RESEARCH

AN EMOTIONAL PROCESSING MODEL FOR COUNSELLING AND PSYCHOTHERAPY, A WAY FORWARD?

Professor Roger Baker, Consultant Clinical Psychologist, Dorset Healthcare NHS Trust and
Co-ordinator of Dorset Research & Development Support Unit, Poole Hospital NHS Trust

"I don’t feel I am an emotional person and when you first said about emotional experience, I thought ‘I don’t have any’. I don’t focus on emotion a lot …. I think there is something about emotions that I probably don’t feel too comfortable with, so that when these feelings come I want to channel it into something else, something more practical. I think sometimes it is a deliberate ploy on my part not to deal with emotional things." (Sandy T; participant in a research interview study on the topic of emotion)

Most of us are familiar with ways we tend to suppress, deny, avoid, switch off, bottle up, control or smother emotions. The belief in the superiority of rational thought and mistrust of emotions is summarised in our supposed national characteristic – the British ‘stiff upper lip’. Even researchers seem to have regarded emotions as a rather unacceptable subject for study and Scheff in 1984 went so far as to suggest there was a ‘taboo’ on research into emotions. The historical emphasis in clinical psychology too has been behaviour therapy (1965-1985) and cognitive therapy (1985- 2001), and in psychiatry, key negative human emotions such as anxiety and sadness are usually defined as symptoms of illnesses. However, in the last decade, there has been a growth in research on emotions as well as new developments in psychological therapy such as Gendlin’s ‘focussing oriented psychotherapy’ (1996) and Greenberg, Rice and Elliot’s experiential approach (1993).

Emotional Control and Panic Attacks

In the late eighties, when we were developing a cognitive invalidation approach for panic attack sufferers with Malcolm McFadyen (Baker 1989, 95) we also noticed that the patients seemed to go to great lengths to control their emotions and wondered if this might relate to why panic attacks develop in certain individuals. We looked to see if this was so. Researchers at the Courtauld Institute (Watson & Greer 1983, Pettingale, Watson & Greer 1984) had already developed an emotional control assessment scale and had suggested that excessive control of emotions might contribute to the development of cancer. We used their emotional control scale with other tests to measure other emotional dimensions such as frequency and severity of emotions and beliefs about emotional expression. We compared fifty patients with panic attacks with normal individuals from Aberdeen and London and the breast cancer patients that Watson and Greer had studied.

What did we find?

We found that panic attack sufferers tried to control all types of emotional experience measured (anger, sadness, worry) more than normal individuals or the cancer group. They were hyper-aware of the bodily sensations accompanying emotions and were not as good at identifying what emotions they were feeling (Baker 2000). In both research and therapy we found that patients with a range of other psychological conditions such as obsessive compulsive disorder and post traumatic disorder showed similar emotional control difficulties which suggested that this might be a factor underlying quite diverse psychological disorders. We wanted to understand the relationship between emotions, psychological disorder and psychotherapy and to see if a new way of understanding emotion was possible which might have practical applications to counselling and psychological therapy.

Emotional Processing

In 1980 Rachman developed a concept with potential application to many types of psychological therapy, called emotional processing. He believed that "most people successfully process the overwhelming majority of the disturbing events that occur in their life". If people were unable to remove or "process" strong emotions they would stay at a constantly high level of arousal with so much intrusion from their feelings that it was difficult to concentrate on the daily tasks of living.

Much counselling involves working with events in the client’s life that they have failed to process emotionally. They may have tried to ignore events such as bereavement and suppressed their emotional reaction or had not worked out the links between the events and the way they were feeling. We thought that counselling could help clients to recognise the significance of such an event, make connections with their feelings and work through the experience to a point of resolution by adequately processing these emotional events. This could apply not only to current life events but also to events experienced in childhood, such as sexual or physical abuse.

Emotional processing was further developed by Foa & colleagues (1986) in the context of post traumatic stress disorder, rape and obsessive compulsive disorder. However researchers had so far failed to unpick the different mechanisms involved in emotional processing or reached a stage where it had practical application to counselling.

The Emotional Processing Research Programme – A way forward?

To address this failure we began a research programme in 1988. Its aims were to:

1. Develop a model of emotional processing to explain the psychological mechanisms involved in processing negative life events.

2. Devise a way to assess emotional processing deficits which could assist psychological therapists of all kinds to help clients and patients.

3. Develop new ways of integrating the model of emotional processing into person centred counselling and cognitive therapy.

The Model

We wanted to develop a theoretical model to be useful in both the assessment and counselling of clients. Most individuals when faced with stressful, negative or adverse events in life successfully "emotionally process" these events in such a way that they do not intrude, persist or impinge on their daily life. They achieve this by (1) expressing feelings, (2) talking about issues, thinking about them and reaching conclusions (3) changing life circumstances which lead to the distress (4) dreaming or daydreaming, (5) getting involved in other activities, (6) experiencing other emotions, and (7) use of alcohol or drugs. However, if the individual fails to process events (such as trying to suppress any negative emotional experience) we thought it might make it hard for them to deal with or reduce the emotional impact of the event. This might not matter for the smaller, everyday negative events, but if more serious traumas, stress or abuse should occur, then failure to process these emotional events could have serious consequences.

We tried to identify the crucial emotional processing mechanisms which are necessary for successful emotional processing.

The accompanying diagram shows how we have tried to conceptualise the stages in experiencing and expressing an emotion. It suggests how the emotional experience is related to other mental events and what the conditions are for satisfactory emotional processing. The arrows suggest how the different processes interact with each other.

Input

Emotions start with an event, usually an interpersonal event. This may be a small discrete event such as severe criticism or ongoing conditions like stressful work environments or major traumatic events. It can also refer to memories or thoughts about an event which can also invoke emotion. For this to happen the event needs to be consciously or unconsciously ‘registered’ by the person. If the event was not even unconsciously detected by the person (like a blind person failing to see an object in front of them) no emotion would be experienced at any point within the person’s psyche. However, an unconscious, rapid and extremely complex appraisal of the meaning of the event is usually made by the person based on past memory and experience and the cognitive developmental level of the person. For instance, someone who has previously been criticised and has come to expect rejection from others may unconsciously ‘read’ someone’s words as critical and will respond by feeling hurt. Problems that can occur include the failure to register and respond to important events, or interpersonal cues, a block in feeling emotions, or feeling too much emotion because of exaggerated input like a person with paranoid constructs who sees slights and threats in innocent remarks and gestures.

Emotional Experience

We believe the emotional event and the meaning the person attributes to that event determines the type of emotion experienced. The emotion itself involves physical reactions and sensations and is also experienced psychologically. Frijda (1988) has suggested that emotions consist of a few fixed patterns of physiological reactions which are switched on as a package but each person has a complex way of viewing the world and will unconsciously understand events in their own unique way. The psychological experience of the emotion will depend critically not so much on the physiological reactions engendered but more on how the person has interpreted the event.

Problems of Control

Problems of control of the emotional experience could mean that although the emotional event is initially ‘registered’ (consciously or unconsciously) the experience is aborted, suppressed or constricted. This in turn inhibits emotional processing and can lead to unrelieved tension, panic attacks and dysfunctional attempts to control feelings, such as over-use of alcohol and drugs. The degree to which the person allows themselves to experience an emotion will be affected by their attitude to having emotions. For instance there may be certain family or community rules such as ‘men don’t cry’ which may cause individuals to stifle the experience of emotion as soon as they begin. The individual may also be afraid of experiencing emotions (as in panic disorder) and so has learned to suppress angry, fearful or depressed feelings.

Labelling

Automatically and usually unconsciously, individuals feel the emotion as a psychological whole and ‘label’ the psychological state. Some individuals however are unable to label such an emotion at this psychological level and instead experience it as a set of physical reactions or sensations; so instead of experiencing ‘anger’ they label it as ‘going red in the face’, trembling or feeling faint. Individuals widely differ in the way they can accurately label their emotions but generally we would expect these skills to improve during their development and upbringing and they are moulded for instance by gender expectations.

Linkage

Linking the emotions that individuals feel with the events which cause the felt emotions may be consciously or unconsciously achieved. It may be done appropriately (‘the boss is criticising me’) or inappropriately (‘it was something I ate this morning’) or the person may be just not good at linking events to emotions. We believe that correct linkage depends on the person’s ability to label their emotions. If the person is poor at labelling, it is unlikely that they will then be able to accurately link an event with the emotions they feel.

Awareness

This describes the degree to which the person is consciously aware of their emotions or the physical sensations that make up the felt emotion. Problems occur if individuals are hyper-aware of increased heart rate, choking sensations or difficulties in breathing and ruminate on these rather than their psychological emotional state. Patients with panic attacks or hypochondriasis are usually hyper-aware of bodily sensations. However awareness of one’s emotional state is not a prerequisite for successful emotional processing because much emotional processing occurs unconsciously.

Emotional Expression

This describes how the person gives bodily expression to their emotional experience. In practice it is closely tied to the emotional experience and may occur almost simultaneously, for instance sad feelings and crying usually occur together. Emotions can be expressed directly and immediately, such as (1) shouting at someone who has let you down at work or who has upset you in some way (2) directly but more tactfully, such as trying to deal with the reasons why they let you down (3) by talking to others about your feelings or writing down your experiences. Indirect expression of emotion include the proverbial kicking the cat or generally directing emotional expression at unrelated people, or things. Individuals will have developed familial or cultural attitudes towards the expression of emotion which also need to be understood.

It is also quite possible to experience emotions very strongly without expressing them by word or action to others.

Blocks in the System

Problems can emerge if there is some deficit or blockage in any of these processes. Different problems occur depending on the nature of the deficit or blockage. For instance, failure to label emotions correctly may result in confusion about one’s experiences; suppression of the experience may lead to tension; failure to input events properly may produce emotional blankness. If a therapist could identify where the emotional processing deficit lay, it would provide direction for the counselling and psychological therapy.

Case Example :

The following case example provides a practical illustration of how these concepts might be used during therapy.

A 28 year old woman was referred to me for psychological therapy by her GP with ‘a history of stress related symptoms and depressive illness’. She had previously responded to antidepressant medication but low mood and an inability to satisfactorily cope with work continued. I used a combination of psychotherapy in which patterns of childhood upbringing were explored and linked to current behaviour and attitudes and cognitive therapy, based on her current way of interpreting her own actions and those of others. As part of my approach the patient was invited to fill in our Emotional Processing Scale. This suggested that she experienced both strong positive and negative emotions and was in many respects emotionally healthy. However, the assessment showed that she failed to link correctly emotions with triggering events.

We explored this in the therapy session and it became clear to the patient that there was a pattern in which she would typically experience strong emotions, particularly sadness, but which she failed to connect with events such as being ignored or blamed by her family. In the absence of any such associations the patient had assumed she was ‘a depressive’ with a hereditary biological weakness which periodically caused depression. Further therapy involved exploring the links between ‘mysterious’ bouts of depression and the emotional events triggering the bouts which helped the patient realise that strong emotions do not emerge ‘out of the blue’ for no reason. She then realised that her self concept of being ‘a depressive’ was unsustainable and she took on a much more positive way of seeing herself. Not only did she feel greatly relieved by this realisation but she went on to develop a new way of understanding which prevented ‘depressive breakdown’ in the future. Sadness was regarded as the natural and normal consequence of difficult life events, as opposed to deficiency or illness. The use of the Emotional Processing Scale was a useful adjunct to both psychotherapy and cognitive therapy and was entirely congruent with both.

The Future

One way to make these concepts useful to psychological therapists of all kinds is by the use of an assessment scale, which the client could complete at the start of therapy. The benefit of a psychometrically designed scale is that the different dimensions (ie ‘labelling’, ‘control of expression of emotion’ etc) can be measured and scored indicating the different strengths and weakness of the client’s emotional processing ability. If for instance prior to counselling an assessment indicated the client showed considerable confusion about labelling emotions the counsellor might choose to focus more on self-awareness and correct identification of what the client is actually feeling before trying to help them explore life stresses causing such feelings.

Apart from guiding the therapeutic process, it is important to measure the effectiveness of counselling. An emotional processing assessment filled in before and at the end of counselling allows the counsellor to assess changes in the way clients deal with their emotions. Helping the client explore and understand a particularly stressful situation is useful, but less important perhaps than helping them develop better ways of processing difficult life events which could help them withstand future crises. Counsellors need to know for instance, what emotional areas counselling benefits, so from both an individual client and from a clinical service perspective, an emotional processing assessment may have much to offer.

Where are we now?

Since the development of the model in 1990 whilst conducting psychological therapy with patients, in reading the psychological literature on emotions and from personal incidents in my own life, I have built a list of possible useful questions for an emotional processing scale and have explored different methods of recording and scoring emotional information.

In early 2000 the first version of the emotional processing scale (109 items) was constructed and given to consenting patients seen by counsellors and psychological therapists, ‘normal’ volunteers and patients waiting to see their GP, in total 150 individuals. Paper-based questionnaires were tested against computer based ones with short versus longer instructions, etc. so that we could test whether answers depended on the content rather than the mode of presentation. Participants were invited to comment on the questionnaire as a whole or any individual questions they found hard to answer. The questionnaires were scored and the qualitative and (mainly) quantitative data were examined. The psychometric statistical analyses we conducted examined questionnaire item distributions, internal reliability, split-half reliability, convergent-discriminant analysis and factor analysis.

The Future

A shorter improved 40 item ‘mark 2’ questionnaire has now been developed to provide (1) measures of frequency and strength of emotions (2) measures of control of the experience and expression of emotions, (3) ‘a way to measure’ the ability to label emotions and to link them with life events, (4) awareness of emotions and other key dimensions in emotional processing. The scale is now ready for use with various types of patients to explore their differing emotional processing abilities and deficits. The first group of studies involves patients who ‘somatise’ their psychological distress seen in medical settings. The second group of studies aims to explore the use of the assessment in other counselling and clinical psychology settings. As the scale is used in different medical and psychological settings, we hope to build up a greater understanding of emotional processing and be able to make further refinements for a final ‘mark 3’ version which we hope will be employed more widely in counselling, psychological and medical settings. The scale is designed to integrate both with person-centred and cognitive therapy approaches.

References

Baker, R. (Ed) (1989) Panic Disorder: Theory Research & Therapy. Wiley, Chichester.

Baker, R. (1995) Understanding Panic Attacks and Overcoming Fear. Lion Publishing, Oxford.

Baker, R. (2000) Emotional Processing and Panic Attacks. Proceedings of the British Psychological Society, 8, 23.

Baker, R., Allen, H., Gibson, S., Newth, T. & Baker, E. (1998) Evaluation of a Primary Care Counselling Service in Dorset. British Journal of General Practice, 48, 1049-1053.

Baker, R., Allen, H., Penn, W., Daw, P. & Baker, E. (1996) The Dorset Primary Care Counselling Service Research Evaluation. Institute of Health & Community Studies, Bournemouth University.

Baker, R., Nunn, J. & Sinclair, J. (1993) A System of evaluating the clinical effectiveness of therapy. Royal Cornhill Hospital, Final Research Report to the Grampian Health Board Psychology Department,.

Foa, E.B. & Kozak, M.J. (1986) Emotional Processing of Fear. Psychological Bulletin, 99, 20-35.

Frijda, NH (1988) The Laws of Emotion. American Psychologist, 43 (5), 349-359.

Gendlin, E.T. (1996) Focussing oriented psychotherapy, a manual of the experiential method. Guilford Press, New York.

Greenberg, L.S., Rice, L.N., Elliot, R. (1993) Facilitating Emotional Change. The Moment by Moment Process. Guilford Press, New York.

Pettingale, K.W., Watson, M. & Greir, S. (1984) The Validity of Emotional Control as a Trait in Breast Cancer Patients. Journal of Psychosocial Oncology, 2, 21-30.

Rachman, S. (1980) Emotional Processing. Behaviour Research & Therapy, 18, 51-60.

Scheft, T.J. (1984) The Taboo on coarse emotion. Review of Personality and Social Psychology, 5, 146-169.

Watson, M., & Greer, S. (1983) Development of a questionnaire measure of emotional control. Journal of Psychosomatic Research, 27, 299-305.

Counselling and Emotional Processing Research Project

We would be pleased to hear from any counsellors and other psychological therapists who would like to collaborate in the research projects we plan.

Research Project 1 – Aims and Objectives

Improving counselling through the use of the EPS

We want to give the emotional processing scale to patients to complete at the start of counselling or psychological therapy. This would provide the counsellor with information on the emotional processing strengths and weaknesses of individual clients. We want to find out if this is useful to counsellors and to discover if it influences the way that issues are covered in therapy and if it affects the way in which therapy is offered. We also want to find out if it improves counsellors’ conceptualisation of their clients problems.

Research Project 2 – Aims and Objectives

Emotional processing changes during counselling

We want to give the emotional processing scale to clients at the start and the end of counselling/psychological therapy together with anxiety and depression scales previously used successfully to evaluate a counselling service and a psychology service (Baker et al 1993, 1996, 1998). We hope to discover which emotional dimensions improve during therapy and how this relates to improved mood. This would help any therapist who wishes to assess their own work or if a group of counsellors or service providers wished to audit a service.

If you are interested in participating in either or both of these research projects please write to:

The Counselling and Emotional Processing Research Project

Dorset Research & Development Support Unit
Cornelia House
Poole Hospital NHS Trust
Longfleet Road
Poole BH15 2JB

Tel: 01202 448489 Fax: 01202 448490 E-mail: crichards@poole-tr.swest.nhs.uk

The projects will start in Spring 2001 and run for a year. Back up training, advice and literature will be provided.

© Dorset RDSU 2003