Question 1

What kind of preparation is needed to prepare the client for cognitive behavioral chairwork?

Matthew Pugh · Accepted Answer

Chairwork is often best when it is introduced spontaneously and in the context of a good therapeutic alliance. In fact, too much preparation can cause individuals to feel more anxious or ‘second guess’ these methods. An exception to this is when chairwork is used to recreate distressing memories (e.g. historical role-play). This type of chairwork can be very demanding and clients should be able to make an informed decision about making use of it.

Question 2

Can you speak to how chair work in CBT can help in getting an emotional shift...beyond the intellectual?

Matthew Pugh · Accepted Answer

Dual-processing theories such as interacting cognitive subsystems (Teasdale & Barnard, 1993) suggest that heart-level emotional shifts often require interventions which are more evocative and multisensory than ‘standard’ cognitive techniques. Because chairwork is both emotionally-charged and incorporates multiple sensory channels simultaneously (sights, sounds, movement, and bodily feedback), it is well suited to this purpose.

Question 3

Due to the intensity of chairwork, I find that often my clients 'break out' of the process and redirect their dialogue back to me. How do you know when to gently encourage them back vs continue the dialogue with me?

Matthew Pugh · Accepted Answer

While speaking to the therapist can support the process, chairwork is most helpful when it is immersive and evocative. Pushing and holding the client during chairwork is a delicate balance. If speaking to the therapist seems to be detracting from the encounter, clients are encouraged to focus on the dialogue instead. Other signals to re-focus on the chairs include moments where the client makes a poignant or important statement, or if an unanswered question arises (“I still don’t understand why she left me”).

Question 4

Hi Matthew, is it ever okay to facilitate clients to talk to their abuser/perpetrator in chairwork?

Matthew Pugh · Accepted Answer

Chairwork can be an empowering way for individuals to confront abusers and hold them to account. This usually involves the client imagining their abuser in an empty seat (chair one) and expressing their hurt and anger. This might be followed by the client soothing and caring for their past abused self (chair two). However, speaking with an abuser can be highly anxiety-provoking, so therapists must ensure that the client feels safe during this work. Whether or not the client adopts the role of the abuser during chairwork is a matter of clinical judgement and can be counter-therapeutic.

Question 5

Can chairwork be delivered effectively in online therapy?

Matthew Pugh · Accepted Answer

Tele-chairwork is often just as effective as face-to-face chairwork, but may require some adaptations. For example, if extra chairs are not available, the client can be asked to move their chair to different spaces, to stand and speak from different locations, or dialogue using a seat in the therapist’s space. As long as therapists are guided by the underlying principles and processes of chairwork, chairwork is highly compatible with online therapy. Guidance on tele-chairwork can be found in a recent article: https://www.researchgate.net/publication/342425501_Process-based_chairwork_Applications_and_innovations_in_the_time_of_COVID-19).

Question 6

What is cognitive behavioral chairwork?

Matthew Pugh · Accepted Answer

Chairwork refers to a collection of experiential interventions which utilise chairs, their positioning, movement, and dialogue for therapeutic purposes. The aim of cognitive behavioural forms of chairwork is to bring about changes in unhelpful patterns of thought and behaviour.

Question 7

What presenting issues does chairwork interventions best target?

Matthew Pugh · Accepted Answer

Chairwork has many, many applications. Research suggests that cognitive behavioural chairwork can help tackle difficult-to-shift cognitions and negative core beliefs, as well as supporting the development of new behaviours and positive core beliefs. Studies also indicate that other styles of chairwork (e.g. emotion-focused and compassion-focused chairwork) can help address shame, self-criticism, anxiety, trauma, ‘unfinished business’, emotional regulation, distressing voice-hearing, decision making, grief, and many other issues.

Question 8

I have a client who I believe would benefit greatly from chairwork, but the client feels this work is “silly” and therefore hesitant to engage in it; what are some tips on helping the client genuinely engage with chairwork in order for them to gain from the experience?

Matthew Pugh · Accepted Answer

Many clients are initially apprehensive about chairwork. Some of the ways this issue could be addressed include modelling the process of chairwork to correct any misunderstandings; framing chairwork as a behavioural experiment to test out its ‘silliness’; or agreeing a brief enactment (e.g. five minutes or so), after which the client is free to stop or continue depending on how productive this feels.

Question 9

Can chairwork help a client get to their primary emotion of sadness when anger is the emotion being expressed as a protective mechanism? And if so, how?

Matthew Pugh · Accepted Answer

Chairwork offers some creative routes to accessing the sadness and vulnerability which sometimes underlies anger. Examples include introducing a second chair which represents the vulnerability ‘sitting behind’ protective anger; inviting the client to speak as their ‘angry self’ (chair one) followed by their ‘sad self’ (chair two); interviewing the part of the client which is concerned about connecting with sadness; or setting up a dialogue between the client’s protective anger and vulnerability. Primary sadness is often much easier to access once protective anger has been heard, validated, and processed in chairwork.

Question 10

How does cognitive behavioural chairwork help a person express anger in a meaningful/helpful way?

Matthew Pugh · Accepted Answer

Cognitive behavioural chairwork can be used to support helpful expressions of anger in several ways. These include using empty-chair dialogues to ‘vent’ frustrations which are usually suppressed, or to test out fears about expressing one’s anger; using two-chair dialogues to validate, regulate, or instruct oneself when anger arises; and using role-plays to practice expressing anger in constructive ways.

Question 11

What is the best way to introduce chairwork?

Matthew Pugh · Accepted Answer

Chairwork is best introduced as an experiment worth trying out (“I’d like to suggest doing something different today, which will involve speaking from different chairs”). Experience shows that the more confidently therapists introduce chairwork, the more confident clients feel using these methods. Collaboration is central to CBT, and for this reason chairwork is presented as an invitation - not a command.

Question 12

What are some dos and don’ts about chairwork?

Matthew Pugh · Accepted Answer

Do: consider using chairwork if ‘traditional’ cognitive-behavioural methods prove ineffective; set sufficient time to facilitate and reflect on chairwork; support the client during evocative chairwork dialogues; work collaboratively so that the client feels safe and in control; assess the outcome of chairwork (“what have you learnt? what do you take from this experiment?”); practice delivering chairwork to build skill and confidence.

Don’t: force a client to use chairwork; push the client beyond their limits; encourage the client to enact an abuser if this could be counter-therapeutic; give up if chairwork brings about limited change (it often needs repetition); become scripted or copy the way others deliver chairwork – find your own style and be creative.

Question 13

What is the rationale behind implementing chairwork in CBT?

Matthew Pugh · Accepted Answer

‘Traditional’ cognitive techniques such as automatic thought records sometimes bring about limited changes in thought and feeling. An example of this is when individuals experience shifts at an intellectual level (“rationally I know I am a good person”) but not an emotional level (“but deep down I feel bad”). Experiential interventions such as chairwork are particularly helpful in bringing about head-level and heart-level belief change in CBT. Chairwork can also be used as a method of exposure, allowing individuals to confront anxiety-provoking situations through enactment (e.g. rejection or criticised from others) and intense emotions. In terms of behaviour, chairwork is a particularly effective way to develop and rehearse new skills such as assertiveness.

Question 14

How is chairwork in CBT different from chairwork in Schema-Focused Therapy or Gestalt Therapy?

Matthew Pugh · Accepted Answer

There are similarities in how chairwork is used in CBT and schema therapy. For example, both approaches use chairwork to address maladaptive self-beliefs through dramatisations (e.g. historical role-plays) and dialogues (e.g. between a client’s positive and negative self-belief). However, cognitive behavioural chairwork rarely involves working with schema modes. Rather, its focus tends to be discrete cognitions, cognitive processes (e.g. worry, self-criticism, rumination), and behaviour.

Question 15

I am curious about how this approach differs/is similar to chair work in other modalities, e.g. emotion focused therapy (Greenberg et al), gestalt therapy.

Matthew Pugh · Accepted Answer

There are several ‘forms’ of chairwork which are common across psychotherapies. These include dialogues (inviting a client to speak to parts of the self or other individuals held in an empty seat), dramatisations (role-playing scenes from the past, present, or future), depictions (using the space between chairs to represent relationships and attachments), and interviews (questioning the client in the role of another person or part of the self). However, psychotherapies vary as to the aims and foci of chairwork. For example, emotion-focused chairwork seeks to transform emotional experience, while gestalt therapy aims to bring closure to unfinished situations and other internal conflicts. In CBT, the focus of chairwork is problematic cognitions and behaviour. Cognitive behavioural chairwork also tends to be more structured and goal-orientated than the gestalt approach.

Cognitive Behavioral chairwork