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Ladislav Timulak, Ph.D. - Guest
Ladislav Timulak, Ph.D. is Professor in Counseling Psychology at Trinity College Dublin. He is Course Director of the Doctorate in Counseling Psychology. Ladislav (or short Laco; read Latso) is involved in the training of counseling psychologists. His main research interest is psychotherapy research, particularly the development of emotion focused therapy as well as online mental health interventions. He has written (or co-written) 10 books, over 100 peer reviewed papers and chapters in both his native language, Slovak, and in English. His most recent books include Transforming Emotional Pain in Psychotherapy: An Emotion‐Focused Approach (Routledge, 2015) and Transforming Generalized Anxiety: An Emotion-Focused Approach (Routledge, 2017)(with James McElvaney; 2018), and Essentials of Descriptive-Interpretive Qualitative Research: (with co-author Robert Elliott) and Transdiagnostic Emotion-Focused Therapy (with co-author Daragh Keogh) published by the American Psychological Association (2021). His latest books include Essentials of Qualitative Meta-Analysis (with Mary Creaner; American Psychological Association) and Transforming Emotional Pain: An Emotion-Focused Workbook (with several co-authors; Routledge). He provides trainings for clinicians using the approach presented in his books internationally. He directs Emotion-Focused Therapy Research Group and co-directs an E-Mental Health Research group.He previously co-edited Counselling Psychology Quarterly. He serves on various editorial boards and provides expert reviews of academic papers and research grants internationally. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D.: (00:24)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up-to-date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including family systems, cognitive behavioral therapy, emotionally-focused couples therapy, eye movement desensitization and reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on-demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, which are each grounded in evidence-based approaches. With our lifespan centers, our Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using emotionally-focused couples therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and then EMDR for trauma, and our Center for ADHD and our Oppositional and Conduct Disorder Clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D.: (01:33)
Additionally, we have our associated nonprofit, Bay Area Community Counseling, where we provide treatment for those in financial need who can’t afford the licensed experienced therapists in the Institute but can work with associates and clinicians developing their expertise through our nonprofit. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley where we provide treatment training and one-way mirror trainings in family systems. To learn more about training, treatment, or employment opportunities, please go to https://sfiap.com, and to support our nonprofit, you can go to https://sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible. Today, I'll be speaking with Ladislav Timulak, who is the course director of the Counseling Psychology Department at Trinity College in Dublin, Ireland.
Keith Sutton, Psy.D.: (02:30)
Ladislav, or Laco for short, is involved in the training of counseling psychologists, and his research interests are in the development of emotion-focused therapy, as well as online mental health interventions. He has written or co-written 10 books, chapters, and over a hundred peer-reviewed papers in both his native language, Slovak, and in English. Some of the titles of his most recent books are Transforming Emotional Pain in Psychotherapy: An Emotion-Focused Approach, Transforming Generalized Anxiety: An Emotion-Focused Approach, Essentials of Descriptive-Interpretive Qualitative Research, Transdiagnostic Emotion-Focused Therapy, Essentials of Qualitative Meta-Analysis, and Transforming Emotional Pain: An Emotion-Focused Workbook. He provides trainings for clinicians in these approaches internationally and directs the Emotion-Focused Therapy Research Group and co-directs an eMental health research group. He previously co-edited Counseling Psychology Quarterly and serves on various editorial boards and provides expert reviews of academic papers and research grants internationally. Let's listen to the interview. Okay. Well, hi. Welcome.
Ladislav Timulak, Ph.D.: (03:41)
Welcome, Keith. Yes. Thanks for having me.
Keith Sutton, Psy.D.: (03:44)
Yeah, thank you so much for joining me on the podcast today. So we had met when I was over in Dublin doing some traveling, and I was interested in learning more about what psychotherapy's like in Ireland. I was reaching out to a number of folks, couldn't find people to connect with during that time, and I ended up coming to Trinity College in Dublin there and talking to some of the office staff, and they gave me your contact information. You were gracious to come and have tea with me and bring me to the faculty area at Trinity College, which was a special treat. It was just a beautiful area. I forget, what year was Trinity founded?
Ladislav Timulak, Ph.D.: (04:29)
It’s uh, Trinity was founded 1592.
Keith Sutton, Psy.D.: (04:32)
Yeah. So it was just an incredible building, incredible college. You're head of the psychology program there at Trinity, and we got a chance to chat and talk, and I learned more about your work with EFT, Emotionally-Focused Therapy. I got to read some articles and also watch a video of a live demonstration that you did. So I thought it was really great and interesting and wanted to learn more about your work and about EFT, but before we even get into that, I always like to ask people about the kind of evolution of their thinking. How did they get to doing what they're doing now?
Ladislav Timulak, Ph.D.: (05:10)
Same. Thanks. Thank you, Keith. It's a complex question. We have an hour, and it may take the full hour, but no, I'll try to be short. First of all, I just want to correct you – I'm a director of a counseling psychology program, not the whole psychology department, which is much, much bigger. I don't want to take credit for the whole department. So that's that. And just to situate the room where we were, it was actually common room. So it was staff room, as you said, but it was...
Keith Sutton, Psy.D.: (05:41)
Oh, okay. Got it.
Ladislav Timulak, Ph.D.: (05:43)
Okay. So I'm trained or, you know, I'm based in Ireland now. It's almost 19 years since I'm in Trinity, and I originally trained – my name is a Slovak name – and I originally trained in Slovakia. I spent some time as a part of my Ph.D. in Belgium in a center for person-centered and experiential psychotherapy at Catholic University of Leuven. I also did postdoc with Robert Elliott in U.S. actually, in Toledo. So I had this type of training as, yeah, I'm a counseling psychologist. My primary training was in person-centered therapy, and my Ph.D. – I mean as a psychologist, I'm trained in other approaches like CBT and so on, but person-centered was my main focus.
Ladislav Timulak, Ph.D.: (06:38)
One of my main mentors was a person-centered therapist, and my Ph.D. was on helpful events in person-centered therapy. That was the focus of Ph.D. And as a part of that Ph.D., obviously I became familiar with current incarnation of humanistic experiential therapy, that it's research-informed, and that was emotion-focused therapy, or in early days, also in individual form called process experiential therapy. So that was the context. I knew it from the literature, and then obviously I spent some time with Robert Elliott who is one of the co-founders of individual emotion-focused therapy. I mean primary developer being Les Greenberg. Robert was his collaborator on the first book on individual therapy. So this is what brought me to EFT, I think. I'm an academic. I'm a practitioner as well.
Ladislav Timulak, Ph.D.: (07:39)
I'm a trainer, a supervisor. I do train also internationally in emotion-focused therapy. I'm in individual format. I'm a couple therapist as well, but 99% of my academic and research and scholarly work focuses on individual therapy, although we are currently running also a couple project. I will have a couple supervision later after we finish, so that's a part of that project. But my primary focus of my writing and research is individual therapy, primarily emotion-focused therapy in the last maybe 14, 15 years. Prior that, I mean, it would be broader as well. I collaborate, I did a lot of work also on online interventions, and they happened to be cognitive behavioral interventions. Anyway, so I had broader focus, but EFT is one of the primary ones.
Keith Sutton, Psy.D.: (08:43)
Yeah. Great. Can you talk a little bit about person-centered therapy? I think everybody in graduate school has learned about Rogers and person-centered therapy, but at least from my experience, not in significant depth. I was listening to the interview with you from that series where you were doing the live demonstration and talking about some of the training, and they were talking about Rogers being really interested in research on person-centered therapy. I was wondering if you can speak, too, a little bit about the nuances or the essential aspects of person-centered therapy that you think…
Ladislav Timulak, Ph.D.: (09:21)
So that's a little bit my past me, yes, but obviously, person-centered therapy is somehow integrated into emotion-focused therapy, like a current research-informed incarnation of an experiential approach. It's difficult to say how to contextualize it, and also for your listeners depending on their background. You know, obviously person-centered therapy, client-centered therapy, dominated academically probably in 1940s and 50s, maybe a little bit into 1960s as well where the most research and the most fruitful work of Carl Rogers was happening. I think that the focus was on – I mean, most of it is now integrated into psychotherapy as such, as attentive listening, warmth of the therapist, kind of caring attitude, nonjudgmental approach to the experience as such of a client.
Ladislav Timulak, Ph.D.: (10:21)
It now sounds normal, but that was actually introduced also in the context of when probably, at least in Europe, predominant treatment was psychoanalytic treatment where you basically were sitting behind the patient and were neutral, so you wouldn't show warmth or caring attitude. I'm not saying it's a current practice in psychodynamic world. Obviously, there is warmth conveyed, but that was revolutionary, and I think it's now integrated as a mainstream in therapy, that the therapist conveys a caring, compassionate, warm, nonjudgmental presence. The main mean of therapeutic interviewing is trying to check with the client, whether you understand their experience, or focus on some aspects of that experience – often emotional aspects of that experience, but also bodily aspects of that experience.
Keith Sutton, Psy.D.: (11:29)
Yeah. Making sure you get it, that you understand, and the client feels like you really understand.
Keith Sutton, Psy.D.: (11:36)
Great.
Ladislav Timulak, Ph.D.: (11:37)
So I think that that's an important component of all therapy currently. Sometimes it's forgotten that the origin – obviously I'm not a psychotherapy historian, I'm not saying Rogers couldn't be influenced also by other people practicing at around that time – but I mean, it came to prominence through his work as that level of presence. He wrote this famous paper on necessary and sufficient conditions of therapeutic change in 1957 where he was claiming that non-judgmental, authentic relating coupled with empathic exploration is indeed necessary. I mean, he had six conditions, so it was a little bit more complex than that, but it is like a major component of what's responsible for therapeutic change.
Keith Sutton, Psy.D.: (12:35)
Sure. Sure. Great. Yeah, and I know that sometimes people see a Rogers tape and they think like, oh, he is just reflecting. I had one teacher that would pause and then ask the class, what might he reflect next? Then he would reflect something that was sometimes different from what other people are thinking, and so there was a lot of thought that was going into the reflection, and kind of he was doing the dance between the therapist and the client to really help create change. Now you were saying that – so emotionally-focused therapy, or Les Greenberg’s model, is an outgrowth of client-centered? And I know in Sue Johnson's work, it's kind of that basis of the Rogerian reflection, validation. But yeah, tell me a little bit about the connection between client-centered and emotionally-focused therapy
Ladislav Timulak, Ph.D.: (13:26)
So I know it mainly – some of it I know from conversations with people who are involved in developing emotion-focused therapy, and a lot of it I know from the books and papers as well. Les Greenberg's Ph.D. supervisor was Laura Rice, who was supervised by Carl Rogers. So there is a lineage of scholarly kind of supervision. I know that Les was also, apart from being trained in person-centered therapy, he was trained as a gestalt therapist, and together with Laura Rice and then with a contribution of Robert Elliott, they focus on studying fruitful processes in client-centered and gestalt therapy. Specifically, they studied what currently we would refer to as teacher dialogue for self-criticism, or an empty chair dialogue for emotional injury or so-called unfinished business.
Ladislav Timulak, Ph.D.: (14:28)
So Les actually would study processes in them, in the sessions that involved this type of dialogues. That led to some sort of resolution that expert therapists could agree that this was like a productive process versus not productive. He was trying to capture constituting elements. He was trying to capture constituting elements of what's decisive in the process. That also involved Laura Rice's focus on similar things in person-centered, client-centered therapy, where she focused on so-called problematic reaction points where people were puzzled by something, and she was studying how the puzzlement unfolded. So these are the origins. Then I know that Les collaborated with Sue Johnson in Vancouver and outlined the couple therapy. That had its own kind of development.
Keith Sutton, Psy.D.: (15:39)
Sure. So it sounds like Les was kind of focused on those change moments? And kind of looking at those moments with the kind of gestalt, the person-centered, where there was like a significant shift? And like kind of understanding that?
Ladislav Timulak, Ph.D.: (15:56)
Exactly. I mean, in the context of self-critical dialogue, what actually – we now know that it’s quite defining process in a lot of what constitutes psychopathology or, you know, problems. So, self-criticism can be found in clients who struggle with depression, low mood, with anxiety, with eating disorders. It's quite universal process. When rigid, when self-criticism very harsh or rigid, that it's an important part of a lot of presentations. He basically studied how we can address self-critical processes in the format of like a chair dialogue, where the critic dialogues with the critic part of you, or critical voice in you dialogues with the part of you impacted by the critic.
Ladislav Timulak, Ph.D.: (16:52)
And you rebalance that criticism either by standing up to it or softening and becoming more compassionate. So this is what he studied in the context of self-critic. In terms of unfinished business, it was more pivotal injuries that you experienced with significant people in your life that left unfinished, hurtful feelings in you. You had an opportunity in targeted intervention, again to access the hurt, articulate the needs in the hurt. For instance, “I felt unloved or neglected. I wanted you to love me.” Exposed to the caregiver, and then either facilitating compassionate response, “I'm here and I love you,” or more boundary setting anger like, “I deserve your love,” or something along those lines.
Ladislav Timulak, Ph.D.: (17:43)
But these are the processes that he outlined in terms of – and he and his collaborators, and a lot of other researchers since, elaborated a lot of processes like this that inform practice of emotion-focused therapy currently. We look at the processes in session that we try to facilitate, but the common thread is that we are trying to look at what’s at the core of the pain, emotional pain. What's the unmet need in that pain? Then we are trying to generate new experiences, often a compassionate response or boundary setting. I call it protective anger symptoms, grieving as well, of what was not met. That's the focus of therapy that currently is practiced.
Keith Sutton, Psy.D.: (18:31)
Okay. Great. So the core of the pain, how do you access that or get to that? Or how do you zero in on that core pain?
Ladislav Timulak, Ph.D.: (18:42)
Okay. So, you see in many…
Keith Sutton, Psy.D.: (18:46)
That's central to EFT, right? That core pain.
Ladislav Timulak, Ph.D.: (18:48)
That's very central. That's correct. Yes. Many approaches do not differentiate between, you know, like something is upsetting or unpleasant. They refer to it as bad or negative emotion or something like that, and obviously they're trying to address it somehow. EFT has a very differentiated perspective on emotions, and certain types of emotions are seen as more symptom-level emotions, like hopeless, helpless, often, not always, but are more symptom-level. Then there is more, kind of underlying, more central emotion. I'll give you an example. A fictional example is: I'm coming home after a difficult day at college. You know, my students were not very attentive or whatever it is. They were on their mobiles or something.
Ladislav Timulak, Ph.D.: (19:44)
So I feel quite subdued and down, and I'm coming home, and I'm hoping that my partner – that I will be able to chat about it with her. My context is that I could chat with her and rebound or something. And I come and she's on her laptop as well or something, and I'm trying to engage her, and she doesn't respond. Now, I can start to feel, if I'm sensitive to feeling alone, she's not there. That's like a primary response. She's not there. Now it may be, if it's not my core issue, I may just come to her because that's adaptive. I mean, it could be adaptive sadness, and it would, for my adaptive action, and I could come to her.
Ladislav Timulak, Ph.D.: (20:32)
“Darling, would you have… I had difficult day. Would you have some moments this evening? I could make ourselves a tea and we can… I would appreciate if you could just be with me a little bit.” And she would say, “Fine.” So that's fine. I wouldn't go to therapy with it. But now imagine that I have – we refer to it like more, you know, problematic, or over time developed emotion schemes where I often feel alone. I come home, she's not there, and I feel alone. And it starts to define me. She's not here. Then it goes to more secondary distress. Nobody's ever here, and it will never change. I lie down in bed and will feel hopeless, helpless, maybe irritable, and will stay in bed for two months, and then will go to my GP.
Ladislav Timulak, Ph.D.: (21:20)
GP is a medical doctor in our context in Ireland. And I will say, “Nothing brings me joy. I feel depressed.” So that's more symptom-level, but at the core is really a chronic experience of not having a need met. Like in this example, loneliness. That I feel alone, and you are not here, and I miss connection. I miss your presence. Studying, in session processes where, when we look at what's at the core of the presentation, where clients feel most vulnerable, meaning also that they touch on something that is freshly painful yet has historical context, it occurs that we find three types of experiences that we refer to as core pain or core vulnerability or core emotional vulnerability.
Ladislav Timulak, Ph.D.: (22:17)
It's a triad of sometimes overlapping feelings. One is like sad/lonely, or sometimes it may be a loss, or some sort of sadness. I'm alone, or I miss you, or I lost you or something. The second one is shame. It's like, I'm inadequate, I'm worthless, I'm incapable, I'm weak, I'm stupid, and whatever it is – so this type of experiences. And the third one are experiences of chronic fear, and it's like, I'm unsafe, I'm unprotected, I'm exposed, or so. What we see that regardless – my latest book is on transdiagnostic emotion-focused therapy – that if you look at it from the typical presentations in outpatient clinic, depression, various forms of anxiety, like generalized anxiety, social anxiety, panic disorder and so on.
Ladislav Timulak, Ph.D.: (23:13)
Or OCD or PTSD, and then so on. We see that clients present with symptoms, but at the core – I mean, we are looking at those tapes of the clients in the research studies – we find a variant of either alone, or worthless, inadequate, or scared, and corresponding unmet needs for connection, for validation or acceptance, or for protection. That's the core. We are trying to activate it in therapy and generate new experiences that would kind of counter. That I feel not only alone, but I also feel connected to or loved. Or I feel worthy of love. This is what we are trying to generate in therapy in the format of imaginary dialogues because they are particularly vivid. We want to bring and build the full experience.
Keith Sutton, Psy.D.: (24:04)
That's going to evoke that emotional experience. So the symptom-level and the underlying, that's not necessarily the concept of secondary and primary emotions?
Ladislav Timulak, Ph.D.: (24:16)
It is, yes. I sometimes refer to it as a symptom-level and more core, more underlying vulnerability, but in EFT literature, including EFT for couples, you'll find reference to secondary and primary.
Keith Sutton, Psy.D.: (24:32)
Sure, sure. Okay.
Ladislav Timulak, Ph.D.: (24:37)
So sometimes for people with non-EFT background, sometimes it sounds too jargony, like secondary and primary. It's like, how do you decide? So it needs to be understood as a heuristic. It's basically an assessment that informs therapist judgment. In my example, I would feel hopeless, helpless that nobody will be there for me ever. But the therapist will not focus on it. Like, ”Let's stay with how hopeless you feel. Can you tell me more about it?” No, the therapist would actually focus, “What is it? If you stay with your partner, if you look at her in imagination, what is it, what you're missing?” And that will be her presence, her closeness, her warmth or whatever. Do you understand? Her care or something.
Keith Sutton, Psy.D.: (25:20)
So it's kind of underneath that helpless hope.
Ladislav Timulak, Ph.D.: (25:22)
Exactly. So that differentiation is there for therapists to have a map what to acknowledge and what to actually focus on. So you do acknowledge and validate that hopelessness feels miserable, but you're rather looking at what preceded hopelessness, what preceded your resignation that you resigned to feeling unhappy. That's the focus of therapy. In therapy, we are trying to focus on those primary – but not all primary emotions, I mean, you can focus on all primary, but on the ones that are chronically painful. So they're chronically coming back and are quite defining of who I am, how I experience myself.
Keith Sutton, Psy.D.: (26:06)
Yeah. Yeah. Part of the way I've been conceptualizing secondary and primary emotions is that the biggest ones that I end up working in therapy, or in couples therapy, is – there's secondary: Anxious, annoyed, hopeless, helpless, frustrated, resentful, all those kind of things. Underneath, right, are those primary emotions of feeling sad, feeling alone, feeling hurt, feeling fear, or feeling shame, which I actually think like shame's right in the middle because underneath shame is usually fear. Are those kind of similar to your… Or any to add with emotionally-focused therapy?
Ladislav Timulak, Ph.D.: (26:48)
No, no. I think – I mean, we are observing as therapists, and particularly if you're working either with imaginary dialogues or with an intention to access vulnerability, you'll come to experiences: I feel alone, I feel inadequate, I feel scared. Sometimes people have different language. So what you described and what you consider to be more central than the others, it's also what guides your interpretation, but I think we are seeing the same phenomenon. It's just like people may understand it a little bit differently or interpret it a little bit differently depending on their training, writings that or readings that they did, or supervision experiences and so on. And you have combinations of those. You may feel alone and unprotected. Or you may feel unloved and unlovable. So that's sad and shame together, you know? I don't judge it. I mean, it's more for scholarly work that I reduce it to sad/lonely slash shame slash fear, but in terms of actual work with the client, I'll stay with their experience.
Keith Sutton, Psy.D.: (27:58)
Yeah, definitely.
Ladislav Timulak, Ph.D.: (27:59)
If I write a scholarly paper on it, I'll describe it as something, but otherwise I stay with their words, with their phenomenological experience of what's the most painful, what's the most vulnerable, where I feel most that this is the difficult chronic feeling that I know, and it comes in similar situations. And it's the feeling that is quite defining of me.
Keith Sutton, Psy.D.: (28:22)
Sure. Yeah. And I think you said schemes? Of like that the person is feeling like, I'm alone, I'm always alone, I'm always going to be alone. Like there's a narrative that they have or reminds me of the schema concept in CBT. Is that kind of similar, this underlying story or narrative?
Ladislav Timulak, Ph.D.: (28:46)
I believe that we talk about the same phenomena. It's again, as I said, depending on your training, you interpret it differently. EFT tries to – I mean, Les Greenberg's term, it's kind of central in it refers to emotion schemes, trying to emphasize, you may communicate it in therapy that I feel stupid or I feel worthless or I feel inadequate or something like that, but what's important here is that it's a very holistic experience. It's not just a thought. I mean, thoughts are part of it, but by calling it emotion scheme, what wants to be stressed is that there's a felt reference. It feels horribly.
Ladislav Timulak, Ph.D.: (29:39)
It's not just an empty thought that I can reinterpret. It feels real. It feels like this is the sentient way of feeling, the reality of how I am. So that's one thing. The other thing is the fact that it's scheme, it's memory based. So my experiences of coming home and my partner not being responsive are colored by all other experiences when I was seeking connection. I mean, implicitly present. So if I chronically experience a non-response, then I'm more likely kind of perceive environment as non-responsive or more inclined to be quickly assuming, but that's all very fast process outside awareness. I mean, some of it can be in awareness if I focus attention on it.
Ladislav Timulak, Ph.D.: (30:34)
And it's quite defining and quick. So this is what wants to be emphasized by calling it emotion scheme. Anyway, so we try to activate those emotion schemes and rework them, make them less rigid, make them more differentiated, I would say. There are experiences that I can feel alone, but I also can feel responded. I'm sure there is a role of biology in it as well, because we may have stronger reactions. Some of us are more reactive than others, so we are more likely to develop if we have adverse events that they leave mark, because we may be more reactive to certain things. So it's a complex issue, but the bottom line…
Keith Sutton, Psy.D.: (31:18)
So you're going – oh, sorry.
Ladislav Timulak, Ph.D.: (31:19)
I just wanted to say that the bottom line is that we are going to phenomenologically go to the vulnerable feelings, try to activate them in therapy, articulate needs in them, because feelings tell us what our needs are being fulfilled in the interaction with the environment, and we try to generate new experiences that would restructure those emotion schemes and make them more flexible or we build – that's Antonio Pascual-Leone’s term – we build emotional flexibility or emotional resilience.
Keith Sutton, Psy.D.: (31:55)
Uh huh. Okay. So you're going to the core pain, and it generally plays out that it tends to be in one of three areas – a sad/lonely, shame or fear – and each one kind of has a bit of an antidote or so on – connection development, acceptance, safety…
Ladislav Timulak, Ph.D.: (32:16)
Protection, yes. Yeah.
Keith Sutton, Psy.D.: (32:17)
Safety, protection. So in the session, you're then having the person go through an experience with the empty chair to then express these unmet needs? And begin to have this, I guess, corrective experience where they're able to respond in the way they maybe wish to have responded or get the response that they were needing in those moments. And then…
Ladislav Timulak, Ph.D.: (32:51)
Yeah. I think in general, yes. I mean, I'll elaborate a little bit, but in general, yes [laughter]. What would you just described, what I just would want to stress small things in it. First of all, you want to create focus. Sometimes it's easier, sometimes it's less easy, but we have now developed case conceptualization and everything. We also have more map on symptom-level distress. And sometimes you have to work on symptom level because people do suffer from worries or from ruminations or they are avoiding pain and so on. So it's very complex. But the core work is then to activate that vulnerable feeling in imaginary dialogues, typically. Sometimes outside of the dialogues, but in general, in the dialogues, and express it either in recreating pivotal memories, or it can be in a current stage.
Ladislav Timulak, Ph.D.: (33:42)
It's very flexible, but you want to freshly experience, let's say that feeling. I'm feel alone, and I miss you. You're not here. Then when you express vulnerability, you are testing, you're bringing the person and you enact other person originally that you felt contributed to the injury or whose behavior you perceived as hurtful. First of all, you first enact them to recreate injury early on in the work, but when it's freshly expressed, you want to see whether there is different response from them. Because often, if in reality relationships are complex and ambivalent and people were sometimes responsive, seeing fresh vulnerability can make your enactment of them, your mental map of them or something, more responsive.
Ladislav Timulak, Ph.D.: (34:36)
Or you can explicitly ask, was there somebody who would understand? And enact that person. Or you can have a look at yourself from an adult perspective at younger you, and when you see the vulnerability, you may see whether there is a response, but that response has to happen. It has to come from within. So it's actually accessed or it is enacted by seeing vulnerability. Seeing your vulnerability, evolutionary makes you more responsive. Like seeing vulnerable child, you want to be caring. So when you see vulnerable you, just expressing fresh feelings, it elicits compassionate, caring response. So that's one pillar of work.
Ladislav Timulak, Ph.D.: (35:29)
The second pillar of work is actually – which is not stressed in many therapies, I mean, I'm not saying that in none – but is the boundary setting anger actually, or protective anger. So if the other is not responsive or if the other is hurtful, we are working on, is it acceptable to you to get this type of treatment? So the focus is, later on in the imaginary dialogue, is more focused highlighting mistreatment, and whether that mistreatment generates response that is protective towards the mistreatment. So these are the two. Compassion and anger are two pillars of how where lonely was can be now I'm here with you. It can be, I deserve your presence. Or where shame was, I value you, I'm proud of you. Or I'm proud of myself, I deserve your respect.
Ladislav Timulak, Ph.D.: (36:17)
Or where the fear is, I'm here, I protect you. Or I will face you, I will not let you to intimidate me or terrify me, and I'll face you. So this is the gist of the work. Often particularly compassion is followed by grieving as well. So once you'll get the response, there is a natural grieving that it wasn't like that in reality in the past years. Sometimes you come to terms more. I mean, it's always painful, it's not like it's gone. but there is a grieving of what happened, what I endured, and so on.
Keith Sutton, Psy.D.: (36:55)
Yeah. Well, it's incredible. It sounds like it's so much of this kind of bottom-up processing that happens. I'm hearing a number of pieces in here that it sounds like it's allowing a person to access those emotions. And it sounds like what you're saying is that they're going in both sides, and you're saying, seeing the vulnerability in their self that was harmed or seeing the vulnerability in the person that harmed them, or both. And what I've actually…
Ladislav Timulak, Ph.D.: (37:27)
So I didn't focus on that one, but you can have some scenarios where that could be – that you may have experience of connection with the other. So you may see their vulnerability, but it may not fit all kind of potential scenarios. So sometimes there may be also experience, or particularly if you had regrets, if you felt like you hurt somebody, obviously then there can be more expression of I see and I'm sorry or so. But I mean, the example I was giving, it was not that much focus on the other’s vulnerability, but I tried to simplify things. But of course, it may be more complex at times.
Keith Sutton, Psy.D.: (38:03)
Well it's making me think of, sometimes in EMDR, that we’ll have the person go in and confront the person that hurt them or whatever it might be. Sometimes if that person is responsive, oftentimes I find that they go from kind of anger to almost like a compassionate response. And then, just like you're saying, then to that loss. It almost feels like the cycle of loss happens in that process. Seeing the vulnerability and speaking to that younger self also reminds me of in internal family systems, where the person is using that adult self to have compassion and understanding and care for their younger self and to validate and witness them. So I really like that. I consider EMDR and internal family systems these bottom-up processing ways of really processing those unprocessed emotions. So it totally makes sense with the EFT that, in a little bit, it sounds like maybe there's some top-down and understanding the schema as a therapist and so on, but not necessarily going into cognitions or explaining or so on. Instead, just kind of going right for the heart of it.
Ladislav Timulak, Ph.D.: (39:23)
You can't get clients where they are not, so it has to come from within. You are just increasing probability. Seeing vulnerability increases probability to, let's say, soften or be compassionate, yes, when you see your own vulnerability, but it may not happen. With more chronic people – I mean, chronically self-critical or something, or very harsh on themselves – it actually is a huge struggle in therapy. Antonio Pascual-Leone did that research on studying emotional sequences, and he calls it two step forward, one step back. So you can't go…it has to be authentic, it has to happen almost unexpectedly. It's not scripted, or, “Now look at the child and what do you feel?” I mean, if you don't feel compassion, you have to then acknowledge what protects you from seeing that vulnerability.
Keith Sutton, Psy.D.: (40:26)
Yeah. I see what's coming up.
Ladislav Timulak, Ph.D.: (40:27)
Yeah. What's the fear if you saw it sometimes. These are sometimes, it may be internalized judgment. Often it's self-protective. If I soften, you would fool yourself, and then you would get even more hurt. So I mean, I'm simplifying everything, but it's a complex process, and it's very important that – it's not that the therapist would say, “Oh, repeat yourself a hundred times, ‘I'm proud of myself,’” and then it will work. No, it has to come almost unexpectedly in the face of adversity or in the face of mistreatment, you stand up for yourself. Or in the face of seeing that vulnerability and achievement or the effort that spontaneously this has to come. So we're just creating…
Keith Sutton, Psy.D.: (41:10)
[unintelligible] moved.
Ladislav Timulak, Ph.D.: (41:11)
Exactly. We just create opportunities that this would happen. We don't know whether it would happen. We're just trying to do our best, and if something is too much, we slice it back. We scaffold it more, and we'll take a step back, and a smaller step may be important first than any other step.
Keith Sutton, Psy.D.: (41:30)
Well, and it reminds me of in emotionally-focused couples therapy, we're helping one partner to be vulnerable, and that often engages empathy from the other partner. Although sometimes in stage one and deescalation it engenders defensiveness or so on, but I imagine if the person is doing that to themselves, right, and that empty chair, that it might be easier to access that empathy because they literally had that experience.
Ladislav Timulak, Ph.D.: (41:57)
Yeah. So it may or it may not. It depends on chronicity of, let's say, a very critical attitude towards yourself or something. So sometimes it may be puzzling that you would feel that the person is very vulnerable. Of course they would soften and be caring towards themselves, and you are met with a lot of contempt. That's at the core of why people suffer, because it's not that easy to bounce back or something. So that vulnerability is very ingrained and very rigid in how I process things. Anyway, so it's not that simple. As it's not simple with some couples. With some couples, it may be more…
Keith Sutton, Psy.D.: (42:43)
Well especially with complex PTSD, oftentimes that critical part was a protecting part, or the person has disowned that vulnerable part, and so there's kind of those aspects too. I like how you're saying too, that there's both the compassion aspect, but also that kind of boundary setting or anger. Talking with Pete Walker, the author of Complex PTSD: Surviving to Thriving, and he talks about getting angry at that internalized, kind of, abusive parent who is that critical voice. Versus maybe a lot of other therapies that are only focused on being compassionate towards those different parts of self. But both have that aspect.
Ladislav Timulak, Ph.D.: (43:24)
That's very important, and actually we go back to person-centered therapy. It didn't emphasize importance of anger or need. It was more about that warm, compassionate presence, of the relational presence of the therapist that would allow to process vulnerable experiences. But the anger is very pivotal, and I would say, I spent a few years studying and worked with generalized anxiety, and we have a book on generalized anxiety. I would say that anger is even more pivotal, because if you feel that something is scary, if you stand up to it, if you are firm with it, it actually makes you stronger. Rather than if you're relying only on reassurance or calming or something, or protective presence from outside in. So from inside out and facing what’s scary…
Keith Sutton, Psy.D.: (44:18)
Like exposure. It's like exposure.
Ladislav Timulak, Ph.D.: (44:22)
I mean, it's a little bit more than exposure because in exposure you get used to it that it's not that threatening. Here, it's also that I don't want you to limit my life. I want to reach out and do what I want to be doing. I don't want – so it's actually, exposure is more about habituation. This is more about, I don't want to miss out because of the anxiety or fear.
Keith Sutton, Psy.D.: (44:46)
Definitely. Yeah, yeah. It reminds me of like, and the way I think with exposure work is that we're not getting rid of anxiety, we're getting the confidence that I can feel the discomfort and still go forward.
Ladislav Timulak, Ph.D.: (44:56)
Yeah. So that's close to it. Yeah. I think so. Yeah.
Keith Sutton, Psy.D.: (44:58)
And it also, it makes me think too of, as you're describing about not letting it get in the way anymore, it makes me think of in narrative therapy, that externalizing and not letting the anxiety or such get in the way of being able to do the things you want or have the life that you wish. Or with kids, getting in the way of your fun.
Ladislav Timulak, Ph.D.: (45:16)
Yeah. I think that there are a lot of overlaps in there. We are looking at very similar phenomena. I think if we watch tapes, we would often agree, people from different orientation, that that's adaptive process. That's a healing process. That's therapeutic. Schema therapy, I think, has a lot of concepts that are similar as well, in terms of healing the vulnerability or hurt and so on. What EFT specifically focuses on, and how it can contribute is because it's based on a lot of process research. So there's a lot of – that we have emotional productivity scale, emotional arousal scale. We have cognitive classification of affective meaning scale. I mean, these are all process research scales.
Ladislav Timulak, Ph.D.: (46:04)
But they're also used in training to train people to be able to assess, what's the level of arousal? Does this client have capacity to touch on their vulnerability more? Is that vulnerability too much now? What's the optimal window for them to be with? What's the healthy anger? Because you have also unhealthy anger, like reactive. We call it reactive or rejecting anger, or secondary anger you can say, Iike it may not be fitting. Often, a healthy boundary setting anger is not with much arousal, but it's with the firmness and strength inside, like along the lines of confidence that you mention and so on. So it may not be very reactive, like “What you did to me, you horrible person.” It may be, “I'm strong, you can't harm me.” Or, “I'm not afraid of you,” or something like that. Or, “I just feel okay in myself.”
Keith Sutton, Psy.D.: (47:03)
Yeah. This emotional processing – so one way that I've conceptualized, like for example with trauma, is that this trauma happened and the person wasn't able to process it at the time. So it's kind of like these emotions are stuck, and that's where in EMDR or different trauma therapies you're sitting with those emotions and helping process or put it together. I don't know if that nicely fits at all for this model, but I'm hearing too that when the person has this corrective experience, or has this change moment, that they're experiencing themselves and their emotions in a more flexible way rather than maybe having that rigid emotional scheme. Is that kind of what…?
Ladislav Timulak, Ph.D.: (47:48)
Yeah, exactly. Exactly. If you talk specifically about trauma – narrowly defined, trauma is where you were endangered or your close one were endangered in terms of health or life or so. I mean more narrowly because every adverse experience, even shaming or abandonment, are traumatic. But if I'm just thinking more in terms of danger, like more kind of narrower definition of trauma, this is particularly – it's powerful experience, so you'll be scared of similar type of situations, or you may experience some situations as scary, because it's a very quick processing that certain things are experienced and felt as dangerous very quickly. And you may not want to feel, or you avoid where you could feel it, so you may have emotional avoidance or behavioral avoidance that you don't want to have this type of experiences. But what actually happens here, it increases the window that I'm able to stay with those experiences and have them kind of experience differently. Either that there is more response to that vulnerability or scary fear, terrifying feelings I felt…
Ladislav Timulak, Ph.D.: (48:57)
Or I stand up and face the memory of abuse or the memory of assault or something, and I stand up and fight back. So you are reworking, that next time you are in vicinity of similar triggering situations, you are not only organized by, “Is it dangerous?” It's also, “I’m powerful.” Or, “It's not totally dangerous.” You're becoming more differentiated in your responses. But it's not because of an analysis. I mean, analysis is fine, but it's also implicitly safer or you feel implicitly more powerful to be confident and so on.
Keith Sutton, Psy.D.: (49:42)
Or even like in internal family systems connecting to your adult self, that you're no longer that young child who is maybe five years old and helpless and powerless and so on. And kind of, even though it still feels scary or so on, but kind of almost experiencing yourself differently than more that emotional flashback.
Ladislav Timulak, Ph.D.: (50:00)
I believe we refer to same phenomenon. Different approaches may have different language for something like that, but I think that we are trying to name – I mean, scholars are academic psychotherapists – very similar phenomena that we encounter, you know?
Keith Sutton, Psy.D.: (50:19)
Yeah. Well, it sounds like incredible work. Tell me about what you're working on now or what's upcoming.
Ladislav Timulak, Ph.D.: (50:28)
So we had a book that will be promotion now. So there was a book published 2022, Transdiagnostic Emotion-Focused Therapy, by APA with my colleague Daragh Keogh, and we are running an RCT now that's specifically looking at EFT for depression, various anxiety presentations like GAD, social anxiety, panic disorder, and so on. And OCD and PTSD. So that's a trial we are running, and we are learning even more about the interaction between symptom-level work and more underlying core vulnerability learning work. So that's one of the projects. We have also a published book – many experiential approaches do not have client workbooks type of books.
Keith Sutton, Psy.D.: (51:21)
Yeah. Yeah.
Ladislav Timulak, Ph.D.: (51:22)
I mean, there are some, but they can't be compared to the amount in CBT because often there is a sense that you can't recreate something so flexible or, you know, as I described, but we attempted to do it a little bit. So we have a book out that is called Transforming Emotional Pain Client Workbook, and Aman Kwatra is the first author. It's one of my former students. And we are running psychoeducational programs for students in student counseling service in our college. It's a six-week program where they're learning also to work with how they stop themselves from feeling, or how they worry themselves that something would happen that would bring painful feelings, or how they learn to regulate when they're upset, but also how they can do imaginary dialogues with people that hurt, that they hurt with, or with a dialogue with own self-criticism.
Ladislav Timulak, Ph.D.: (52:22)
So we do that as a project. We have a couples project that we currently run, and we collaborate with Les Greenberg on it, and that's for comorbid relational dissatisfaction in romantic couples, coupled with at least one of the partners meeting criteria for clinical diagnosis – either depression or GAD, social anxiety, panic disorder or OCD or PTSD. So similar like we do in individual therapy, we are at the start of a project with comorbid mental health issues and relational distress. I'm sure we are running much more than that because…
Keith Sutton, Psy.D.: (53:08)
Sure. Wow. Sounds like a whole lot of different areas. I love looking at the comorbidities because so much of the research is just, you know, only picking clients with the very certain kind of particular thing, but as in practice, many times the majority have comorbidities going on.
Ladislav Timulak, Ph.D.: (53:31)
I actually now remember that – I'll just add one more thing, if I may – that that's actually what I'm working currently on, but that's at the very start, that's why I didn't mention it. It's, you know, that in therapy over the years, we didn't improve outcomes. I'm not talking about EFT, I'm talking about psychotherapy as such. If you look at the outcomes in eighties of the first rigorous, randomized controlled trials, like of CBT and interpersonal therapy for depression – I mean, if you replicate those 20, 30 years later, we do not have better outcomes. So something is happening. I mean, they're roughly the same, the outcomes. Occasionally, you may have better outcomes, but roughly, it's not dramatically better. That attest to complexity of mental health issues and so on.
Ladislav Timulak, Ph.D.: (54:22)
But it also tells us that probably there is room to improve, and I think one of the ways that is intriguing me currently is to have a look at how processes that are good in session can be further supported outside of session. I mean, beyond homework. Beyond homework. Because people are left 24/7 their week, but they're only one hour in therapy. So what's happening outside of therapy, how we can interweave their social practice or being outside of the session. So that's actually of interest of mine to develop a scaffolding processes that could map what happens in the session and what would be potentially good to do to capitalize on it outside the session, but beyond more just simple homework. It's a little bit more complex and maybe, you know, I have that other hat, a little bit of online interventions that are accessible at any point as well. That's in the area of interest.
Keith Sutton, Psy.D.: (55:38)
Sure, sure. Great. Well, I love the work you're doing, and just, I'm really inspired by the process, focus in the EFT work, and just the nuances, I think, that are just really great, that it sounds like are involved in the training and involved in the research. Yeah, it sounds amazing. Thank you so much for taking the time today. It was great to learn more about your work and about emotionally-focused therapy. I really appreciate it. Thank you.
Ladislav Timulak, Ph.D.: (56:07)
Thanks for having me, Keith. It's just excellent that you were in Dublin a few months back and we continue our conversation. We just started it in, was it September or something? It's really interesting.
Keith Sutton, Psy.D.: (56:20)
Yeah. Yeah. And I appreciate your openness and your warmness just to respond to this guy emailing you and saying like, “Hey, can we chat?”
Ladislav Timulak, Ph.D.: (56:28)
Oh, no, no, no. I actually like what you do. Yes. Because I looked it up, and I think it's really great that not only that you run service, but that you are doing also something for community of therapists and I mean, it's fantastic. So thanks for including me in your very useful and very impressive work.
Keith Sutton, Psy.D.: (56:51)
Oh, thank you so much. Okay. This was wonderful. I look forward to speaking with you again soon. Take care.
Ladislav Timulak, Ph.D.: (56:57)
Thanks. Thank you.
Keith Sutton, Psy.D.: (56:58)
Bye-bye.
Ladislav Timulak, Ph.D.: (57:00)
Bye-bye.
Keith Sutton, Psy.D.: (57:01)
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Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up-to-date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including family systems, cognitive behavioral therapy, emotionally-focused couples therapy, eye movement desensitization and reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on-demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, which are each grounded in evidence-based approaches. With our lifespan centers, our Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using emotionally-focused couples therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and then EMDR for trauma, and our Center for ADHD and our Oppositional and Conduct Disorder Clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D.: (01:33)
Additionally, we have our associated nonprofit, Bay Area Community Counseling, where we provide treatment for those in financial need who can’t afford the licensed experienced therapists in the Institute but can work with associates and clinicians developing their expertise through our nonprofit. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley where we provide treatment training and one-way mirror trainings in family systems. To learn more about training, treatment, or employment opportunities, please go to https://sfiap.com, and to support our nonprofit, you can go to https://sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible. Today, I'll be speaking with Ladislav Timulak, who is the course director of the Counseling Psychology Department at Trinity College in Dublin, Ireland.
Keith Sutton, Psy.D.: (02:30)
Ladislav, or Laco for short, is involved in the training of counseling psychologists, and his research interests are in the development of emotion-focused therapy, as well as online mental health interventions. He has written or co-written 10 books, chapters, and over a hundred peer-reviewed papers in both his native language, Slovak, and in English. Some of the titles of his most recent books are Transforming Emotional Pain in Psychotherapy: An Emotion-Focused Approach, Transforming Generalized Anxiety: An Emotion-Focused Approach, Essentials of Descriptive-Interpretive Qualitative Research, Transdiagnostic Emotion-Focused Therapy, Essentials of Qualitative Meta-Analysis, and Transforming Emotional Pain: An Emotion-Focused Workbook. He provides trainings for clinicians in these approaches internationally and directs the Emotion-Focused Therapy Research Group and co-directs an eMental health research group. He previously co-edited Counseling Psychology Quarterly and serves on various editorial boards and provides expert reviews of academic papers and research grants internationally. Let's listen to the interview. Okay. Well, hi. Welcome.
Ladislav Timulak, Ph.D.: (03:41)
Welcome, Keith. Yes. Thanks for having me.
Keith Sutton, Psy.D.: (03:44)
Yeah, thank you so much for joining me on the podcast today. So we had met when I was over in Dublin doing some traveling, and I was interested in learning more about what psychotherapy's like in Ireland. I was reaching out to a number of folks, couldn't find people to connect with during that time, and I ended up coming to Trinity College in Dublin there and talking to some of the office staff, and they gave me your contact information. You were gracious to come and have tea with me and bring me to the faculty area at Trinity College, which was a special treat. It was just a beautiful area. I forget, what year was Trinity founded?
Ladislav Timulak, Ph.D.: (04:29)
It’s uh, Trinity was founded 1592.
Keith Sutton, Psy.D.: (04:32)
Yeah. So it was just an incredible building, incredible college. You're head of the psychology program there at Trinity, and we got a chance to chat and talk, and I learned more about your work with EFT, Emotionally-Focused Therapy. I got to read some articles and also watch a video of a live demonstration that you did. So I thought it was really great and interesting and wanted to learn more about your work and about EFT, but before we even get into that, I always like to ask people about the kind of evolution of their thinking. How did they get to doing what they're doing now?
Ladislav Timulak, Ph.D.: (05:10)
Same. Thanks. Thank you, Keith. It's a complex question. We have an hour, and it may take the full hour, but no, I'll try to be short. First of all, I just want to correct you – I'm a director of a counseling psychology program, not the whole psychology department, which is much, much bigger. I don't want to take credit for the whole department. So that's that. And just to situate the room where we were, it was actually common room. So it was staff room, as you said, but it was...
Keith Sutton, Psy.D.: (05:41)
Oh, okay. Got it.
Ladislav Timulak, Ph.D.: (05:43)
Okay. So I'm trained or, you know, I'm based in Ireland now. It's almost 19 years since I'm in Trinity, and I originally trained – my name is a Slovak name – and I originally trained in Slovakia. I spent some time as a part of my Ph.D. in Belgium in a center for person-centered and experiential psychotherapy at Catholic University of Leuven. I also did postdoc with Robert Elliott in U.S. actually, in Toledo. So I had this type of training as, yeah, I'm a counseling psychologist. My primary training was in person-centered therapy, and my Ph.D. – I mean as a psychologist, I'm trained in other approaches like CBT and so on, but person-centered was my main focus.
Ladislav Timulak, Ph.D.: (06:38)
One of my main mentors was a person-centered therapist, and my Ph.D. was on helpful events in person-centered therapy. That was the focus of Ph.D. And as a part of that Ph.D., obviously I became familiar with current incarnation of humanistic experiential therapy, that it's research-informed, and that was emotion-focused therapy, or in early days, also in individual form called process experiential therapy. So that was the context. I knew it from the literature, and then obviously I spent some time with Robert Elliott who is one of the co-founders of individual emotion-focused therapy. I mean primary developer being Les Greenberg. Robert was his collaborator on the first book on individual therapy. So this is what brought me to EFT, I think. I'm an academic. I'm a practitioner as well.
Ladislav Timulak, Ph.D.: (07:39)
I'm a trainer, a supervisor. I do train also internationally in emotion-focused therapy. I'm in individual format. I'm a couple therapist as well, but 99% of my academic and research and scholarly work focuses on individual therapy, although we are currently running also a couple project. I will have a couple supervision later after we finish, so that's a part of that project. But my primary focus of my writing and research is individual therapy, primarily emotion-focused therapy in the last maybe 14, 15 years. Prior that, I mean, it would be broader as well. I collaborate, I did a lot of work also on online interventions, and they happened to be cognitive behavioral interventions. Anyway, so I had broader focus, but EFT is one of the primary ones.
Keith Sutton, Psy.D.: (08:43)
Yeah. Great. Can you talk a little bit about person-centered therapy? I think everybody in graduate school has learned about Rogers and person-centered therapy, but at least from my experience, not in significant depth. I was listening to the interview with you from that series where you were doing the live demonstration and talking about some of the training, and they were talking about Rogers being really interested in research on person-centered therapy. I was wondering if you can speak, too, a little bit about the nuances or the essential aspects of person-centered therapy that you think…
Ladislav Timulak, Ph.D.: (09:21)
So that's a little bit my past me, yes, but obviously, person-centered therapy is somehow integrated into emotion-focused therapy, like a current research-informed incarnation of an experiential approach. It's difficult to say how to contextualize it, and also for your listeners depending on their background. You know, obviously person-centered therapy, client-centered therapy, dominated academically probably in 1940s and 50s, maybe a little bit into 1960s as well where the most research and the most fruitful work of Carl Rogers was happening. I think that the focus was on – I mean, most of it is now integrated into psychotherapy as such, as attentive listening, warmth of the therapist, kind of caring attitude, nonjudgmental approach to the experience as such of a client.
Ladislav Timulak, Ph.D.: (10:21)
It now sounds normal, but that was actually introduced also in the context of when probably, at least in Europe, predominant treatment was psychoanalytic treatment where you basically were sitting behind the patient and were neutral, so you wouldn't show warmth or caring attitude. I'm not saying it's a current practice in psychodynamic world. Obviously, there is warmth conveyed, but that was revolutionary, and I think it's now integrated as a mainstream in therapy, that the therapist conveys a caring, compassionate, warm, nonjudgmental presence. The main mean of therapeutic interviewing is trying to check with the client, whether you understand their experience, or focus on some aspects of that experience – often emotional aspects of that experience, but also bodily aspects of that experience.
Keith Sutton, Psy.D.: (11:29)
Yeah. Making sure you get it, that you understand, and the client feels like you really understand.
Keith Sutton, Psy.D.: (11:36)
Great.
Ladislav Timulak, Ph.D.: (11:37)
So I think that that's an important component of all therapy currently. Sometimes it's forgotten that the origin – obviously I'm not a psychotherapy historian, I'm not saying Rogers couldn't be influenced also by other people practicing at around that time – but I mean, it came to prominence through his work as that level of presence. He wrote this famous paper on necessary and sufficient conditions of therapeutic change in 1957 where he was claiming that non-judgmental, authentic relating coupled with empathic exploration is indeed necessary. I mean, he had six conditions, so it was a little bit more complex than that, but it is like a major component of what's responsible for therapeutic change.
Keith Sutton, Psy.D.: (12:35)
Sure. Sure. Great. Yeah, and I know that sometimes people see a Rogers tape and they think like, oh, he is just reflecting. I had one teacher that would pause and then ask the class, what might he reflect next? Then he would reflect something that was sometimes different from what other people are thinking, and so there was a lot of thought that was going into the reflection, and kind of he was doing the dance between the therapist and the client to really help create change. Now you were saying that – so emotionally-focused therapy, or Les Greenberg’s model, is an outgrowth of client-centered? And I know in Sue Johnson's work, it's kind of that basis of the Rogerian reflection, validation. But yeah, tell me a little bit about the connection between client-centered and emotionally-focused therapy
Ladislav Timulak, Ph.D.: (13:26)
So I know it mainly – some of it I know from conversations with people who are involved in developing emotion-focused therapy, and a lot of it I know from the books and papers as well. Les Greenberg's Ph.D. supervisor was Laura Rice, who was supervised by Carl Rogers. So there is a lineage of scholarly kind of supervision. I know that Les was also, apart from being trained in person-centered therapy, he was trained as a gestalt therapist, and together with Laura Rice and then with a contribution of Robert Elliott, they focus on studying fruitful processes in client-centered and gestalt therapy. Specifically, they studied what currently we would refer to as teacher dialogue for self-criticism, or an empty chair dialogue for emotional injury or so-called unfinished business.
Ladislav Timulak, Ph.D.: (14:28)
So Les actually would study processes in them, in the sessions that involved this type of dialogues. That led to some sort of resolution that expert therapists could agree that this was like a productive process versus not productive. He was trying to capture constituting elements. He was trying to capture constituting elements of what's decisive in the process. That also involved Laura Rice's focus on similar things in person-centered, client-centered therapy, where she focused on so-called problematic reaction points where people were puzzled by something, and she was studying how the puzzlement unfolded. So these are the origins. Then I know that Les collaborated with Sue Johnson in Vancouver and outlined the couple therapy. That had its own kind of development.
Keith Sutton, Psy.D.: (15:39)
Sure. So it sounds like Les was kind of focused on those change moments? And kind of looking at those moments with the kind of gestalt, the person-centered, where there was like a significant shift? And like kind of understanding that?
Ladislav Timulak, Ph.D.: (15:56)
Exactly. I mean, in the context of self-critical dialogue, what actually – we now know that it’s quite defining process in a lot of what constitutes psychopathology or, you know, problems. So, self-criticism can be found in clients who struggle with depression, low mood, with anxiety, with eating disorders. It's quite universal process. When rigid, when self-criticism very harsh or rigid, that it's an important part of a lot of presentations. He basically studied how we can address self-critical processes in the format of like a chair dialogue, where the critic dialogues with the critic part of you, or critical voice in you dialogues with the part of you impacted by the critic.
Ladislav Timulak, Ph.D.: (16:52)
And you rebalance that criticism either by standing up to it or softening and becoming more compassionate. So this is what he studied in the context of self-critic. In terms of unfinished business, it was more pivotal injuries that you experienced with significant people in your life that left unfinished, hurtful feelings in you. You had an opportunity in targeted intervention, again to access the hurt, articulate the needs in the hurt. For instance, “I felt unloved or neglected. I wanted you to love me.” Exposed to the caregiver, and then either facilitating compassionate response, “I'm here and I love you,” or more boundary setting anger like, “I deserve your love,” or something along those lines.
Ladislav Timulak, Ph.D.: (17:43)
But these are the processes that he outlined in terms of – and he and his collaborators, and a lot of other researchers since, elaborated a lot of processes like this that inform practice of emotion-focused therapy currently. We look at the processes in session that we try to facilitate, but the common thread is that we are trying to look at what’s at the core of the pain, emotional pain. What's the unmet need in that pain? Then we are trying to generate new experiences, often a compassionate response or boundary setting. I call it protective anger symptoms, grieving as well, of what was not met. That's the focus of therapy that currently is practiced.
Keith Sutton, Psy.D.: (18:31)
Okay. Great. So the core of the pain, how do you access that or get to that? Or how do you zero in on that core pain?
Ladislav Timulak, Ph.D.: (18:42)
Okay. So, you see in many…
Keith Sutton, Psy.D.: (18:46)
That's central to EFT, right? That core pain.
Ladislav Timulak, Ph.D.: (18:48)
That's very central. That's correct. Yes. Many approaches do not differentiate between, you know, like something is upsetting or unpleasant. They refer to it as bad or negative emotion or something like that, and obviously they're trying to address it somehow. EFT has a very differentiated perspective on emotions, and certain types of emotions are seen as more symptom-level emotions, like hopeless, helpless, often, not always, but are more symptom-level. Then there is more, kind of underlying, more central emotion. I'll give you an example. A fictional example is: I'm coming home after a difficult day at college. You know, my students were not very attentive or whatever it is. They were on their mobiles or something.
Ladislav Timulak, Ph.D.: (19:44)
So I feel quite subdued and down, and I'm coming home, and I'm hoping that my partner – that I will be able to chat about it with her. My context is that I could chat with her and rebound or something. And I come and she's on her laptop as well or something, and I'm trying to engage her, and she doesn't respond. Now, I can start to feel, if I'm sensitive to feeling alone, she's not there. That's like a primary response. She's not there. Now it may be, if it's not my core issue, I may just come to her because that's adaptive. I mean, it could be adaptive sadness, and it would, for my adaptive action, and I could come to her.
Ladislav Timulak, Ph.D.: (20:32)
“Darling, would you have… I had difficult day. Would you have some moments this evening? I could make ourselves a tea and we can… I would appreciate if you could just be with me a little bit.” And she would say, “Fine.” So that's fine. I wouldn't go to therapy with it. But now imagine that I have – we refer to it like more, you know, problematic, or over time developed emotion schemes where I often feel alone. I come home, she's not there, and I feel alone. And it starts to define me. She's not here. Then it goes to more secondary distress. Nobody's ever here, and it will never change. I lie down in bed and will feel hopeless, helpless, maybe irritable, and will stay in bed for two months, and then will go to my GP.
Ladislav Timulak, Ph.D.: (21:20)
GP is a medical doctor in our context in Ireland. And I will say, “Nothing brings me joy. I feel depressed.” So that's more symptom-level, but at the core is really a chronic experience of not having a need met. Like in this example, loneliness. That I feel alone, and you are not here, and I miss connection. I miss your presence. Studying, in session processes where, when we look at what's at the core of the presentation, where clients feel most vulnerable, meaning also that they touch on something that is freshly painful yet has historical context, it occurs that we find three types of experiences that we refer to as core pain or core vulnerability or core emotional vulnerability.
Ladislav Timulak, Ph.D.: (22:17)
It's a triad of sometimes overlapping feelings. One is like sad/lonely, or sometimes it may be a loss, or some sort of sadness. I'm alone, or I miss you, or I lost you or something. The second one is shame. It's like, I'm inadequate, I'm worthless, I'm incapable, I'm weak, I'm stupid, and whatever it is – so this type of experiences. And the third one are experiences of chronic fear, and it's like, I'm unsafe, I'm unprotected, I'm exposed, or so. What we see that regardless – my latest book is on transdiagnostic emotion-focused therapy – that if you look at it from the typical presentations in outpatient clinic, depression, various forms of anxiety, like generalized anxiety, social anxiety, panic disorder and so on.
Ladislav Timulak, Ph.D.: (23:13)
Or OCD or PTSD, and then so on. We see that clients present with symptoms, but at the core – I mean, we are looking at those tapes of the clients in the research studies – we find a variant of either alone, or worthless, inadequate, or scared, and corresponding unmet needs for connection, for validation or acceptance, or for protection. That's the core. We are trying to activate it in therapy and generate new experiences that would kind of counter. That I feel not only alone, but I also feel connected to or loved. Or I feel worthy of love. This is what we are trying to generate in therapy in the format of imaginary dialogues because they are particularly vivid. We want to bring and build the full experience.
Keith Sutton, Psy.D.: (24:04)
That's going to evoke that emotional experience. So the symptom-level and the underlying, that's not necessarily the concept of secondary and primary emotions?
Ladislav Timulak, Ph.D.: (24:16)
It is, yes. I sometimes refer to it as a symptom-level and more core, more underlying vulnerability, but in EFT literature, including EFT for couples, you'll find reference to secondary and primary.
Keith Sutton, Psy.D.: (24:32)
Sure, sure. Okay.
Ladislav Timulak, Ph.D.: (24:37)
So sometimes for people with non-EFT background, sometimes it sounds too jargony, like secondary and primary. It's like, how do you decide? So it needs to be understood as a heuristic. It's basically an assessment that informs therapist judgment. In my example, I would feel hopeless, helpless that nobody will be there for me ever. But the therapist will not focus on it. Like, ”Let's stay with how hopeless you feel. Can you tell me more about it?” No, the therapist would actually focus, “What is it? If you stay with your partner, if you look at her in imagination, what is it, what you're missing?” And that will be her presence, her closeness, her warmth or whatever. Do you understand? Her care or something.
Keith Sutton, Psy.D.: (25:20)
So it's kind of underneath that helpless hope.
Ladislav Timulak, Ph.D.: (25:22)
Exactly. So that differentiation is there for therapists to have a map what to acknowledge and what to actually focus on. So you do acknowledge and validate that hopelessness feels miserable, but you're rather looking at what preceded hopelessness, what preceded your resignation that you resigned to feeling unhappy. That's the focus of therapy. In therapy, we are trying to focus on those primary – but not all primary emotions, I mean, you can focus on all primary, but on the ones that are chronically painful. So they're chronically coming back and are quite defining of who I am, how I experience myself.
Keith Sutton, Psy.D.: (26:06)
Yeah. Yeah. Part of the way I've been conceptualizing secondary and primary emotions is that the biggest ones that I end up working in therapy, or in couples therapy, is – there's secondary: Anxious, annoyed, hopeless, helpless, frustrated, resentful, all those kind of things. Underneath, right, are those primary emotions of feeling sad, feeling alone, feeling hurt, feeling fear, or feeling shame, which I actually think like shame's right in the middle because underneath shame is usually fear. Are those kind of similar to your… Or any to add with emotionally-focused therapy?
Ladislav Timulak, Ph.D.: (26:48)
No, no. I think – I mean, we are observing as therapists, and particularly if you're working either with imaginary dialogues or with an intention to access vulnerability, you'll come to experiences: I feel alone, I feel inadequate, I feel scared. Sometimes people have different language. So what you described and what you consider to be more central than the others, it's also what guides your interpretation, but I think we are seeing the same phenomenon. It's just like people may understand it a little bit differently or interpret it a little bit differently depending on their training, writings that or readings that they did, or supervision experiences and so on. And you have combinations of those. You may feel alone and unprotected. Or you may feel unloved and unlovable. So that's sad and shame together, you know? I don't judge it. I mean, it's more for scholarly work that I reduce it to sad/lonely slash shame slash fear, but in terms of actual work with the client, I'll stay with their experience.
Keith Sutton, Psy.D.: (27:58)
Yeah, definitely.
Ladislav Timulak, Ph.D.: (27:59)
If I write a scholarly paper on it, I'll describe it as something, but otherwise I stay with their words, with their phenomenological experience of what's the most painful, what's the most vulnerable, where I feel most that this is the difficult chronic feeling that I know, and it comes in similar situations. And it's the feeling that is quite defining of me.
Keith Sutton, Psy.D.: (28:22)
Sure. Yeah. And I think you said schemes? Of like that the person is feeling like, I'm alone, I'm always alone, I'm always going to be alone. Like there's a narrative that they have or reminds me of the schema concept in CBT. Is that kind of similar, this underlying story or narrative?
Ladislav Timulak, Ph.D.: (28:46)
I believe that we talk about the same phenomena. It's again, as I said, depending on your training, you interpret it differently. EFT tries to – I mean, Les Greenberg's term, it's kind of central in it refers to emotion schemes, trying to emphasize, you may communicate it in therapy that I feel stupid or I feel worthless or I feel inadequate or something like that, but what's important here is that it's a very holistic experience. It's not just a thought. I mean, thoughts are part of it, but by calling it emotion scheme, what wants to be stressed is that there's a felt reference. It feels horribly.
Ladislav Timulak, Ph.D.: (29:39)
It's not just an empty thought that I can reinterpret. It feels real. It feels like this is the sentient way of feeling, the reality of how I am. So that's one thing. The other thing is the fact that it's scheme, it's memory based. So my experiences of coming home and my partner not being responsive are colored by all other experiences when I was seeking connection. I mean, implicitly present. So if I chronically experience a non-response, then I'm more likely kind of perceive environment as non-responsive or more inclined to be quickly assuming, but that's all very fast process outside awareness. I mean, some of it can be in awareness if I focus attention on it.
Ladislav Timulak, Ph.D.: (30:34)
And it's quite defining and quick. So this is what wants to be emphasized by calling it emotion scheme. Anyway, so we try to activate those emotion schemes and rework them, make them less rigid, make them more differentiated, I would say. There are experiences that I can feel alone, but I also can feel responded. I'm sure there is a role of biology in it as well, because we may have stronger reactions. Some of us are more reactive than others, so we are more likely to develop if we have adverse events that they leave mark, because we may be more reactive to certain things. So it's a complex issue, but the bottom line…
Keith Sutton, Psy.D.: (31:18)
So you're going – oh, sorry.
Ladislav Timulak, Ph.D.: (31:19)
I just wanted to say that the bottom line is that we are going to phenomenologically go to the vulnerable feelings, try to activate them in therapy, articulate needs in them, because feelings tell us what our needs are being fulfilled in the interaction with the environment, and we try to generate new experiences that would restructure those emotion schemes and make them more flexible or we build – that's Antonio Pascual-Leone’s term – we build emotional flexibility or emotional resilience.
Keith Sutton, Psy.D.: (31:55)
Uh huh. Okay. So you're going to the core pain, and it generally plays out that it tends to be in one of three areas – a sad/lonely, shame or fear – and each one kind of has a bit of an antidote or so on – connection development, acceptance, safety…
Ladislav Timulak, Ph.D.: (32:16)
Protection, yes. Yeah.
Keith Sutton, Psy.D.: (32:17)
Safety, protection. So in the session, you're then having the person go through an experience with the empty chair to then express these unmet needs? And begin to have this, I guess, corrective experience where they're able to respond in the way they maybe wish to have responded or get the response that they were needing in those moments. And then…
Ladislav Timulak, Ph.D.: (32:51)
Yeah. I think in general, yes. I mean, I'll elaborate a little bit, but in general, yes [laughter]. What would you just described, what I just would want to stress small things in it. First of all, you want to create focus. Sometimes it's easier, sometimes it's less easy, but we have now developed case conceptualization and everything. We also have more map on symptom-level distress. And sometimes you have to work on symptom level because people do suffer from worries or from ruminations or they are avoiding pain and so on. So it's very complex. But the core work is then to activate that vulnerable feeling in imaginary dialogues, typically. Sometimes outside of the dialogues, but in general, in the dialogues, and express it either in recreating pivotal memories, or it can be in a current stage.
Ladislav Timulak, Ph.D.: (33:42)
It's very flexible, but you want to freshly experience, let's say that feeling. I'm feel alone, and I miss you. You're not here. Then when you express vulnerability, you are testing, you're bringing the person and you enact other person originally that you felt contributed to the injury or whose behavior you perceived as hurtful. First of all, you first enact them to recreate injury early on in the work, but when it's freshly expressed, you want to see whether there is different response from them. Because often, if in reality relationships are complex and ambivalent and people were sometimes responsive, seeing fresh vulnerability can make your enactment of them, your mental map of them or something, more responsive.
Ladislav Timulak, Ph.D.: (34:36)
Or you can explicitly ask, was there somebody who would understand? And enact that person. Or you can have a look at yourself from an adult perspective at younger you, and when you see the vulnerability, you may see whether there is a response, but that response has to happen. It has to come from within. So it's actually accessed or it is enacted by seeing vulnerability. Seeing your vulnerability, evolutionary makes you more responsive. Like seeing vulnerable child, you want to be caring. So when you see vulnerable you, just expressing fresh feelings, it elicits compassionate, caring response. So that's one pillar of work.
Ladislav Timulak, Ph.D.: (35:29)
The second pillar of work is actually – which is not stressed in many therapies, I mean, I'm not saying that in none – but is the boundary setting anger actually, or protective anger. So if the other is not responsive or if the other is hurtful, we are working on, is it acceptable to you to get this type of treatment? So the focus is, later on in the imaginary dialogue, is more focused highlighting mistreatment, and whether that mistreatment generates response that is protective towards the mistreatment. So these are the two. Compassion and anger are two pillars of how where lonely was can be now I'm here with you. It can be, I deserve your presence. Or where shame was, I value you, I'm proud of you. Or I'm proud of myself, I deserve your respect.
Ladislav Timulak, Ph.D.: (36:17)
Or where the fear is, I'm here, I protect you. Or I will face you, I will not let you to intimidate me or terrify me, and I'll face you. So this is the gist of the work. Often particularly compassion is followed by grieving as well. So once you'll get the response, there is a natural grieving that it wasn't like that in reality in the past years. Sometimes you come to terms more. I mean, it's always painful, it's not like it's gone. but there is a grieving of what happened, what I endured, and so on.
Keith Sutton, Psy.D.: (36:55)
Yeah. Well, it's incredible. It sounds like it's so much of this kind of bottom-up processing that happens. I'm hearing a number of pieces in here that it sounds like it's allowing a person to access those emotions. And it sounds like what you're saying is that they're going in both sides, and you're saying, seeing the vulnerability in their self that was harmed or seeing the vulnerability in the person that harmed them, or both. And what I've actually…
Ladislav Timulak, Ph.D.: (37:27)
So I didn't focus on that one, but you can have some scenarios where that could be – that you may have experience of connection with the other. So you may see their vulnerability, but it may not fit all kind of potential scenarios. So sometimes there may be also experience, or particularly if you had regrets, if you felt like you hurt somebody, obviously then there can be more expression of I see and I'm sorry or so. But I mean, the example I was giving, it was not that much focus on the other’s vulnerability, but I tried to simplify things. But of course, it may be more complex at times.
Keith Sutton, Psy.D.: (38:03)
Well it's making me think of, sometimes in EMDR, that we’ll have the person go in and confront the person that hurt them or whatever it might be. Sometimes if that person is responsive, oftentimes I find that they go from kind of anger to almost like a compassionate response. And then, just like you're saying, then to that loss. It almost feels like the cycle of loss happens in that process. Seeing the vulnerability and speaking to that younger self also reminds me of in internal family systems, where the person is using that adult self to have compassion and understanding and care for their younger self and to validate and witness them. So I really like that. I consider EMDR and internal family systems these bottom-up processing ways of really processing those unprocessed emotions. So it totally makes sense with the EFT that, in a little bit, it sounds like maybe there's some top-down and understanding the schema as a therapist and so on, but not necessarily going into cognitions or explaining or so on. Instead, just kind of going right for the heart of it.
Ladislav Timulak, Ph.D.: (39:23)
You can't get clients where they are not, so it has to come from within. You are just increasing probability. Seeing vulnerability increases probability to, let's say, soften or be compassionate, yes, when you see your own vulnerability, but it may not happen. With more chronic people – I mean, chronically self-critical or something, or very harsh on themselves – it actually is a huge struggle in therapy. Antonio Pascual-Leone did that research on studying emotional sequences, and he calls it two step forward, one step back. So you can't go…it has to be authentic, it has to happen almost unexpectedly. It's not scripted, or, “Now look at the child and what do you feel?” I mean, if you don't feel compassion, you have to then acknowledge what protects you from seeing that vulnerability.
Keith Sutton, Psy.D.: (40:26)
Yeah. I see what's coming up.
Ladislav Timulak, Ph.D.: (40:27)
Yeah. What's the fear if you saw it sometimes. These are sometimes, it may be internalized judgment. Often it's self-protective. If I soften, you would fool yourself, and then you would get even more hurt. So I mean, I'm simplifying everything, but it's a complex process, and it's very important that – it's not that the therapist would say, “Oh, repeat yourself a hundred times, ‘I'm proud of myself,’” and then it will work. No, it has to come almost unexpectedly in the face of adversity or in the face of mistreatment, you stand up for yourself. Or in the face of seeing that vulnerability and achievement or the effort that spontaneously this has to come. So we're just creating…
Keith Sutton, Psy.D.: (41:10)
[unintelligible] moved.
Ladislav Timulak, Ph.D.: (41:11)
Exactly. We just create opportunities that this would happen. We don't know whether it would happen. We're just trying to do our best, and if something is too much, we slice it back. We scaffold it more, and we'll take a step back, and a smaller step may be important first than any other step.
Keith Sutton, Psy.D.: (41:30)
Well, and it reminds me of in emotionally-focused couples therapy, we're helping one partner to be vulnerable, and that often engages empathy from the other partner. Although sometimes in stage one and deescalation it engenders defensiveness or so on, but I imagine if the person is doing that to themselves, right, and that empty chair, that it might be easier to access that empathy because they literally had that experience.
Ladislav Timulak, Ph.D.: (41:57)
Yeah. So it may or it may not. It depends on chronicity of, let's say, a very critical attitude towards yourself or something. So sometimes it may be puzzling that you would feel that the person is very vulnerable. Of course they would soften and be caring towards themselves, and you are met with a lot of contempt. That's at the core of why people suffer, because it's not that easy to bounce back or something. So that vulnerability is very ingrained and very rigid in how I process things. Anyway, so it's not that simple. As it's not simple with some couples. With some couples, it may be more…
Keith Sutton, Psy.D.: (42:43)
Well especially with complex PTSD, oftentimes that critical part was a protecting part, or the person has disowned that vulnerable part, and so there's kind of those aspects too. I like how you're saying too, that there's both the compassion aspect, but also that kind of boundary setting or anger. Talking with Pete Walker, the author of Complex PTSD: Surviving to Thriving, and he talks about getting angry at that internalized, kind of, abusive parent who is that critical voice. Versus maybe a lot of other therapies that are only focused on being compassionate towards those different parts of self. But both have that aspect.
Ladislav Timulak, Ph.D.: (43:24)
That's very important, and actually we go back to person-centered therapy. It didn't emphasize importance of anger or need. It was more about that warm, compassionate presence, of the relational presence of the therapist that would allow to process vulnerable experiences. But the anger is very pivotal, and I would say, I spent a few years studying and worked with generalized anxiety, and we have a book on generalized anxiety. I would say that anger is even more pivotal, because if you feel that something is scary, if you stand up to it, if you are firm with it, it actually makes you stronger. Rather than if you're relying only on reassurance or calming or something, or protective presence from outside in. So from inside out and facing what’s scary…
Keith Sutton, Psy.D.: (44:18)
Like exposure. It's like exposure.
Ladislav Timulak, Ph.D.: (44:22)
I mean, it's a little bit more than exposure because in exposure you get used to it that it's not that threatening. Here, it's also that I don't want you to limit my life. I want to reach out and do what I want to be doing. I don't want – so it's actually, exposure is more about habituation. This is more about, I don't want to miss out because of the anxiety or fear.
Keith Sutton, Psy.D.: (44:46)
Definitely. Yeah, yeah. It reminds me of like, and the way I think with exposure work is that we're not getting rid of anxiety, we're getting the confidence that I can feel the discomfort and still go forward.
Ladislav Timulak, Ph.D.: (44:56)
Yeah. So that's close to it. Yeah. I think so. Yeah.
Keith Sutton, Psy.D.: (44:58)
And it also, it makes me think too of, as you're describing about not letting it get in the way anymore, it makes me think of in narrative therapy, that externalizing and not letting the anxiety or such get in the way of being able to do the things you want or have the life that you wish. Or with kids, getting in the way of your fun.
Ladislav Timulak, Ph.D.: (45:16)
Yeah. I think that there are a lot of overlaps in there. We are looking at very similar phenomena. I think if we watch tapes, we would often agree, people from different orientation, that that's adaptive process. That's a healing process. That's therapeutic. Schema therapy, I think, has a lot of concepts that are similar as well, in terms of healing the vulnerability or hurt and so on. What EFT specifically focuses on, and how it can contribute is because it's based on a lot of process research. So there's a lot of – that we have emotional productivity scale, emotional arousal scale. We have cognitive classification of affective meaning scale. I mean, these are all process research scales.
Ladislav Timulak, Ph.D.: (46:04)
But they're also used in training to train people to be able to assess, what's the level of arousal? Does this client have capacity to touch on their vulnerability more? Is that vulnerability too much now? What's the optimal window for them to be with? What's the healthy anger? Because you have also unhealthy anger, like reactive. We call it reactive or rejecting anger, or secondary anger you can say, Iike it may not be fitting. Often, a healthy boundary setting anger is not with much arousal, but it's with the firmness and strength inside, like along the lines of confidence that you mention and so on. So it may not be very reactive, like “What you did to me, you horrible person.” It may be, “I'm strong, you can't harm me.” Or, “I'm not afraid of you,” or something like that. Or, “I just feel okay in myself.”
Keith Sutton, Psy.D.: (47:03)
Yeah. This emotional processing – so one way that I've conceptualized, like for example with trauma, is that this trauma happened and the person wasn't able to process it at the time. So it's kind of like these emotions are stuck, and that's where in EMDR or different trauma therapies you're sitting with those emotions and helping process or put it together. I don't know if that nicely fits at all for this model, but I'm hearing too that when the person has this corrective experience, or has this change moment, that they're experiencing themselves and their emotions in a more flexible way rather than maybe having that rigid emotional scheme. Is that kind of what…?
Ladislav Timulak, Ph.D.: (47:48)
Yeah, exactly. Exactly. If you talk specifically about trauma – narrowly defined, trauma is where you were endangered or your close one were endangered in terms of health or life or so. I mean more narrowly because every adverse experience, even shaming or abandonment, are traumatic. But if I'm just thinking more in terms of danger, like more kind of narrower definition of trauma, this is particularly – it's powerful experience, so you'll be scared of similar type of situations, or you may experience some situations as scary, because it's a very quick processing that certain things are experienced and felt as dangerous very quickly. And you may not want to feel, or you avoid where you could feel it, so you may have emotional avoidance or behavioral avoidance that you don't want to have this type of experiences. But what actually happens here, it increases the window that I'm able to stay with those experiences and have them kind of experience differently. Either that there is more response to that vulnerability or scary fear, terrifying feelings I felt…
Ladislav Timulak, Ph.D.: (48:57)
Or I stand up and face the memory of abuse or the memory of assault or something, and I stand up and fight back. So you are reworking, that next time you are in vicinity of similar triggering situations, you are not only organized by, “Is it dangerous?” It's also, “I’m powerful.” Or, “It's not totally dangerous.” You're becoming more differentiated in your responses. But it's not because of an analysis. I mean, analysis is fine, but it's also implicitly safer or you feel implicitly more powerful to be confident and so on.
Keith Sutton, Psy.D.: (49:42)
Or even like in internal family systems connecting to your adult self, that you're no longer that young child who is maybe five years old and helpless and powerless and so on. And kind of, even though it still feels scary or so on, but kind of almost experiencing yourself differently than more that emotional flashback.
Ladislav Timulak, Ph.D.: (50:00)
I believe we refer to same phenomenon. Different approaches may have different language for something like that, but I think that we are trying to name – I mean, scholars are academic psychotherapists – very similar phenomena that we encounter, you know?
Keith Sutton, Psy.D.: (50:19)
Yeah. Well, it sounds like incredible work. Tell me about what you're working on now or what's upcoming.
Ladislav Timulak, Ph.D.: (50:28)
So we had a book that will be promotion now. So there was a book published 2022, Transdiagnostic Emotion-Focused Therapy, by APA with my colleague Daragh Keogh, and we are running an RCT now that's specifically looking at EFT for depression, various anxiety presentations like GAD, social anxiety, panic disorder, and so on. And OCD and PTSD. So that's a trial we are running, and we are learning even more about the interaction between symptom-level work and more underlying core vulnerability learning work. So that's one of the projects. We have also a published book – many experiential approaches do not have client workbooks type of books.
Keith Sutton, Psy.D.: (51:21)
Yeah. Yeah.
Ladislav Timulak, Ph.D.: (51:22)
I mean, there are some, but they can't be compared to the amount in CBT because often there is a sense that you can't recreate something so flexible or, you know, as I described, but we attempted to do it a little bit. So we have a book out that is called Transforming Emotional Pain Client Workbook, and Aman Kwatra is the first author. It's one of my former students. And we are running psychoeducational programs for students in student counseling service in our college. It's a six-week program where they're learning also to work with how they stop themselves from feeling, or how they worry themselves that something would happen that would bring painful feelings, or how they learn to regulate when they're upset, but also how they can do imaginary dialogues with people that hurt, that they hurt with, or with a dialogue with own self-criticism.
Ladislav Timulak, Ph.D.: (52:22)
So we do that as a project. We have a couples project that we currently run, and we collaborate with Les Greenberg on it, and that's for comorbid relational dissatisfaction in romantic couples, coupled with at least one of the partners meeting criteria for clinical diagnosis – either depression or GAD, social anxiety, panic disorder or OCD or PTSD. So similar like we do in individual therapy, we are at the start of a project with comorbid mental health issues and relational distress. I'm sure we are running much more than that because…
Keith Sutton, Psy.D.: (53:08)
Sure. Wow. Sounds like a whole lot of different areas. I love looking at the comorbidities because so much of the research is just, you know, only picking clients with the very certain kind of particular thing, but as in practice, many times the majority have comorbidities going on.
Ladislav Timulak, Ph.D.: (53:31)
I actually now remember that – I'll just add one more thing, if I may – that that's actually what I'm working currently on, but that's at the very start, that's why I didn't mention it. It's, you know, that in therapy over the years, we didn't improve outcomes. I'm not talking about EFT, I'm talking about psychotherapy as such. If you look at the outcomes in eighties of the first rigorous, randomized controlled trials, like of CBT and interpersonal therapy for depression – I mean, if you replicate those 20, 30 years later, we do not have better outcomes. So something is happening. I mean, they're roughly the same, the outcomes. Occasionally, you may have better outcomes, but roughly, it's not dramatically better. That attest to complexity of mental health issues and so on.
Ladislav Timulak, Ph.D.: (54:22)
But it also tells us that probably there is room to improve, and I think one of the ways that is intriguing me currently is to have a look at how processes that are good in session can be further supported outside of session. I mean, beyond homework. Beyond homework. Because people are left 24/7 their week, but they're only one hour in therapy. So what's happening outside of therapy, how we can interweave their social practice or being outside of the session. So that's actually of interest of mine to develop a scaffolding processes that could map what happens in the session and what would be potentially good to do to capitalize on it outside the session, but beyond more just simple homework. It's a little bit more complex and maybe, you know, I have that other hat, a little bit of online interventions that are accessible at any point as well. That's in the area of interest.
Keith Sutton, Psy.D.: (55:38)
Sure, sure. Great. Well, I love the work you're doing, and just, I'm really inspired by the process, focus in the EFT work, and just the nuances, I think, that are just really great, that it sounds like are involved in the training and involved in the research. Yeah, it sounds amazing. Thank you so much for taking the time today. It was great to learn more about your work and about emotionally-focused therapy. I really appreciate it. Thank you.
Ladislav Timulak, Ph.D.: (56:07)
Thanks for having me, Keith. It's just excellent that you were in Dublin a few months back and we continue our conversation. We just started it in, was it September or something? It's really interesting.
Keith Sutton, Psy.D.: (56:20)
Yeah. Yeah. And I appreciate your openness and your warmness just to respond to this guy emailing you and saying like, “Hey, can we chat?”
Ladislav Timulak, Ph.D.: (56:28)
Oh, no, no, no. I actually like what you do. Yes. Because I looked it up, and I think it's really great that not only that you run service, but that you are doing also something for community of therapists and I mean, it's fantastic. So thanks for including me in your very useful and very impressive work.
Keith Sutton, Psy.D.: (56:51)
Oh, thank you so much. Okay. This was wonderful. I look forward to speaking with you again soon. Take care.
Ladislav Timulak, Ph.D.: (56:57)
Thanks. Thank you.
Keith Sutton, Psy.D.: (56:58)
Bye-bye.
Ladislav Timulak, Ph.D.: (57:00)
Bye-bye.
Keith Sutton, Psy.D.: (57:01)
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