Emotion Focused Therapy for Youth
This edited collection is the first book of its kind to apply the theory, research,
and teaching of emotion focused therapy to youth and their families, equipping
clinicians and students with the practical skills to facilitate individual, dyadic,
and parent sessions confidently.
Mirisse Foroughe is joined by an impressive group of internationally
acclaimed contributors, including clinician-scientists and scholars, as well as
the developer of Emotion Focused Therapy, Dr. Leslie Greenberg. This clinical
manual offers a trauma-informed perspective on how to apply EFT for youth
in primary care as well as more complex mental health difficulties. The manual
begins with an incredibly user-friendly overview of core EFT principles before
moving on to clinical applications with individual youth, parents, and dyads.
The contributors then address how EFT can be implemented with specific
client populations, such as youth with anxiety, depression, and borderline per-
sonality disorder, before examining important considerations that clinicians
should bear in mind when working with parent and youth trauma and complex
clinical presentations.
Interweaving a trauma-informed perspective throughout, the manual is
filled with practical summary tables, helpful tips, and eye-catching illustrations
to ensure it is useful for students and experienced therapists. Emotion Focused
Therapy for Youth is essential reading for marriage and family therapists, clinical
social workers, and other mental health professionals working with youth and
their families.
Dr. Mirisse Foroughe completed her doctoral studies at York University and
now directs the Family Psychology Centre and the Emotion Transformation
Institute in Toronto. She has received numerous awards and accolades for her
work, including the CPA 2017 PFC Innovative Service Award and the OPA
2019 Harvey T. Brooker Award for Excellence in Clinical Teaching.
Emotion Focused Therapy
for Youth
The Clinical Manual
Edited by Mirisse Foroughe
Designed cover image: Getty Images
First published 2023
by Routledge
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and by Routledge
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© 2023 selection and editorial matter, Mirisse Foroughe individual chapters, the contributors
The right of Mirisse Foroughe to be identified as the author of the editorial material,
and of the authors for their individual chapters, has been asserted in accordance with
sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised
in any form or by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying and recording, or in any information
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and are used only for identification and explanation without intent to infringe.
ISBN: 9781032112312 (hbk)
ISBN: 9781032112299 (pbk)
ISBN: 9781003218968 (ebk)
DOI: 10.4324/9781003218968
Typeset in Adobe Caslon Pro
by Newgen Publishing UK
CONTENTS
BRIEF BIOGRAPHY OF DR. FOROUGHE,
EDITOR vii
LIST OF CONTRIBUTORS viii
PREFACE ix
Chapter 1 Emotion Focused Therapy 1
Sarah Thompson and Les Greenberg
Chapter 2 Emotion Focused Therapy for Youth 36
Mirisse Foroughe
Chapter 3 Emotion Focused Therapy for Parents 58
Mirisse Foroughe and Angela Ashley
Chapter 4 Parent–Youth Dyadic EFT 83
Mirisse Foroughe and Imayan Neela
Chapter 5 Emotion Focused Therapy for Youth
with Anxiety 105
Mirisse Foroughe, Angela Ashley, and Imayan Neela
Chapter 6 Emotion Focused Therapy for Youth
with Depression 127
Mirisse Foroughe and Serena Darking
v
vi Contents
Chapter 7 Emotion Focused Therapy for Youth with
Borderline Personality Disorder 147
Mirisse Foroughe and George A. Langdon
Chapter 8 EFT-Y for Parent and Youth Trauma 176
Mirisse Foroughe, Robert T. Muller, and Lucas Liu
GLOSSARY 208
INDEX 213
BRIEF BIOGRAPHY OF
DR. FOROUGHE, EDITOR
Dr. Mirisse Foroughe is a clinical psychologist and Director of Clinical
Training and Research at the Family Psychology Centre. She has over 15 years
of experience providing assessment and treatment to children and families
utilizing emotion focused therapeutic approaches. After completing a Master’s
degree in Health Psychology, Dr. Foroughe completed her doctorate degree in
Clinical-Developmental Psychology at York University with a focus on family-
based therapy. She was Ontario’s first full-time child and family psychologist
in a family health team. Dr. Foroughe currently oversees clinical services at
the Family Psychology Centre and directs the Emotion Transformation Lab.
She has received numerous awards and accolades for her work, including the
OPA Ruth Berman Early Career Psychologist Award, the CPA 2017 PFC
Innovative Service Award, and the 2019 OPA Harvey Brooker Award for
Excellence in Clinical Teaching. She holds adjunct faculty positions with
York University and the University of Waterloo and is an Adjunct Clinical
Supervisor for OISE at the University of Toronto.
vii
LIST OF CONTRIBUTORS
Dr. Leslie S. Greenberg, Ph.D., C. Psych. Distinguished Research Professor,
York University, and developer of EFT
Dr. Robert T. Muller, Ph.D., C. Psych. Professor of Clinical Psychology, York
University, and Director of the Trauma & Attachment Lab
Sarah Thompson, Ph.D., C. Psych. Adjunct Faculty, Dept. of Psychology,
Toronto Metropolitan University, and Director of Transforming Emotions
Transforming Emotions
Lucas Liu, B.A.H., Emotion Transformation Lab and REACh Lab
Angela Ashley, B.Sc.H., Emotion Transformation Lab, The Addiction and
Mental Health Lab, Toronto Metropolitan University
Imayan Neela, B.Sc.H., Emotion Transformation Lab, McMaster University/
Hamilton Health Sciences
George A. Langdon, B.A.H., TULiP Lab, Emotion Transformation Lab,
Trauma & Attachment Lab
Serena Darking, B.Sc.H., Emotion Transformation Lab, Trauma &
Attachment Lab, The Till Lab
viii
PREFACE
I attended my first emotion focused therapy (EFT) training in 2010. At that
single day training on EFT for Depression, I took 31 pages of notes while
Dr. Leslie Greenberg spoke in the packed lecture hall at York University in
Toronto.
“You can’t change what happened, but you can change how you feel
about what happened.”
“You have to get to place before you can leave it.”
“Pain is a compass.”
“You have to feel it to heal it.”
I didn’t quite understand the meaning of these assertions, but they sounded
intriguing, and I wanted to learn more. Many years later, I find that I continue
to learn so much from the EFT community—a generous and brilliant group
of people who can analyze 20 seconds of video at a level of detail only matched
by acting coaches and police detectives. Of course, the attention that EFT pays
to minute detail in human behaviour is not concerned with performance or
objective truth, but with the journey of self-healing.
In my work as a child and adolescent psychologist, I have found EFT to be
the single most impactful model for working productively and directly with
emotion. As in the adult-focused model, EFT for youth (EFT-Y ) focuses on
relationship and alliance building and technical skills for working with emotion
in the moment. It provides specific roadmaps for helping youth work with their
emotions by helping clinicians know what to do, why to do it, when to do it,
and how much to do it.
In these chapters, you will not find a manual or checklist of what should
happen in each session. Rather, you will strengthen the ability to notice, iden-
tify, and deepen understandable emotion-based processes that occur in the
ix
x Preface
therapy session. EFT’s marker-driven approach helps to develop an “if–then”
blueprint of clinical decisions—if you find yourself here, then this is where you
could go, and this is how to go about it. It’s like a therapist GPS: the more
you use it, the wider and more detailed your roadmap becomes. This marker-
driven approach provides us with the flexibility to make clinical decisions in
the moment and based on the client in front of us. Each of our clients is unique,
and EFT-Y does not follow a one-size-fits-all recipe. We constantly evaluate
our next step based on where we are but also on who we are with, how our rela-
tionship is doing, and how much this client can tolerate right now.
Many youth come to therapy when there have been painful or overwhelming
experiences in their lives. It’s true that they cannot change the fact that
these experiences took place, but how do they feel when they remember these
experiences? How much do they suffer as a result? And what other feelings
can they access? EFT’s emotion transformation process simply and brilliantly
demonstrates how emotions can undo other emotions and reduce suffering.
It also provides us with keys to unlock productive emotion processing along
the way.
In the search for their own path to healing, EFT-Y directs youth to their
emotions as a fundamental meaning system. Each emotion provides clues to
how a person is experiencing their world while also organizing them to think
and act in certain ways. In our practice of EFT-Y, we have found that the
client-centred emphasis is much appreciated by youth. In addition to praising
the fact that there’s no workbook and no homework, young people often rec-
ognize that EFT-Y is individualized for them and places them at the centre of
the process:
“I like that you don’t really know what we are going to do in therapy that
day until I start feeling something important. It’s really about me and
what I feel, not like someone is telling me what to think or what to do.”
EFT engages youth and requires their active involvement. This necessarily
challenges emotion avoidance:
“It’s definitely not boring and it’s impossible to zone out for the whole
session like I have in therapy before.”
In fact, young people tell us that EFT feels undeniably authentic”
“I literally can’t lie to myself when I’m in the chairs. There’s nowhere
to hide. Sometimes I feel things that I didn’t even know were there, so
I actually know myself better now and I’m more honest with myself
because of this.”
preface xi
As child and adolescent therapists, the potential for greater engagement,
self-awareness, and authenticity for our clients is a compelling reason to learn
EFT. We have adapted EFT for youth based on ten years of clinical research.
We observed recordings of therapy sessions, identified key moments in therapy,
and mapped ideal therapist responses that helped youth make real changes in
their inner experience and their lives.
In this book, we share with you our emotion focused therapy model for
youth as well as special considerations for the populations we see most often
in child and adolescent practice. Chapter 1 provides a dynamic introduction to
the broader model and theory of change in EFT. Chapter 2 outlines core EFT
applications for youth including the use of empathic responses and evocative
tasks to identify and begin to treat a youth’s core wound or to pave the way for
parent–child therapy. Chapters 3 and 4 are focused on working with primary
caregivers and the clinical decision points related to involving caregivers in a
youth’s therapy. Chapters 4 through 8 share our application of EFT-Y for spe-
cific presenting concerns (anxiety, depression, borderline personality traits, and
trauma), offering theoretical considerations, technical adaptations, and prac-
tical tips to help engage youth in an emotion focused intervention.
When we work directly with emotions, youth build their capacity for pro-
cessing emotion and their openness to the therapeutic process. Productive
engagement with emotion and emotional memories, without emphasizing
coping-or avoidance-based methods such as distraction, behavioural shaping,
or changing thoughts, can provide youth with evidence of their own emotional
resilience and self-directed healing. It is an exercise in concentration, focusing
inwards, and attending fully to their own feelings and sensations. Whereas
self-conscious thoughts or feeling pushed to change can impede therapeutic
engagement, being immersed in their own experience can allow therapy to
move forward.
Perhaps the most satisfying aspect of using EFT-Y in our practice has been
the increased confidence and hope for improvement that our therapists see in
their young clients. All too often, children or teens who do not progress quickly
in treatment are perceived as being unmotivated or not ready for therapy. EFT-Y
encourages us to instead consider and address the emotional blocks that get in
the way of positive treatment response. Does the youth feel worried that they
cannot tolerate the emotions that will come up in therapy? Are they feeling
guilty or ashamed about something that has happened? Are they concerned
that they will make themselves vulnerable and end up feeling alone? Have
they learned that their feelings and needs are too much for others to handle?
There are many emotion blocks that can prevent youth from engaging in and
benefiting from therapy. Without attending to these blocks, youth may leave
therapy believing that they “tried therapy but it doesn’t work.” We use EFT-Y
to change that.
newgenprepdf
xii Preface
The EFT community is inspiring. Collectively, they have spent half a cen-
tury studying precisely how and why therapy works and have produced volumes
of literature and training videos. When you are first learning, I encourage you
not to concern yourself with the outstanding scholarship on therapy process
or the seamless transition from task to resolution in an EFT demonstration
video. Instead, just start with the moment you are in, the client in front of you,
and a focus on your client’s emotion. The process is in the name of the therapy
itself. Be emotion focused in the content you bring attention to, the words you
use, the nonverbal behaviours you watch for, and the way you connect with
physical sensations in your own body. Keep doing these things and you will be
on your way to practising EFT-Y with your own clients and in your own way.
From there, allow the road maps in this book to help guide you on your journey
to discovering the power of centring emotion in the therapy room and in your
practice. Your clients, of all ages, will thank you for it.
Mirisse Foroughe
1
Emotion Focused Therapy
Sarah Thompson and Les Greenberg
The brain is an almost mystical entity in its complexity. Its processing power,
its capacity for retention of memory, the depth of human experience that it
generates, and, of course, the tremendous growth occurring throughout
childhood and adolescence are all quite simply amazing. I think about these
things often when reflecting on change in psychotherapy—wondering what is
happening as someone shifts from feeling shut down, self-loathing, painfully
anxious, or irritable to the warmth of self-compassion, the calm of self-soothing,
and the healthy emotional flexibility that can follow deep transformational work.
In this chapter, we lay out the theory and practice of emotion focused
therapy (EFT) in accessible terms. We briefly introduce you to EFT, its
origins, and the research base that supports it. Then, we move on to a bit
about the brain (trust us, it will be worth it!) and what fundamental processes
we are working with as we facilitate change in psychotherapy. We will high-
light how EFT uses six change processes to transform emotion with emotion
through early, middle, and late phases of therapy, and how we help clients to
rewire old, stuck emotional patterns to create feelings and responses that are
anchored in the “here and now.” We end by translating theory into practice
DOI: 10.4324/9781003218968-1 1
2 Sarah Thompson and Les Greenberg
through the case of “Clara,” a fictional client based on composites of real
clients we have worked with in our practices over the years. Fundamentally,
we believe that, once you understand the basic change processes in psycho-
therapy, it’s easier to be a flexible and effective clinician—and that’s what this
chapter is all about.
EFT: Origins and Research
If EFT were the child of prior therapeutic models, it would belong to
Rogers’s client-centred therapy (Rogers, 1957; Gendlin, 1996) and Perls’s
Gestalt therapy (Gendlin, 1996; Perls et al., 1951), achieving a strong blend
of some of the best qualities of each parent model. Developed by Dr. Leslie
Greenberg, Dr. Laura Rice, and Dr. Robert Elliott, beginning in the late 1970s
(Greenberg et al., 1996; Elliott & Greenberg, 2021), this therapy arose from
the basic research question of what differentiated strong versus poor outcome
therapies—fundamentally asking the question, “When therapy works, why?”
Researchers carefully analyzed client-centred therapy sessions using both video
and session transcripts and using line-by-line analysis of therapist and client
speech to determine what patterns occurred between therapist and client that
predicted positive and negative outcomes over the course of therapy. The results
of several decades of painstaking research can be boiled down to one, rather
complicated, sentence:
Moderate to high aroused emotions that
are deeply experienced and reflected on
in order to make narrative sense
in the context of
an empathically-attuned relationship
with a good working alliance
with a therapist who is present
predicts therapeutic outcome.
(Greenberg & Warwar, 2019)
While we will spend the rest of this chapter unpacking this sentence,
decades later, EFT is a tested therapy model that excels in working directly
with a client’s emergent emotional experience. EFT has been demonstrated
to be effective in creating lasting therapeutic change in the treatment
of social anxiety (Elliott, 2013; Shahar et al., 2017), generalized anxiety
(Timulak & McElvaney, 2018; Watson & Greenberg, 2017), depression
(Elliott et al., 2013; Goldman et al., 2006; Watson et al., 2003), childhood
trauma (Paivio & Pascual-L eone, 2010), and eating disorders (Dolhanty &
Lafrance, 2019).
emotion focused therapy 3
Why Work with Emotion?
Fun Facts about the Brain
Our brains are incredibly complex. Neuroscientists estimate that our
brains contain roughly 120 billion neurons (Dance, 2020). That’s equiva-
lent to about one-third of all the stars in the whole Milky Way galaxy
(Voytek, 2013)! Each neuron is estimated to have 7–10,000 connections
with other neurons (Dance, 2020), with each neuron firing 1–200 times
per second (Bryant, 2013). Just take a moment to try to wrap your own
brain around that.
While not all therapies acknowledge the centrality of emotion, the majority
of clients in our practices come in with reports of feeling bad in some way
or another. Throughout this chapter, we’ll refer to the case of Clara. She is a
16-year-old whose mother called our clinic after they had been struggling for
months to manage Clara’s anxiety related to school and friendships. Although
Clara has a number of close friends, when she is invited out to parties or social
gatherings, she worries that no one really wants her to come, and she will
somehow make a fool out of herself. Her mom reports that she often finds it
hard to comfort Clara, who spends hours getting ready to go out, which often
includes bouts of tearful self-doubt. For Clara, coming to therapy is all about
wanting to feel better.
In this chapter, we define emotion as an automatic unfolding process that
occurs in our nervous system in response to changes in our environment. Mediated
by neurotransmitter and hormone levels (LeDoux, 1998), these processes impact
our breathing, muscle tension, blood flow, memory, attention, and thought
patterns (Levenson, 1994). For example, when we feel fear, we experience:
• Physiological changes in our body: our heart rate and breathing increase;
we may sweat or shake.
• Changes in our thought patterns: we may be more likely to believe that our
environment is unsafe or that we are unable to cope.
• Changes in our perception and accessible memories: we monitor our
environment for signs of danger; we most easily remember times when we
have been scared in the past.
• Changes in motivation and action: this leads us to seek safety.
As therapists, we can often observe the impact of these changes in a person’s
posture, movement, tone of voice, and more. These changes are important to
4 Sarah Thompson and Les Greenberg
pay attention to because they can guide us to the heart of a client’s experi-
ence. For example, in early sessions with Clara, we noticed that she often spoke
quietly while looking down at the floor when talking about herself, sometimes
with a tear in her eye.
Emotion Schemes
We use the term “emotion scheme” to refer to the (not so simple) whole experi-
ence of a certain emotion state and what is then activated in one’s body and
mind (Elliott & Greenberg, 2021). Figure 1.1 reflects five key component
processes of the emotion scheme of shame as we observe them with Clara. We
can help clients deepen their emotions by exploring different aspects of the
emotion scheme.
Follow Emotion to the Heart of the Matter
Leaning into the heart of clients’ painful feelings helps to heal and transform
stuck emotional processes. How do we know this? By understanding what is
happening in the brain during therapy.
Fundamentally, therapy is about helping our nervous systems learn, and
learning is about creating and modifying memory. When we help clients
become aware of their emotions, tolerate their emotions, and follow where
their emotions lead, we more quickly arrive at the core of what brings clients
Figure 1.1 Shame as an Emotion Scheme.
Adapted from Elliott and Greenberg, 2021.
emotion focused therapy 5
into therapy. One of the processes associated with this is state-dependent
memory.
State-dependent memory is a well-researched phenomenon. When we feel
a strong emotion, we are most likely to recall memories from the last time we
felt that way (Eich et al., 1994). As EFT therapists, we speak of following
“the pain compass” (Goldman & Greenberg, 2015), a process in which we
empathically reflect, follow, and deepen those aspects of the client’s experi-
ence that are accompanied by signs of painful or difficult expressed emotion.
If a client spends a few minutes telling us about their weekend and expresses
anger and hurt in the second last sentence, we can focus on and empathically
reflect the hurt that they shared, probing gently to focus the client in this area.
In EFT, we make use of the phenomenon of state-dependent memory, trusting
that, as we follow the pain and evoke problematic aspects of a client’s emotional
experience, the most relevant thoughts, memories, and meaning will emerge.
You’ve Got to Feel It to Heal It
Once we’ve arrived at the heart of a client’s experience, what do we do? We
help clients feel it to heal it—literally. This is based on two principles:
1. Neuroplasticity: neurons that fire together, wire together.
2. Memory reconsolidation: how we change memories.
Neurons That Fire Together, Wire Together
Our brain is composed of billions of neurons organized into networks of
interconnected cells, something psychologist Francis Stevens (2022) likens
to a three-dimensional spider-web of interconnecting threads and nodes. The
threads represent individual neurons (cells), and the nodes are where the cells
connect. Each time we activate a pathway through the web, the neurons along
that path fire with tiny electrical signals. Only when a pathway is “firing” can
it create links to new pathways, creating new connections or nodes. Essentially,
when firing, the pathway becomes plastic and ready for change (Lane et al.,
2015). This process underpins the saying “neurons that fire together, wire
together.”
This is important to understand as EFT clinicians. If we simply help our
clients talk about emotion, we are most able to help clients make changes in
how and what they think about emotions—change happens in the part of
the brain where we understand and make sense of emotion. If we help our
clients feel their emotions, we are most able to help them make changes in the
parts of their brain that create automatic emotion-based responses to their
environments—literally changing emotion with emotion. In EFT, we aim
to help clients “fire up” parts of the brain associated with feeling old, painful,
stuck feelings while also “firing up” parts of the brain that feel adaptive healthy
6 Sarah Thompson and Les Greenberg
emotions. Neurons that fire together, wire together, resulting in brand new
feelings.
How We Change Memories
Stevens (2022) talks about affect reconsolidation, a process based on a growing
body of literature related to memory (Nadel et al., 2012, 2000). What this
research tells us is that each time we recall a memory—each time we pull
up a memory out of our brain’s filing system—if the memory meets new
contradictory experience, the memory becomes labile (changeable) and is
changed a little bit before it goes back into the filing system. Each time we
remember something and what we expect to encounter differs from what
happens in our environment, the memory itself is altered in the process and
is reconsolidated as an updated memory (Fernández et al., 2016). This is
captured in Figure 1.2.
If, while a strong emotion is activated, we can help a client to have a new
emotional experience, the memory that gets re-encoded will be sent back to
the filing system with the new emotion attached to it and with new meaning
associated with it. While we can’t change the past, we can change the feelings
that come when we remember the past.
Now, here is where it gets tricky. If we help a client to pull a big emotional
memory out of storage and we do not help the client to feel something new,
we may just reinforce the old memory, repeating the same connections and
strengthening them. The strength of these “wired” connections in our brains
is impacted by repetition (Nadel et al., 2007). Memories of new experiences
become more easily reactivated with repetition—this is why regular review of
Figure 1.2 Making and Updating Memories.
Adapted from Nadel et al., 2012, p. 1641.
emotion focused therapy 7
new material (as opposed to last-minute cramming) is so helpful before tests
and exams (Nadel et al., 2007).
If we switch our metaphor up a bit, we can think of Clara as having a fear-
shame superhighway running through her brain—thick pathways that have
been well maintained and repeatedly repaved. In contrast, pathways associated
with pride, confidence, and feelings of safety have not been fired up very often
and, thus, are not well maintained or well connected to her fear-shame super-
highway. These more positive feelings are hard to trigger and tend to be weaker.
In order to strengthen connections to positive feelings and associated memories,
we have to repeatedly help Clara activate new feelings and connections and tie
them into her existing superhighways. Think of building new ramps on to and
off of the fear-shame superhighway until the highway itself is so altered that it is
no longer recognizable, with as many routes characterized by confidence, safety,
and pride as by fear or shame. What a different road trip that would be!
There is just one more important point to consider: timing. Research
suggests that a memory can be sent back to long-term storage in an altered
state when we recall a memory and then have a new experience within the next
several minutes to a few hours (Nader et al., 2013). On a practical level, this
means that we want to fully activate old, stuck, painful emotions in session and
then co-activate fresh, new adaptive emotions in the same session (Lane et al.,
2015). If we go back to our superhighway metaphor, we want to help Clara feel
her stuck anxiety, fear, and shame in session and then feel safe, soothed, confi-
dent, or proud in the same session. This allows us to help her to build on-ramps
and off-ramps connecting one highway to another and changing her overall
emotional experience. If we help Clara to experience stuck old feelings in one
session and then fresh new feelings in the next session, it’s like we’re helping
Clara to travel (and repave) the old superhighway in one session and then travel
(and repave) the new highway in the next session, without changing either
route and connecting them together. This process is outlined in Figure 1.3.
The Type of Emotion You Work with Matters
As therapists, we know that emotions are key to the change process, and that
there is healing power in following a client’s emotional process closely and
empathically. However, many therapists find it a challenge to articulate why
helping clients attend to, work with, and express their emotions is more effective
sometimes and less impactful at other times. Through EFT, we learn that the
type of emotion we are working with is the key to understanding this puzzle.
In EFT, we refer to three broad types of emotion: primary, secondary,
and instrumental (Greenberg, 2015, Chapter 2). Only one of these types of
emotion gives us immediately useful information about what we need to feel
better, along with a push in a specific direction to get that need met. The other
categories of feelings need a bit more decoding before they can be helpful to
us or our clients.
8 Sarah Thompson and Les Greenberg
Figure 1.3 Memory Consolidation and Reconsolidation.
Adapted from Nader et al., 2013.
Primary emotions are the first thing we feel in response to a change in
our environment. They are a reaction to an event or situation and they can be
maladaptive or adaptive. It’s important to note that words such as “adaptive”
and “maladaptive” are not meant to pass judgement on the individual feelings;
rather, these words refer to whether or not the information provided by the
emotion will lead us towards what we need (adaptive) or away from what we
need (maladaptive).
Primary Adaptive Emotions
Primary adaptive emotions are the ones that give us immediately useful infor-
mation. Our emotion systems have evolved to be rapid signal detection systems,
alerting us to the details in our environments that most need our attention
(Hoscheidt et al., 2013; LaBar & Cabeza, 2006; McGaugh, 2003; Roozendaal
et al., 2009). For example, when organized in calm satisfaction, our attention
may be flexibly deployed, turning inwards towards pleasant daydreams, solving
problems, being creative, or simply attending to things we enjoy around us.
When organized in fear, our attention is oriented towards signs of potential
danger in the environment, and, once we have perceived and addressed any
threat, a healthy fear signal is turned off. These “here and now” responses to our
environments help us to know what we need and are fundamentally adaptive
emotional responses.
emotion focused therapy 9
As a therapist, these tips can help you identify primary adaptive emotions:
• These feelings seem fresh and new (not old, repetitive, and stuck).
• They are experienced at an intensity that matches the current situation.
When a client is feeling a primary adaptive emotion, we want to help them
attend to this feeling, understand what it is telling them about their envir-
onment and what they need, and then act on the information appropriately
within their current environment. If Clara is feeling scared that she will fail a
test because she has skipped classes and has not opened a book, we want to help
her to attend to this feeling. It is telling her that she’s in danger of violating her
own standards and action is needed.
Table 1.1 provides examples of primary adaptive feelings and the needs and
healthy action tendencies associated with each one. As EFT clinicians, these
concepts help us to understand and make meaning of our clients’ emotions.
Primary Maladaptive Emotions
Primary maladaptive emotions can be very intense, both for our clients and
for us as therapists as we bear witness. They tend to have the quality of feeling
repetitive, stuck, old, and familiar for clients (Elliott & Greenberg, 2021;
Greenberg, 2002). The problem with primary maladaptive feelings is that they
tell us more about what has happened to a client in the past (and about what
they needed “then and there”) than about what is happening or is needed in
the “here and now.”
For example, clients with pervasive anxiety can be viewed as struggling
with underlying disavowed and undifferentiated pain, experiencing surface
symptoms of worry and anxiety as a way both to maintain a sense of control
and to avoid feared internal states or feared external outcomes. These under-
lying dreaded internal states—typically loneliness, shame, or fear—are the pri-
mary maladaptive emotions that are perpetually triggered and that underlie
surface symptoms (Timulak & McElvaney, 2018; Watson & Greenberg, 2017).
In general, the unmet need and the action tendency will be the same
whether I am feeling primary adaptive or primary maladaptive emotion. The
difference is that primary maladaptive feelings are like the emotion part of an
old memory—they are not truly a reaction to current circumstances and can
lead to reactions that are not helpful. For example, a child may naturally feel
frustration when they can’t do something new. With support, they may over-
come their frustration to persevere, succeed, and enjoy a (primary adaptive)
sense of accomplishment. If, instead, the child is humiliated by a parent each
time they make a mistake, the child may learn to respond to mistakes with
shame, withdrawing and giving up in the face of challenge in all situations. This
10 Sarah Thompson and Les Greenberg
Table 1.1 Primary Adaptive Emotions.
Situation Emotion Need Adaptive Action
Loss of someone Sadness Comfort Express pain to
or something elicit comfort
important and connection.
If that’s not
possible,
withdraw and
disengage
Violation (attack Anger Protect boundaries, Raise my voice,
on self, family, dignity stand up for
possessions, goals, myself, seek
values) distance
Danger Fear/anxiety Safety Flee, freeze, seek
protection
Having acted Shame Protect or repair Hide, correct, or
inappropriately social standing or express awareness
or revealed a connection with of impropriety
social defect others
Harming a valued Guilt Repair the damage Apologize, make
other amends
Offensive, dirty, Disgust Reject noxious Expel, avoid
indigestible object or person
object or person
Psychological injury Emotional pain Disengage to Withdraw into self
prevent further to heal if possible
injury
Novel, unknown, Interest/curiosity Explore, understand Attend, approach,
unexpected engage, immerse
stimuli
Achievement of Joy/happiness Savour and share Stop and appreciate,
goal, task, need, let others know,
or connection strengthen
connections
Suffering of a Compassion Provide caregiving Offer comfort,
vulnerable other soothing, support,
validation
Adapted from Greenberg and Paivio, 1997, and Elliott and Greenberg, 2021.
emotion focused therapy 11
would be an example of the development of a primary maladaptive emotion
scheme of shame.
As a therapist, we can pay attention to these patterns to help identify pri-
mary maladaptive emotions:
• These feelings seem familiar, stuck, repetitive, and uncomfortable.
• They are experienced at an intensity that often does not match the current
situation.
When a client is feeling primary maladaptive emotions, we want to
help them fully explore, express, and transform these primary emotions. As
therapists, we can do this by helping clients:
• Acknowledge and name their old, stuck feelings.
• Express what they are truly feeling and what they need.
• Feel and express new feelings that emerge in session.
As emotion focused therapists, we can remember that, after old, stuck,
familiar feelings have been fully activated, we want to help clients experience
and deepen emerging primary adaptive emotions in the same session so that we
can alter the emotion superhighways in their brains—changing emotion with
emotion! We will explore an example of this later in this chapter through the
case of Clara as we explore the middle phase of therapy through the lens of EFT.
Table 1.2 lists the three types of primary maladaptive feeling we typically
see in our clients. Being familiar with each of these emotion schemes will help
you to spot them in your clients’ stories.
Secondary Emotions
As an earlier career clinician, I (ST) often followed feelings in session based on
their intensity rather than on their quality. I assumed that the strongest feelings
must be the most important ones to follow to facilitate positive change. Often,
I was just plain wrong.
While primary feelings are our first reactions to an event, secondary feelings
are reactions to our own reaction. Secondary feelings are commonly learned
through emotion-socialization processes and will vary across cultures and across
time (Kitzmann, 2012). We are taught by our parents, friends, teachers, and
even pop culture how to feel about our own emotional reactions. For example,
young boys in some cultures may be told to stop crying or “toughen up” when
they express sadness or fear (Pollack, 1999). Little girls may be told to “stop
being so bossy” when they assert themselves (Lamb & Brown, 2007). In this
type of socialization process, boys may learn to feel ashamed of fear and vulner-
ability, while girls may learn to feel ashamed of their assertiveness and desires.
