT from other therapy models. So does the role of the therapist:

An important part is, first it seems unusual to say, but it is a combination of following and guiding. Some therapies are all about being non-directive or really listening and following, and other therapies or manuals are about modifying and guiding. We really take as a fundamental principle that it is important to follow, but it is also helpful to guide. But you have to guide in the proximal zone of development, which means you can be just one step ahead but not three steps ahead. It is a very close following, but also we permit to encourage guiding. And then, we have a combination of relationship plus work, so that these two components are: (1) The relationship – a lot of it involves empathic attunement to affect, conveying an understanding, building an alliance. (2) The work involves marker-guided tasks. A marker is an indicator of a particular emotional state that people enter into and the difficult emotional states that people enter in the therapy like they are torn between two voices within themselves or they have a lot of bad feelings towards a significant other. There we engage in different interventions for different states and that is more guiding. But then even within the guiding, we are combining following and leading. So, you can in that thinking of the whole approach as islands of work within an ocean of empathy.

Again, this presents an integrative approach where there within the therapeutic alliance are some clearly defined tools–or markers that guide the intervention. Leslie Greenberg describes how this approach differs from the current use of diagnosis systems like DSM:

The term actually comes from medicine; you have certain markers of underlying causes–there is a surface marker. And so, what we are doing is that we diagnose that the person is in this state at this moment. And classical diagnoses, they do not have implications for intervention, they do not really tell you how to intervene. So, when a person is in a conflict between two sides this is a process diagnosis of what state you are in, and it is an opportunity for a kind of intervention that most serves that state. We were always opposed to the notion of diagnosis, person diagnosis. And I mean it has completely become scientifically not respectable anymore to have an actual diagnosis; there is no scientific base. So, we were wanting to get away from whatever use of diagnosis. And the idea that we were process-sensitive meant that we were really diagnosing the moment.

In fact, EFT was first called process experiential therapy due to this focus on the process of change:

Well, the first name, process experiential, was because we were coming from a humanistic therapy base and we had not defined emotion as a central, although there was some debate about the name. The name at first was focused on process, moment by moment process, and we focused on experiencing. But then I kept looking at how do people change. I mean, my very first book was called “Facilitating emotional change” or actually my first book was called “Patterns of change”. We were not even interested in developing another therapy, we were interested in studying how people change. But then with the ascendance of cognitive therapy with a big claim that cognition produced emotion, it seemed really important to highlight that: “No, that really was not the fundamental way of human functioning. That is much more that emotion produces cognition in all important subjective experience or all important personal experience.” Of course, cognition does produce emotion, but that is superficial emotions. The deep emotions that we feel in life come from another place. And I had always been focused on emotions because I wrote the book “Emotion in psychotherapy” in 1986–that was even before we used the term process experiential–so emotion was always there. Because we came from the humanistic movement, we first tried a name that fitted the humanistic zeitgeist. But then around 1986 or so emotion started to become really well recognized in psychological science. So that plus the ascendance of cognitive therapy made it seem important to change the name to indicate that we really focused on emotion.

It is clear in that description that the ascendance of cognitive behavioral therapy affected the development of EFT and its explicit emphasis on the importance of emotions. This is not only in theory, but it is seen in practice as well:

One of my doctoral students did a study, which she never published, but we took every time a person stated an emotion in a therapy, and we looked at emotion-focused therapy, cognitive therapy, and interpersonal therapy from a big NIMH study. Within five talk turns after a person had stated an emotion in a session the cognitive therapist focused on “What do you think?”, the interpersonal therapist focused on “What happened between you and an interaction?”, the emotion-focused therapist focused on “What does that feel like?” Therein lies the difference and it is real: In real time and real behavior emotion-focused therapists focus on emotion, a cognitive therapist focuses on cognition, and then the dialogue unfolds about emotion, about cognition, or about interaction. That is the difference. And then, because emotion became more scientifically respectable, cognitive therapists and psychotherapists all said: “We work on emotion. We do work on emotion.” I have been on panels with them, they get quite insistent, but we mean totally different things. Cognitive therapists work on how you downregulate secondary, symptomatic emotions and how you control emotions. Dynamic therapists are closer, but they talk about the underlying motivation. We talk about emotion. “What does it feel like? What it is like in your body? What does it lead you to want to do?” So, we do different things. And I have one situation where I made a film, the same client with three different therapists. Within four minutes, or actually three minutes in my session, the client cried. Within eight minutes with Nancy McWilliam, a very empathic psychodynamic therapist, she cried. Within 17 minutes with Judith Beck, a cognitive therapist, she cried. Assuming therapy is about dealing with vulnerable emotions, look at that difference–that was because of how we responded. But then the most important thing was what we did when the client became vulnerable and cried. Well, I focused on emotion, and I said something like: “Let the tears have a voice, what would they say?” Extracting meaning and information from the emotion. Nancy McWilliams went into, a sort of higher-level interpretation of pattern and Judith Beck basically ignored the emotion and carried on with her manually guided intervention. So, the difference lies there: in what we focus on and what we do.

Laura Mikkelsen, 4. semester

The difference between the approaches to therapy is clear in the examples, and as a consequence, the roles of and the requirements for the therapist are different too.

I have moved away from just the term empathy–emphatic understanding–to empathic attunement to affect. You have to be empathically attuned to affect, and then there is the debate of whether this is inborn or something you develop. I believe it is some of both. I mean people have a whole history–by the time you are 21, or whatever age as a young therapist, you have had a whole 21 years of experience of dealing with emotion in your family, or how emotions were handled, whether you bought into the family or whether you rebelled against the family way of dealing with emotion. So, you have a fundamental orientation to the world and because emotion is automatic, it is not deliberate, I mean, it is in your way of being in the world. I had a student once who I thought would never become able to be empathically attuned to affect, but she was very committed, she believed a lot in the theory, she had been a dancer, which I think helped; after 5 years she was a decent empathic oriented therapist. That changed my view to that people can be trained, but there is also some natural attunement. I think people who are very practical and pragmatic and behaviorally oriented–it is harder for them to be empathically attuned because they want to fix it. But people who are more internally oriented and who can sit and appreciate the sunset, smell the roses, these kinds of things, that is more of a sensory attunement–and there are ways of training that. And then also I have gotten on about that it is perceptual skills that are needed, not executive skills. Students and therapists come and they want to learn “what do I do,” the issue is how to learn you how to see. It is not what you do, it is when do you do what you do–that is marker guided. It is a kind of sensing what is happening in the other person that is hard to teach explicitly. And that sense is something people carry, but it also can be trained. However, it is trained not by reading books, not by sitting in class, but by being in therapy yourself, by supervision, by watching videotapes, and things like that.

These viewpoints are reflected in Leslie Greenberg’s advice to psychology students who are interested in becoming therapists:

I think experiential work on yourself, so awareness and personal work, is probably very important. Then watching videotapes, watching actual therapies.

Leslie Greenberg describes how they in process research have different scales like depth of experiencing, vocal quality, and emotional arousal that they use to rate moment by moment, what is happening. That is time-consuming if you are not doing research. But he maintains that studying actual performance and self-experience are the two things needed to become a good therapist. Those two things are not the main components of the bachelor’s degree in psychology at Aarhus University and they seem to require more personal investment from the therapist compared to other therapy models. How to protect oneself as a therapist is however no reason for any concern according to Leslie Greenberg:

It is an understandable question and often asked. But it does not make sense to me, because I feel most alive when I am in an “I-Thou” relationship with someone sharing; be at their pain or be at their joy. It is not draining on me; it is vitalizing. If I am sitting on a Friday afternoon and you are my sixth client and you are talking, talking, talking, talking, then that is deadening, all right? Like how do I protect myself from boredom? Well not, actually boredom, but losing interest. It drains your energy. But if you are alive and in your pain it brings me alive and I feel very connected. So actually, it is vitalizing. That is not to ignore that when people are going through intense pain or trauma it does take a lot to be in that presence, so one can be tired at the end of that kind of intensity. And when you are in a very different situation where you worry that one might be self-harming or suicidal it is the worry that is draining. So, one should be able to be highly self-compassionate, self-regulated, and let go. There has to be some capacity to regulate your own emotional life. When you start off as a young therapist it is very intense when somebody is highly aroused. But that really means that you are still working with your own emotional regulation. Now, when I am with someone and they weep deeply it is not stressful. When you are young it is stressful, because you have not dealt with these things before and these types of things. If you have been through your own pain and found out that you are still alive at the end of it, then it is not hard to be with someone else in their pain because you are not worried that they are not going to survive.

Even though core principles in EFT concern the act of being present in active emotions, Leslie Greenberg adds that you as the therapist also have to be able to regulate emotions in some instances:

You have to understand when to regulate and when to activate. When clients are outside their zone of tolerance, when they are in highly traumatized material, and they are disintegrating and becoming dysregulated, then you need to know how to help calm and help regulate. So, in order to work with how to activate, you also got to know how to help regulate, and those are skills you can learn.

Suddenly, we are very far into the field of practicing psychotherapy. However, an important feature of EFT is that it is a research-based humanistic therapy model. Leslie Greenberg describes that this fact has had an impact on the recognition of EFT. He exemplifies it with a study made for a student’s dissertation on EFT couple therapy:

We did a comparison of EFT couples with CBT couples and because we showed superior efficacy the couple therapy immediately got a lot of recognition by doing an outcome study. And that sort of had an impact on me realizing that in the politics of the field you have to do outcome studies in order to get attention. But I have never believed that the outcome study was particularly useful other than to provide material for studying the process. There is a lot of politics in research, so it is really also why we did outcome research or RCTs (randomized clinical trials). Because that is a gold standard, or supposed gold standard, it sorts of helped EFT to be recognized, or it helped it as a humanistically based therapy to get some recognition, but still not full recognition. And then the fact that we did so much process research also sort of strengthened that it is research-based. But I believe now that it is the beginning of the end of RCT’s; that there will be a shift back, or I do not know if it is back, but to process-oriented research. Large group studies, the test of the effectiveness, or claim that they test the efficacy, does not really help practice.

Leslie Greenberg describes the pragmatic reason to why he and his colleagues have made outcome research despite his skepticism:

It is kind of like, you have to join them to beat them. And there is a lot of politics in outcome research. There is a lot of money involved. It is what the hospitals support, it is who will get jobs, all these kinds of things. It is almost as corrupt as politics itself because they claim that research is bias-free, but it is not though.

It should be noted, however, that Leslie Greenberg is in favor of research and see a value in some types of it–he himself coined the term change process research:

I think the problem is the kind of research. I am very in favor of research. I have a master’s degree in engineering, so I came from a background with the notion that you observe things and then you try to build mathematical models of what you are observing. That is a very different mentality to running horse races or to make a randomized clinical trial. I think randomized clinical trials have very little to do with real practice. But the kind of research that I did, I felt, really informed practice. We did models of how do people change, and that really fed back into making me, I do not know if it is a better therapist, but making me know more of what I was doing and then being able to do it in a more focused manner.

Leslie Greenberg draws on an example from the making of the first Working Alliance Inventory (WAI) with his student Adam Horvath:

When I went into that research, I believed that empathy was actually the best predictor of outcome, but we found in that research that although empathy helped predict the outcome, task agreement and task relevance were better predictors of outcome. If the client really saw that it made sense to them to engage in a chair dialogue or it made sense to them to explore their feelings, then they did better, and that really changed my view, theoretically, that somehow although empathy and the bond are so important, what was even more important was collaboration, getting agreement. That really changed my understanding of what was going on. That was the first time that I really saw research feeding back into what I believed as a therapist, and then I gained more focus on task agreement and so on. That is one example, but there are many other examples. As we started modeling how change takes place, we could see little steps that were important and that would feed back into practice.

Clearly, EFT both opposes to other tendencies in the field of psychotherapy while trying to integrate humanistic approaches. Leslie Greenberg mentions that as some of the motivations for being one of the founding members of the World Association for Person-Centered and Experiential Psychotherapy and Counseling (WAPCEPC) just before the millennium change:

It was especially because of the ascendance of cognitive therapy and cognitive therapy sort of taking over everything. It seemed really important to try to have an outlet for humanistic experiential therapies. But I also saw it as an important opportunity to try to bring them together. Unfortunately in psychotherapy there had been the school war and even within the humanistic group there was client-centered, person-centered, experiential, and gestalt therapy, and we were developing process therapy. So, in 1986 I edited a handbook of experiential psychotherapy and the effort was to try to bring together person-centered, experiential, gestalt, existential, and psychodrama, all under one umbrella. But now the PCE organization was just trying to bring together people who had a person-centered base and that did not include gestalt and psychodrama, but I was trained in both. I mean it was a very important thing, and one of the important things of having world organizations is for people to network, and networking on the one hand involves just meeting each other and listening to each other. It was important to try to bring together person-centered, experiential, and process-experiential all into one organization. People started talking of different tribes of the same nation. Organizations are important for longevity, for after the founders die the organization carries on.

Actually, the 15th World Conference for Person-Centred & Experiential Psychotherapy & Counseling (PCE2022) is being held this summer from the 4th to the 8th of June in Copenhagen. The gain, also for psychology students at PCE2022, is in agreement with the described goal of WAPCEPC:

Probably, if you are a psychologist who grew up in the last 10 or 15 years, you have been fed cognitive behavioral therapy predominantly, so you would get a very different view of what therapy is. It would be a much more compassionate human encounter-pointed view on what therapy is about. You will get a different view about change and often change comes from understanding another human being, from witnessing their pain, from being with them, rather than trying to change them. The phrase that came from gestalt therapy was: “Change to be who you are and not who you are not”. It is sort of a different approach to coping. I mean, teaching people coping skills to handle symptoms is an important domain. But it is different from human relating in order to help to break clients’ feelings of isolation, and alienation and they are almost like different domains of experience rather than it is a different view on what therapy is all about. I think that is what you will gain as the most fundamental thing and probably the most important thing. We have found that our students who were trained in empathy as their baseline training, when they went to cognitive-behavioral internships, were much better cognitive behavioral therapists because they had this attunement as to when do you do this, when do you back off, when do you move forward. They were much more sensitive and responsive. So probably one of the key variables, that has yet to be fully mined or worked with, is responsiveness. And I think that one of this PCE conference’s key elements is that everybody is coming from this responsiveness which is more like the following than the leading component. And so, people would gain this kind of perspective of how important this is in human relationships.

After mentioning the current debate among the Danish psychology students we end up discussing the importance of getting exposed to such different approaches:

Students should really be exposed to the array of possibilities and the notion that cognitive behavioral is proven to be better than everything else is just false. It truly is a falsehood and it is based on politics and power, and it is not really true. I think that it is coming out now eventually. The good thing about research is that eventually, it leads you closer to, there is no real truth, but it leads you closer to what might be effective. And more and more it is shown that cognitive behavioral therapy is not any more effective than everything else. And anyhow the tools of research are deficient, I mean the measures; if you measure symptom reduction in depression it is not really measuring the full effect of what the therapy has been about. And all approaches reduce depression by about the same amount. But then it is interesting what else do they do, and we do not have measures and we do not have ways, so we got to be very humble in our claims.

Nonetheless, Leslie Greenberg has hope for the future when he places it in the hands of the youth:

Just like with global warming, with environmental concerns, the establishment has a dogma, and it persists because of power, money, politics, and you know, the ones who are going to change the world are going to be the students or the young people coming up, and I hope the same things happen in psychology and psychotherapy. The future always lies in the hands of the students and if the students are self-directed, they normally rebel against the existing dogma. They should be critical analytics and see what is wrong with the dogma and try to get more. So, my hope always lies with students, but they need to be exposed to more than one dogmatic view.