Introduction
Cognitive behavioural therapy (CBT) is an effective, empirically supported psychotherapy, which is recommended for the treatment of a range of emotional disorders (Butler et al., Reference Butler, Chapman, Forman and Beck2006; Hofmann et al., Reference Hofmann, Asnaani, Vonk, Sawyer and Fang2012). While CBT incorporates a variety of therapeutic techniques to promote cognitive-affective change, experiential methods are regarded as being amongst the most powerful (Greenberger and Padesky, Reference Greenberger and Padesky1995; Wells, Reference Wells1997; Young et al., Reference Young, Klosko and Weishaar2003). Cognitive theory provides insights into why this may be the case. Dual process models such as Teasdale and Barnard’s (Reference Teasdale and Barnard1993) theory of interacting cognitive subsystems (ICS) propose that information processing is governed by two subsystems: a propositional code that is concerned with factual, language-correspondent ‘head-level’ beliefs, and an ‘implicational’ code that is concerned with implicit, ‘heart-level’ beliefs which tend to manifest as felt-senses. Similarly, Epstein’s (Reference Epstein2014) cognitive experiential model (CEM) distinguishes between a non-verbal, holistic and emotion-driven experiential information processing system, and a rational system associated with an effortful, analytic and verbal information subsystem. The implication of dual processing models has been that modifying affect-laden implicational/experiential knowledge is preferentially achieved through experiential interventions ‘in which new or modified models are created’ (Teasdale, Reference Teasdale, Clark and Fairburn1997; p. 90). Consistent with this position, preliminary research suggests that experiential methods such as behavioural experimentation and imagery may be more effective than verbal restructuring in generating cognitive-affective change (Bennett-Levy, Reference Bennett-Levy2003; Hyett et al., Reference Hyett, Bank, Lipp, Erceg-Hurn, Alvares, Maclaine and McEvoy2018).
Whilst experiential interventions are often used in CBT, few studies have explored the therapeutic applications of ‘chairwork’: a collection of procedures which utilise chairs, their positioning, and movement in order to facilitate here-and-now interactions with parts of the self, including internalised representations of other individuals (‘horizontal’ dialogues or procedures), or decentred observation of parts of the self (‘vertical’ dialogues or procedures) (Table 1) (Pugh and Broome, Reference Pugh and Broome2020). Archetypal forms of chairwork include enactments in which the client is questioned in the role of parts of the self (‘interviews’); conversations between two or more parts of the self (‘dialogues’); creating scenes from the past, present or future (‘dramatisations’); and using chairs as representational objects to map and measure relationships (‘depictions’) (see Kellogg, Reference Kellogg2019). Originating from psychodrama (Moreno, Reference Moreno1987) and popularised by gestalt therapy (Perls, Reference Perls1973), chairwork is used for many purposes in CBT including cognitive restructuring, behavioural skills training, and, to a lesser degree, emotional regulation (Pugh, Reference Pugh2019a,b). Historically, cognitive therapy has viewed chairwork as a ‘second-line’ intervention for resistant cognitions or when verbal restructuring techniques fail (Beck, Reference Beck1995; Ellis, Reference Ellis, O’Donohue, Henderson, Hayes, Fisher and Hayes2001). In contrast, chairwork represents a more central method in several CBT-allied models of therapy including schema therapy (Young et al., Reference Young, Klosko and Weishaar2003), compassion-focused therapy (Gilbert, Reference Gilbert2010), and trial-based cognitive therapy (de Oliveira, Reference de Oliveira2015).
Table 1. Forms of chairwork
Research examining the effectiveness of cognitive behavioural chairwork is limited, although existing findings are encouraging (Cromarty and Marks, Reference Cromarty and Marks1995; Lipsky et al., Reference Lipsky, Kassinove and Miller1980). For example, studies indicate that the trial-based role play (de Oliveira, Reference de Oliveira2015) is an effective method for modifying negative core beliefs and ameliorating associated distress (de Oliveira, Reference de Oliveira2008; de Oliveira et al., Reference de Oliveira, Hemmany, Powell, Bonfim, Duran, Novais and Cesnik2012a). Moreover, trial-based role playing appears to be advantageous in reducing fears of negative evaluation and avoidance amongst individuals with social phobia when compared with use of automatic thought records and positive data logging (de Oliveira et al., Reference de Oliveira, Powell, Wenzel, Caldas, Seixas, Almeida and de Oliveira Moraes2012b). Qualitative studies have also highlighted the memorability and ‘felt truth’ of changes brought about through chairwork (Bell et al., Reference Bell, Montague, Elander and Gilbert2020; Chadwick, Reference Chadwick2003). In terms of behaviour change, behavioural rehearsal through role play has proved to be a highly effective method for establishing new interpersonal skills, particularly assertiveness (Speed et al., Reference Speed, Goldstein and Goldfried2018).
Despite its supposed effectiveness, competency frameworks have made limited reference to the applications of chairwork in CBT. For example, Roth and Pilling (Reference Roth and Pilling2007) discuss role playing only in the context of modifying core beliefs,Footnote 1 while process-based frameworks limit chairwork to cognitive reappraisal (Arntz, Reference Arntz, Hayes and Hofmann2018; Wenzel, Reference Wenzel, Hayes and Hofmann2018) and interpersonal skills training (Mueser, Reference Mueser, Hayes and Hofmann2018). This leads us to hypothesise that chairwork is used infrequently by practising therapists. Other research has highlighted factors that obstruct the use of evocative interventions including therapist anxiety, negative attitudes, and lack of specialist training (Bell et al., Reference Bell, Mackie and Bennett-Levy2015; Harned et al., Reference Harned, Dimeff, Woodcock and Contreras2013; Waller et al., Reference Waller, Stringer and Meyer2012). In addition, little is known about therapists’ attitudes towards chairwork, including its perceived utility and compatibility with CBT. Such an understanding would help gauge what place chairwork holds in cognitive behavioural practice, as well as potential training needs amongst therapists.
The aim of this exploratory practitioner survey was to provide data relating to cognitive behavioural therapists’ attitudes and experiences of chairwork. The specific aims were to survey CBT therapists’ (a) training, competency and use of chairwork; (b) attitudes towards chairwork in terms of efficacy, relevance and compatibility; and (c) the experience of delivering chairwork within CBT. The study also aimed to determine whether CBT therapists’ use of chairwork varied according to their training backgrounds.
Method
Design
A cross-sectional design was used, using a self-report questionnaire which was completed by hand. A mixed methods approach was employed to provide a comprehensive picture of therapists’ attitudes and experiences of chairwork, as well as to generate hypotheses about its applications in CBT. Equal priority was given to both types of data.
Participants and procedure
The participants were a convenience sample of qualified therapists working in the UK. Participants were recruited at training events facilitated by the first two authors over a 12-month period. Topics for workshops were either applications of chairwork in CBT or introductions to compassion-focused therapy. Survey questionnaires were completed at the start of training events. The clinicians consisted of 88 women and 14 men who routinely delivered CBT. Participants had a mean age of 42.5 years (SD = 10.3; range = 24–71) and reported a mean amount of time delivering CBT of 8.18 years (SD = 5.67; range = 0.25–30.0). Their mean amount of time delivering CBT was reported as 15.3 hours per week (SD = 7.63; range = 1–40). Sixty-eight were accredited CBT clinicians, 10 were accredited CBT supervisors, and three were accredited CBT trainers.
Survey questionnaire
The survey questionnaire was designed specifically for this study. The questionnaire was constructed to assess clinicians’ attitudes towards chairwork in the context of CBT and personal experiences of using these techniques. The questionnaire also contained basic demographic data items and items regarding participants’ professional background (see Results section). The design process consisted of developing, reviewing and refining study-specific items through discussion amongst the research team.
The final survey consisted of a total of five closed-ended items and seven open-ended items. Closed-ended items consisted of the following questions, which were coded on a 5-point Likert scale: self-rated competency using chairwork in the context of CBT (1 = not competent, 5 = very competent); frequency of use of chairwork in CBT (1 = never, 5 = very frequently); perceived compatibility of chairwork and CBT (1 = not at all compatible, 5 = very compatible); perceived effectiveness of chairwork (1 = very ineffective, 5 = very effective); and the perceived value and importance of chairwork in CBT (1 = not important/valuable, 5 = very important/valuable). The remaining six open-ended items invited participants to describe personal experiences of applying chairwork within their cognitive behavioural practice (Table 2).
Table 2. Open-ended questionnaire items
Data analysis
Quantitative data were analysed using SPSS software. Qualitative responses were typed and collated. The resultant data were analysed using Braun and Clarke’s (Reference Braun and Clarke2006) six-stage thematic analysis. This involved an inductive coding of the data, identifying patterns of meaning and significance, and producing a set of initial themes. These were then refined to produce a table of superordinate themes. In line with quality guidelines for qualitative research (e.g. Elliott et al., Reference Elliott, Fischer and Rennie1999), the main analysis was carried out by one author (T.B.) and independently audited by a second author (M.P.) to ensure the credibility of superordinate themes and their grounding in the raw data. Differences in interpretation were negotiated to produce the final set of themes.
Ethics
The study was reviewed by the first author’s research and development and information governance departments and was deemed as not requiring review by an NHS research ethics committee. Participants provided informed consent prior to completing the survey.
Results
Quantitative analysis
Clinician characteristics
Thirty-six clinicians (35%) had received formal training in chairwork and 49 (48%) had been trained in CBT-allied therapies most associated with the use of chairwork (e.g. schema therapy and compassion-focused therapy), although they had not necessarily been exposed to chairwork in those trainings.
Use and perceived value of chairwork
Table 3 shows the clinicians’ perceptions of their own competence and frequency of use of chairwork, and their views of its compatibility with CBT, relevance to cognitive behavioural practice, and its effectiveness. The majority rated their own chairwork skills as weak to moderate (88%) and did not use it often (61%). However, most regarded it as an effective intervention (91%), compatible with CBT (78%), and one which makes a significant contribution to cognitive behavioural practice (81%).
Table 3. Clinicians’ self-reported skill and perceptions of chairwork
Factors associated with opinions regarding chairwork
The association of general CBT accreditation with competence in using chairwork was tested using t-tests (see Table 4). Those clinicians who had CBT accreditation did not feel more competent in using chairwork; did not use chairwork more often; did not feel that chairwork was more CBT-compatible; did not feel that chairwork made more of a contribution; and did not have a more positive attitude to chairwork. None of these differences was significantly different (t < 1.70; not significant in all cases).
Table 4. Comparison of accredited, non-accredited and chairwork-trained clinicians
n.s., not significant.
In contrast, clinicians who had received formal training in chairwork perceived themselves as more competent in its application (t = 4.14, p < .001). Similarly, generic training in chairwork-compatible therapies was associated with feeling more competent in applying it (t = 3.73, p < .001).
Frequency of use of chairwork was correlated (Pearson’s r) with perceived competence, to determine whether the extent of use of this method was linked to the perceived ability to deliver it well. This correlation was strongly significant (r = .671, p < .001). Finally, the temporal variables (age, length of time providing CBT, number of hours per week delivering CBT) were associated with the variables detailed in Table 3 (levels of competence, etc.) and with positive attitudes to chairwork. Pearson’s r was used, with a Bonferroni correction to reduce the risk of Type 1 error. None of these correlations approached significance (r < .25, not significant in all cases). This pattern of correlations indicates that clinician experience and frequency of use leads clinicians to view themselves as being more skilled in delivering chairwork, but that level of use and clinical caseload do not result in such perceived skills.
Qualitative analysis
The analysis of the qualitative data produced four interacting themes: ‘connecting to emotion’; ‘concerns about client reactions’; ‘confidence and competence’; and ‘from self-criticism to compassion’.
Theme 1: Connecting to emotion
Therapists’ predominant reason for using chairwork was to encourage clients to acknowledge, experience and articulate their emotions. Participants were more likely to consider chairwork when clients ‘struggled to connect’ to their feelings or experienced a disjunction between ‘head’ versus ‘heart’ processing:
‘I tend to use [chairwork] more when clients become stuck connecting to an incident or when they can ‘understand’ the rationality, however [they] cannot ‘feel’ it.’
Chairwork was associated with the deepening of emotional experiencing and contrasted with verbal interventions associated with logical challenging. ‘Embodied learning’ and ‘body work’ (the use of gesture, posture and vocalisations) were identified as key factors in making chairwork emotive, immersive and effective:
‘[Chairwork] seems to promise greater effects through dramatisation and intense emotional response as opposed to purely cognitive work.’
‘[Chairwork moves] from the head into the body, to make things more real.’
Working with heightened levels of emotion was often described as ‘empowering’, increasing clients’ agency related to their feelings and their expression. Participants also identified the benefit of using chairwork to reverse and target emotional avoidance or ‘blocking’ in session. Specific forms of chairwork were also valued for allowing emotions to be personified, embodied and addressed directly. Notably, chairwork was associated with facilitating healthy expressions of anger.
Theme 2: Concerns about client reactions
Despite highlighting the benefits of activating emotion, participants were concerned about overwhelming or dysregulating clients due to the emotional intensity of the method:
‘I think they generally find it very powerful, but also highly distressing. Sensitivity and plenty of time are needed… I think their fear makes them find it quite difficult to let go.’
Participants feared making their clients ‘worse’ and ‘causing more harm than good’ through potential destabilisation or disengagement. This consideration interacted with service factors, such as the limited time afforded to developing soothing/grounding skills in short-term work:
‘If you can’t ground person enough to self-soothe, [chairwork] seems too painful/hurtful.’
The presence of a strong therapeutic relationship was deemed to be key factor in mediating and mitigating the potential for causing distress and was frequently identified as an important consideration when deciding to use the approach.
Concerns about client reactions also centred on the potential for chairwork to generate self-consciousness, embarrassment and shame. Participants suggested that some clients might ‘feel too exposed’, perceive the exercise as ‘child-like’ or ‘weird’, or associate the process with acting and pretence:
‘If a client sees it as acting and therefore not real for them. If they’re not open to working with/making space for some resistance about doing chairwork, i.e. willing to experiment with it.’
Client ‘scepticism’ or lack of ‘openness’ to experiential methods was frequently cited as reasons not to use chairwork. Certain presentations were also avoided by some therapists, such as trauma, personality disorder or severe low mood (out of concern for de-stabilisation or the escalation of risk). Clinicians were also concerned that clients might become absorbed or ‘stuck’ in specific roles or emotions:
‘The client [might not] reach the point by the end of the intervention where they are able to think/feel differently.’
Despite these concerns, the majority of participants felt that such reactions would be short-lived, part of the therapeutic process (‘deepening the experience of therapy’), and ultimately helpful or ‘potentially revolutionary’.
Theme 3: Confidence and competence
Participants’ fears of client dysregulation were shaped by doubts about their own confidence and competence using chairwork, sometimes leading to avoidance of these interventions. Doubts were focused on technical ability, decision-making regarding when and where to use chairwork, and how to manage blocks and other difficulties arising during enactments:
‘[I am] concerned I may ‘get it wrong’. Concerned I might misuse it – clients go home feeling very confused.’
‘Messing it up. Getting stuck and not knowing how to guide the role play next.’
Other therapists felt like an ‘imposter’ delivering a technique that was alien to them (‘I was never very good at acting’). In addition, difficulties ‘selling’ the approach to clients and negative experiences using chairwork in the past were also identified as factors reducing its use:
‘I might get confused/they might get confused if I lose sense of [my] rationale.’
Therapists’ anxieties and doubts relating to chairwork were linked to a lack of coverage in their core-training or limited access to formal chairwork training. Participants also identified a professional ‘stigma’ linked to chairwork insofar as its supposed deviation from established models and protocols. The lack of supervisor interest and competence in chairwork was deemed to be an important factor limiting use of chairwork:
‘I suppose not being able to receive adequate supervision for when difficult emotions come up.’
Theme 4: From self-criticism to compassion
A recurrent theme was using chairwork to both explore and target ‘self-to-self relating’, specifically self-criticism and self-compassion:
‘I thought it helped reinforce a different style of self-talk. Moving chairs is likely to distinguish critical thinking from compassionate thinking more easily.’
‘For highly self-critical people with lots of shame. To help people learn alternative ways of self-to-self relating.’
Participants highlighted the therapeutic value of using chairwork to differentiate internal ‘voices’, concretise self-self dialogues, and ‘de-centre’ from self-critical cognitions. In addition, chairwork helped facilitate self-compassion by developing new ‘perspectives’ and self-directed ‘empathy’, as well as new curative ‘feelings’ which ameliorated self-criticism. Participants frequently considered chairwork when working with low self-esteem and suggested its use was particularly helpful with negative core beliefs. Notably, compassion-focused therapy was often therapists’ only exposure to chairwork.
Discussion
Whilst CBT is undoubtedly efficacious, treatment outcomes are not always satisfactory (Hudson et al., Reference Hudson, Rapee, Lyneham, McLellan, Wuthrich and Schniering2015; Westen and Morrison, Reference Westen and Morrison2001). Driven by the need to develop more effective cognitive behavioural interventions, experiential methods have recently experienced renewed interest (Borkovec et al., Reference Borkovec, Newman and Castonguay2003; Saulsman et al., Reference Saulsman, Ji and McEvoy2019). Of these, cognitive behavioural forms of chairwork are perhaps most enigmatic and poorly understood (Pugh, Reference Pugh2019a).
This study explored CBT therapists’ attitudes and experiences of chairwork. In summary, CBT therapists rated their competence and use of chairwork as low. Despite this, clinicians regarded chairwork as an effective and CBT-compatible therapeutic method. Pioneering CBT manuals have emphasised the utility of chairwork (Beck et al., Reference Beck, Rush, Shaw and Emery1979; Beck et al., Reference Beck, Emery and Greenberg1985; Young, Reference Young1990), although its application in practice appears to be sparse. Consistent with therapist training research (Beidas and Kendall, Reference Beidas and Kendall2010; Rakovshik and McManus, Reference Rakovshik and McManus2010), the quantitative results indicated that clinicians who had undertaken training in chairwork or therapeutic models which emphasised its use (e.g. schema therapy and compassion-focused therapy) perceived themselves as more competent and utilised these procedures more frequently. However, this was not the case for accredited CBT therapists, irrespective of temporal factors (e.g. longer durations of experience). Competency frameworks for delivering CBT indicate that chairwork and, relatedly, role play are both useful in treating certain disorders (Hayes and Hoffman, Reference Hayes and Hoffman2018; Roth and Pilling, Reference Roth and Pilling2007), although their importance is under-emphasised compared with other techniques (e.g. cognitive reappraisal and behavioural experimentation).
The qualitative findings contextualised CBT therapists’ attitudes towards chairwork. Key foci for chairwork included emotional processing and cognitive modification, and tended to be used when ‘traditional’ cognitive behavioural methods proved insufficient. While research suggests that chairwork is an effective method for modifying maladaptive thoughts and feelings (e.g. de Oliveira, Reference de Oliveira2008; Greenberg and Malcolm, Reference Greenberg and Malcolm2002; Paivio and Greenberg, Reference Paivio and Greenberg1995), support for chairwork as a behaviour change method is as equally strong (Lazarus, Reference Lazarus1966; Sanchez et al., Reference Sanchez, Lewinsohn and Larson1980). It is unfortunate, then, that use of enactive behavioural methods appears to be declining amongst therapists (Speed et al., Reference Speed, Goldstein and Goldfried2018). The results of this study suggest that more could be done to promote the use of modelling and behavioural rehearsal through chairwork amongst CBT therapists.
The qualitative findings indicated that CBT therapists’ use of chairwork was informed by overlapping conceptual frameworks: ‘embodied’ approaches to cognitive-affective change and the need to achieve ‘head-level’ and ‘heart-level’ belief change. Beginning with the former, embodied approaches to CBT emphasise the reciprocal interactions between bodily events (e.g. posture, gesture and motion) and cognitive-affective experience (Hauke et al., Reference Hauke, Lohr and Pietrzak2016). Research has supported this hypothesis, demonstrating that changes in bodily processes influence mood (Michalak et al., Reference Michalak, Burg and Heidenreich2012), while adaptive changes in thought and feeling can be ‘anchored’ to physiology through action (Bell et al., Reference Bell, Montague, Elander and Gilbert2020). Similarly, ICS has highlighted the role of bodily inputs in the maintenance of negative emotional states and underlying implicational knowledge (Teadale and Barnard, 1993). In order to bring about implicational (‘heart-level’) change, ICS recommends use of multisensory interventions rather than analytic techniques which primarily influence rational (i.e. propositional) processes. Thus, it appears that CBT therapists’ use of chairwork is broadly consistent with theoretical literature.
Alongside contextual factors (e.g. limited experience and access to training), therapist-specific variables also influenced their attitudes and practice. In particular, therapists were often fearful of clients’ negative reactions to chairwork. Therapist anxiety has been shown to obstruct the use of therapeutic procedures, particularly those that are evocative and demanding (Harned et al., Reference Harned, Dimeff, Woodcock and Contreras2013). For example, anxious clinicians tend to favour talk-based strategies (e.g. verbal restructuring) over active interventions such as exposure (Levita et al., Reference Levita, Duhne, Girling and Waller2016; Parker and Waller, Reference Parker and Waller2019). Enactive techniques such as chairwork require both creativity and spontaneity (Moreno, Reference Moreno1987), which can challenge clinicians who favour certainty. Training strategies based on dual-processing theory suggest that simulated therapy exercises are effective both in terms of enhancing technical competence and violating therapists’ expectations of harm through direct experience of interventions (Farrell et al., Reference Farrell, Deacon, Dixon and Lickel2013). Accordingly, learning chairwork through self-practice and self-reflection may offer a particularly valuable medium for building therapists’ confidence and skill (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001).
This is the first study to survey therapists’ experiences of chairwork and requires substantial development. Given that the participants were a convenience sample, it is unclear how far these findings generalise. In order to avoid what could be an overly optimistic picture of cognitive behavioural chairwork, replication studies are needed using a larger and more representative sample. The study also utilised a non-standardised survey questionnaire which relied on self-reported practice. Moreover, the construct validity of survey items was assumed, although this is questionable. Observational studies would provide more reliable data regarding CBT therapists’ application and understanding of chairwork. Finally, future studies should establish the reliability and validity of clinicians’ definitions of chairwork. For example, do CBT therapists regard role play as form of chairwork or a distinct therapeutic method?
In summary, our findings provide a baseline understanding of CBT therapists’ attitudes and applications of chairwork. In terms of future research, an extension of this study would be to examine client attitudes and experiences of chairwork in CBT (Bell et al., Reference Bell, Montague, Elander and Gilbert2020). There is also a need to establish the efficacy of cognitive behavioural chairwork and its change mechanisms. The qualitative results also present a variety of hypothesises. For example, to what extent does therapist anxiety affect the use of chairwork, and what are mediators and moderators of this relationship (e.g. fear of clients’ expressed emotion)? Finally, we must not assume that CBT therapists’ limited use of chairwork is ‘bad’ without better understanding for whom these interventions work, with which presenting difficulties, and at what point(s) in treatment.
Acknowledgements
None.
Financial support
None.
Conflicts of interest
The first author of this paper is provided royalties from a related textbook.
Ethical statement
The authors abide by the Ethical Principles of Psychologists and Code of Conduct as set out by the APA.
Data availability
The data are not publicly available due to their containing information which could compromise the privacy of participants.
Key practice points
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(1) Experiential methods are regarded as highly effective in CBT.
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(2) Therapists view chairwork as effective and compatible with CBT, but seldom use it.
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(3) Anxiety and limited training prevent greater use of chairwork, despite its benefits.
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(4) Improved access to training and additional chairwork-related research is needed.
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