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Article Review: How much emotion is too much in therapy?

Optimal Levels of Emotional Arousal in Experiential Therapy of Depression — Jonathan Carryer and Leslie Greenberg

I recently stumbled upon this article and it answered a question I’d had for a while. First, let’s look at the two big findings:

Specially this study suggest that, in the most emotionally aroused sessions of experiential therapy for depression, expression of intense emotional arousal is related to good therapeutic outcomes provided that the time spent in the expression does not exceed 25% of the time in session. Low arousal suggestive of avoidance, lack of involvement, or intellectualization is also in indicator of potentially poorer outcomes.

Deviations toward lower frequencies, indicated lack of emotional involvement, represented extension of the generally accepted positive relationship between lower levels of expressed emotional arousal and poor outcome. Deviations toward higher frequencies was seen as support for the assertion that excessive amounts of highly aroused emotion over the length of a session in mid to late therapy, or over multiple sessions, may be negatively related to good therapy outcomes.

The idea that you need some emotion but not to much is something I had to learn the hard way.

About a year ago I had a client drop out of therapy. When I called for her termination interview I asked, “was there anything that happened in therapy that didn’t fit for you?” “We talked a lot about my past. There’s just too much pain back there.” “Wow. I’m sorry I missed that. I’m also confused. You rated me really high on empathy.” I said. “Oh yeah, I could definitely tell you cared. I just couldn’t talk about my past. But you’re very empathic. You’re definitely in the right profession.” Looking back on the sessions, my notes, and some video, I now see what she’s saying. It was too emotionally intense, and because of that, probably retraumatizing. There’s a goldilocks zone of emotion in therapy, and I had missed it.

So what do you do? How do I make this information actionable.

First, let’s talk about what not to do. I don’t go off of how I feel about the therapy. Each client is unique, and we need to respect that. What’s too much for one client will be not enough for the next.

Second, at the end of intense sessions I’ll ask clients a scaling question, “on a scale from 1–10, how intense, overwhelming, emotional, would you rate this session?” I’m looking for a number between 5–7. Anything 8 and over and I tell them we’ll pull back next time.

Third, I set the stage from the very beginning. At the end of every first sessions I tell clients that therapy is like a a Pixar movie. Every Pixar movie is the same. Take Toy Story for example. Woody is king of the toys and loves being Andy’s favorite. Then one day Buzz Lightyear shows up and conflict erupts. Buzz and Woody find themselves far from home facing alien lands and strange monsters, but at the end of the movie they wound up back home. And even though everything is back to how it should be, it’s different because they’ve grown from the experience. “Therapy should be like that.” I say, “We’ll face your demons together, but at the end of the session you should feel at home again. If you don’t, we need to change things until you do.”

Finally, I listen for therapy disrupting their work/school/home activities. For example clients might say something like:

  1. “After last session I just went to sleep. I was do drained.”

  2. “I couldn’t work after lest session. I had to take off for the rest of the day.”

I also listen for therapist disrupting being too intense of them to do.

  1. “I had so much anxiety coming in here today.”

  2. “I started doing the homework, but it was too intense. I don’t want to think about that.”

Conclusion Now we have the scientific verdict. There’s a goldilocks zone of emotion in therapy and the real danger is in having too much emotion in therapy. The major way to correct this is to ask our clients their experience. Once we have that information we can easily lower the intensity so they aren’t overwhelmed.

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