What we can learn from clients’ experiences of chairwork in schema therapy
This week’s article combines two of my favourite interests in psychotherapy research: chairwork and studies of consumers’ experiences of psychotherapy. Chairwork has enjoyed a renaissance in the last 10 years, thanks largely to its use in schema therapy, emotion-focused therapy and compassion-focused therapy and through the transtheoretical workshops of Scott Kellogg. The empirical literature contrasting chairwork with more conventionally rational cognitive change techniques is both disappointingly small and does not consistently demonstrate an advantage in cognitive and behavioural change over other interventions beyond emotion activation (Brockman et al., 2023). However, among the raft of roughly equally effective therapeutic activities, chairwork arguably offers some attractive features for certain kinds of situations. First and foremost, chairwork tends to stimulate increased client emotion, so for clients who have a tendency toward intellectualised, detached and avoidant styles of talking, chairwork provides a very conducive structure for engaging emotions and the “hot thoughts” associated with them that might otherwise lay dormant. I’ve also found it very helpful for people who struggle to follow a linear, logical reasoning process such as depicted in traditional CBT textbooks; the ability to have them talk to psychological objects directly, get straight to the point, name their feelings and wants, and respond to the imagined objects, in real time, seems to lighten the working memory load, and help them focus on the core cognitive behavioural components without getting derailed in the narrative. Finally, I find chairwork necessarily entails rehearsal which readily transfers outside the session, whether it be making requests or other assertive statements, compassionate self-talk or statements of coping, self-instruction, self-efficacy or commitment. It tends to allow coverage of problem analysis, perspective change, emotional change and behavioural rehearsal with great efficiency. As Lionel Hutz from the Simpsons says, “we have plenty of hearsay and conjecture. Those are…kinds of evidence”
Josek and colleagues (2023) report on qualitative interviews made of 29 individuals with BPD who received at least 5 months of schema therapy in a study looking at group v individual schema therapy for borderline personality disorder by Arntz and colleagues (2022) which I blogged on previously. Here, I won’t focus on the schema therapy-specific findings. Those who want more on schema therapy-specific chairwork can read our new book The Cambridge Guide to Schema Therapy (sorry, I’m contractually obliged to do that). I would also recommend my co-author Remco van der Wijngaart’s (2023) great book Chairwork: Theory and Practice (for which I receive no promoter fees…yet). In fact, for those who aren’t doing any chairwork, I wanted to highlight how consistent consumers’ perspectives on what made for good chairwork were with what makes for good psychotherapy – of any type. One of the key areas Josek and colleagues asked about was what therapist behaviours either helped or hindered participants’ chairwork.
The most helpful class of therapist behaviour (mentioned by 90% participants) was providing safety, warmth and encouragement. Being empathetic was the most mentioned subcomponent, consistent with its general importance in all forms of psychotherapy. More specific to chairwork, nearly half of clients highlighted how helpful it was for therapists to suggest specific healthy messages within chair dialogues, when they didn’t know what to say. This is arguably consistent with the role of a good cognitive therapist who provides instruction when the client lacks knowledge (so Socratic questioning won’t be able to elicit a useful response) or takes their turn during brainstorming when the client runs out of ideas. Therapists were seen to provide safety through conveying they didn’t expect clients to perform exercises perfectly right away, by offering encouragement and praise during the exercises, and by limiting time spent articulating self-critical messages to only very brief periods. Although these observations make particular sense in Punitive Critic dialogues within schema therapy, they are more generally sound recommendations for engaging in most psychotherapeutic activities. To a lesser extent, participants mentioned that therapists maintaining taking the task seriously helped them also remain engaged properly with the task. This is worth therapists of any persuasion noticing; some therapists cope with their anxiety by downplaying or making light of certain assessment and therapeutic tasks in the hope of “joining with” their clients. This only serves to undermine the value of the exercises and the therapist’s perceived competence.
The next most widely perceived (83% participants) to be helpful class of therapist behaviour was “processing” the exercise after completing the chairwork. It is easy for novices to run down the clock immersed in the free flow and drama of experiential exercises; however, the majority of participants emphasised that it was very important to them to have time after the exercise, before the end of session, to talk about the exercise. This is where the therapist summarises what occurred and discusses with the client what implications that exercise has for how they approach living during the coming week. Chairwork is chosen precisely to increase the intensity of clients’ emotional experiences so clients’ working memories will often be “maxed out” simply participating. The time after the exercise when their emotional arousal reduces is important for consolidating propositional learning to accompany implicit/procedural learning that may have occurred during chairwork.
Also perceived to be important (by 52% participants) was the therapist’s skill in clearly guiding clients through the process. This included therapists restricting how much clients spoke, at times. It is rarely useful to let clients talk at length, uninterrupted, in any form of therapy and chairwork is no exception. Chairwork will always have a focus; typically, to express emotions, wishes or needs. These core foci rarely need many words and excessive verbiage tends to distance the client from identifying and stating their core emotion or desire. Good chairwork therapists recognise this and use questions (and in some traditions, suggestions for statements) to coach the client to express themselves in the most concise and cogent way possible.
Although comments about factors that inhibited the efficacy of chairwork were common across participants, there was less consensus on the specific therapist behaviours that hindered chairwork. A few participants noted practical barriers like insufficient space, insufficient chairs and too much noise, which therapists may or may not easily be able to address. The main concerns were therapists putting too much pressure on the client to engage in chairwork and not providing enough emotional support during the exercises. The balancing act between helping clients move forward and face psychologically significant subjects and tasks but also recognising when a client is too overwhelmed to learn anything, is common across most psychotherapeutic interventions. In fact, responsiveness or “therapist flexibility” was an evident theme in about a third of participants’ responses about therapist behaviours that facilitated chairwork.
The article also documented client experiences of chairwork beyond what their therapists did. It’s worth therapists remembering that most clients experience some difficulty getting started with chairwork. It is a weird exercise, which a minority struggle to take seriously, and more still find difficult to understand and trust, until they have had a few turns experiencing its benefits. About a third reported finding it embarrassing or felt ashamed participating in the exercises. Therapists can normalise, empathise and gently correct unhelpful evaluations, externalising them to a part of the client not central to their healthy sense of self. Most participants (69%) also reported increased short-term distress or agitation which can persist for some hours after the session. It’s important that therapists beginning this work are prepared and know that this is a normal response, and in turn, prepare clients for this. Planning a positive activity to do after the session was explicitly mentioned by a number of clients as a helpful way to manage the short-term distress.
Finally, I should add that all participants reported some positive effect from chairwork, with about a third mentioning multiple positive long-term effects. These included: more openness in relationships with more ability to express emotions and needs, less aggression and more ability to take others’ perspective; thoughts became clearer, and it was easier to both distance from and revaluate automatic thoughts; emotions felt less overwhelming and they were better able to relax; enjoyed better physical wellbeing; as well as having increased awareness of thoughts and feelings.
Some limitations of the study to note include that the sample includes only 11.6% of those randomly assigned to schema therapy and it’s likely these people had a more positive response to schema therapy than others. The sample was mostly female, so it’s possible people of other genders may have different experiences. The chairwork was only one component of schema therapy and despite the aim of the study, participants might struggle to confidently attribute effects to any specific component of a multi-component intervention like schema therapy. And regarding this blog, although I have tried to deemphasise the schema therapy-specific aspects of the study, it’s possible I have not succeeded, or made a big mistake by trying to, and all of these results apply only to chairwork in schema therapy for BPD and turn princesses into frogs when applied outside this framework. However, I don’t think this is likely. For all these caveats, studies of consumers’ experience of psychotherapy remain quite rare at this stage, and the results are helpful in shoring up clinicians’ and trainers’ perspectives on how chairwork is received, accepted and appreciated.
Clinician implications
If using chairwork:
Prepare clients that they are likely to feel emotionally drained after the exercise and plan something enjoyable and easy to do after the session.
During exercises, maintain good common factors practice: express empathy and offer encouragement
Adjust the exercise to meet the client’s needs and capabilities given their level of emotional arousal; ensure the client feels safe.
Interrupt the client to prevent both unproductive detached/avoidant rumination and even more importantly to limit self-critical, self-loathing diatribes. Once the evocative phrase or meaning is encapsulated there is no value in hearing more of it; focus instead on practising responses to it.
Interact often enough with the client that you understand what they are thinking and feeling as much of the time as possible.
Budget enough session time to allow the client to learn a declarative/propositional/rational (choose your favourite theoretical term for this) lesson from the exercise. This could include identifying a key phrase that palpably corrected a harmful belief and planning ways to rehearse and remember it, or a new behavioural plan for encountering a trigger in the next week. Schedule longer-than-usual sessions – especially in the first few times you try chairwork – if needed, to assess the client’s capacity to regulate emotions after evocation, and to return to a calmer state after the chairwork, where they can consolidate rational learning.
Even if not using chairwork:
Ensure you are expressing empathy, creating safety and providing encouragement – these are always among the things that consumers most value in their therapists
Teach clients how to benefit from the session, including when to stop talking about unhelpful topics
Display conviction in the activities you recommend (no matter what doubts you may have inside your head)
Be flexible and responsive to the client’s needs and abilities in session
Don’t let enthusiasm for any activity override sound time management; ensure there is time at the end of the session for the client to be clear about what they ought to have learnt from the session and how they should approach their life differently/better this week
For the original article, go to:https://www.frontiersin.org/articles/10.3389/fpsyt.2023.1180839/full
REFERENCES
Brockman, R.N., Simpson, S., Hayes, C., van der Wijngaart, R., & Smout. M. (2023). Cambridge guide to schema therapy. Cambridge.
Josek, A. K., Schaich, A., Braakmann, D., Assmann, N., Jauch-Chara, K., Arntz, A., Schweiger, U., & Fassbinder, E. (2023). Chairwork in schema therapy for patients with borderline personality disorder—A qualitative study of patients' perceptions. Frontiers in Psychiatry, 14, 1180839–1180839. https://doi.org/10.3389/fpsyt.2023.1180839