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Journal of Contemporary Psychotherapy, Vol. 34, No.

2, Summer 2004 ( C 2004)

Emotion-Focused Therapy: An Interview with Leslie Greenberg


Denise M. Sloan

Over the past 30 years Leslie Greenberg has developed and refined the EmotionFocused Therapy (EFT) approach. This therapy model stands apart from other, humanistic-based approaches in its focus on empiricism. In addition, EFT is one of the few therapy models that is truly integrative in nature, combining clientcentered, gestalt, and cognitive principles. This paper includes a recent interview with Greenberg in which he describes the development of EFT and his views regardingfuturedirectionsofEFT,aswellashisviewsonthefieldofpsychotherapy more generally.
KEY WORDS: psychotherapy; emotion; experiential; humanistic; integrative.

Leslie Greenberg was born and raised in Johannesburg South Africa and attended high school with another well-known clinical psychologist, G. Terence Wilson. Interestingly, Greenberg didnt originally pursue a career in psychology. Instead, he obtained a masters degree in engineering. After working in the engineering field for several years Greenberg realized that his work in the engineering field left him desiring greater human contact. Fortunately for the field of psychology, Greenberg decided to pursue training in clinical psychology. He obtained his Ph.D. in psychology in 1975 and became a faculty member of the Department of Counseling Psychology at University of British Columbia in 1975. He remained in that position until the mid 1980s when he accepted a faculty position in the Department of Psychology at York University where he remains today. Early on in his career Greenberg devoted considerable effort to become informed in a variety of therapy approaches. As a consequence Greenberg pursued training with a variety of leaders in the psychotherapy field, such as Rogers, Pascual-Leone, and Minuchin. These diverse psychotherapy training experiences

106 Address correspondence to Denise M. Sloan, Department of Psychology Temple University, Philadelphia, Pennsylvania 19122; e-mail: dsloan@temple.edu. 105

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ultimately culminated in Greenbergs development of EFT, which is truly an integrativetherapyapproach.WhatsetsEFTapartfrommanyotherintegrativetherapy approaches is its emphasis on empirical support. Throughout the development of EFT Greenberg has attempted to demonstrate the efficacy of EFT and has taken on the difficult task of attempting to identify the change processes in psychotherapy. Demonstrating his dedication as a clinical scientist, Greenberg has published over 100 journal articles. He has also written several books on the topics of EFT, empathy, and change processes in psychotherapy. In addition, Greenberg has served as President of the Society for Psychotherapy Research and has served on a number of journal editorial boards including, Journal of Consulting and Clinical Psychology, Journal of Psychotherapy Integration , and Journal of Marriage and Family Therapy. Has also been the recipient of several large grants from both Canadian and American funding agencies. In this interview Greenberg describes how he came to develop EFT, the core features of the model, and his predictions for the future of EFT. Greenberg also describes his views regarding the psychotherapy field more generally. DS (Denise Sloan): Could you briefly describe emotion-focused therapy (EFT)? LG (Leslie Greenberg): Basically EFT is based on two fundamental ideas. Empathic attunement to affect is very important so that within an understanding relationship being attuned to someone elses feelings is very important in helping to build affect regulation. So within the context of an empathically attuned affect regulating relationship one pays attention to particular kinds of processing difficulties that people have. Then you try to do different things at different times to facilitate different kinds of emotion processes. So everything is saying that its important to pay attention to emotion but that there is both a relational form of helping regulate affect through empathy but then you are also engaging in specific differential interventions. Doing different things at different times. You can either be paying attention to the moment by moment processes by asking someone to pay attention to whats going on inside their bodythis is making a specific moment by moment intervention. Or by asking someone to imagine somebody or talk to somebody youre trying to facilita te the kind of processing they do within a larger task. There are these larger tasks that we have identified, initially we identified about six or seven types of affectively based problems, like unresolved bad feelings towards a significant other and internal conflict. So weve defined different kinds of problems that are then worked on with a focus on emotion. Thats another form of active intervention. DS: How is EFT distinct from other therapy models? LG: First, EFT is focused on emotion and it sees emotion as the prime mover in human experience so that cognition and behavior are, so to speak, dependent on

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affect. In EFT you are trying to work to change peoples emotions. Many non empirically based therapies do work in different ways with emotion. EFT is also different in that its empirically based. Its effectiveness has been shown and its a systematic way of working with affect. There are other approaches that work with affect but they havent been studied, they are not as systematic and they havent been spelled out and based on observation. DS: In terms of affect driving cognition, what is your view on CBT based approach of cognition or behavior driving therapy. That is, if you act or think in a particular way, you will then feel that way? LG: Right. I see problems with that. I think cognitive therapy is useful as a brief intervention to teach people coping skills. Coping is a laudable thing but coping isnt quite the same of basic restructuring or basic change. To be able to talk to yourself and say, its okay, dont get anxious or think of something more positive like dont worry. I think those things do help people cope and people want to be able to cope better but Im not sure that the coping necessarily leads to change so then you spend the rest of your life coping. What Im trying to do is get to the deeper underlying determinants that I see as affectively based. If you can get a change in that then you no longer have to do the coping because youve actually changed. I do think that practicing t hings in the real world and having success experience will lead you to change. So that sometimes if you cope better and you act in the world and then you have success experience you are then actually getting experiential feedback that will change your deeper structures. In that case, you might get change over the long run with coping but Ive seen too many people who cope and they live by coping but when things get too intense or a crisis occurs the coping skills cant cope and then they collapse. These people need to go through a deeper change process. DS: How many sessions are needed in order for a deeper change process to occur? LG: What we found in our research is that people that come in for therapy for clinical depression, which is what weve studied most, can benefit substantially by 16 sessions. If when they come in they have a capacity to experience, that is, they are able to attend to their own bodily felt experiences and they are able to label them, and at least they experience at this level. However, people that have come in and are very cut off from their emotional experience, that is, they are not able to symbolize their own experience, for these individuals by about the end of 16 sessions they began to look like the people who were successful in treatment who came in with a capacity to experience. So it seems like these people who are not able to be minimally aware of their experience at the beginning were not as successful at the end of therapy. I would say that if we gave these people another 16 sessions that would be about right for them. So it really depends on the person.

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But overall I would say about 16 sessions is a good minimum dose for helping someone with these more active emotionally-focused methods to help get to core issues and begin to deal with them. But people who come into therapy without good emotion skills would need at least 32 sessions. People with more chronic or severe concerns would need longer. DS:32sessionsstillseemslikeashortdurationforchangingthetypesofunderlying structures youre talking about. LG:Yes.Thisisnottotalpersonalityrestructuringeitherbuttheemotionalmethods are very effective or powerful at getting to core issues very rapidly in a deeper way so then its in line with the claim that the therapy gets at co re material. You can make quite a lot of gains in a fairly short period of time. DS: Do clients have homework assignments between sessions? LG: We have begun instituting more and more homework. This is something that hasnt been emphasized much but I think the idea of practice between sessions is really a good one. The kind of homework or practice that we use is often more awareness-type homework. However, we dont rely on the homework to produce the change but more to consolidate things that have happened in sessions already. We dont give homework to go out and try something that the person hasnt done already but if they get a shift in their self critical voice such that it becomes more compassionate we would ask people to pay attention to that and practice being more self-compassionate during the week. But we wouldnt do something like this until it had happened in a session first. So its more practice or consolidation of gains already made. DS: EFT seems to have key elements of other therapy models yet its different in some seemingly critical ways, so Im curious how EFT was developed? LG: Yes. Ive also been talking mostly about the individual therapy but not the couples therapy that is also part of the whole EFT package. I was trained originally as a client-centered therapist and then as a gestalt therapist but I was also worked with Laura Rice who was a student of Carl Rogers so I very much started out as a process researcher as well as being trained in psychotherapy. I was studying tapes of therapy from day one. A lot of EFT was developed through the research focus on what makes people change. The first book Laura Rice and I wrote was called Patterns of Change and we were studying how people change. I then looked at these therapies I was being trained in for what seemed to be the most active change processes. We tried to look at how to measure these processes and so on. At this point I began integrating client centered and gestalt therapy and I was very interested in cognition at the level of cognitive science. I did my minor in cognitive development at that same time I studied with Pascual-Leone, a student of Piaget, and so I was very interested in the processes of cognition and affect. But I wasnt interested in cognitive therapy, which is a very primitive view of cognition. Instead, I was very interested in the role of attention, in Piaget notion of schemes or schema, and

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then in emotion theory. So I was bringing all of that to bear on studying the process of change through the lens of cognition and emotion and how these processes take place. So I integrated all of these things but essentially I was integrating a client-centered relationship with gestalt therapies more active interventions, with a type of cognitive view of how meaning is created in people. And then I was psychodynamically informed as well. I had read a lot of psychodynamic material. I began to study specifically how people resolve intrapsychic conflict within themselves, or in gestalt terms splits, which are more conscious conflicts, and I built my first model of change process. The resolution process looked like a conflict between two people except it was between two voices in one person. I was simultaneously very interested in couples and family therapy so I did training in family therapy with people like Virginia Satir and then Minuchin, and then I went to Palo Alto and studied with people there who used a systemic approach. After that I began to direct my attention at how couples resolved conflicts and we built an emotionally focused couples therapy based on similar sorts of ideas that emotion was very important but now there was interaction as well. So what I did was integrated lots of different things and from my family therapy experienceItooktherapistdirectiveness,fromfamilyworkwherethetherapistwas more structuring and guiding and this all fed back into influencing my approach to individual therapy. From this I came up with the idea of the therapist as an emotion coach- - that what the therapist is actually doing is acting as a facilitative coach where they are helping people be more aware of their feelings, regulate their feelings, transform their feelings, and so on. So EFT is an integration of lots of different strands but at its most fundamental its an integration of client-centered and gestalt within a cognitive-affective science framework. DS: Given the different influences in the development of this therapy model what would you say have been the major changes to the model over time? LG: I guess I would say that I started off with much more of a following rather than leading approach. It was more a mirroring kind of approach with more of a view that there were resources within the individual that they needed help to accessan actualizing tendency within. Its moved to more of a n interpersonal, co-constructive view where what Im doing in the room is contributing something more to the environment. Im not only helping people to access their resources and mirroring what they said but Im also leading, adding something but in a very subtle way, by guiding the process within a clients proximal zone of development, just trying to guide with what could be useful at this time and that its the two of us together that are creating something new. So now not everything is coming from the individual, whom my presence helps to free up, but that theres something actually happening between the two of us, that is, the change process. I think thats one of the important evolutions of the model. I think doing couples therapy and family therapy made me more comfortable with being more active, that is, giving more suggestions without feeling like the therapist is potentially distorting the client or being too intrusive. Weve always

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adopted the approach that the therapist is not the expert on the c lients experience. Its really the client who is the expert so the issue was how do you make a contribution without imposing it on clients or distorting their own experience. Eventually we came up with the idea that we are more process directive not content directive, so we dont tell the client what they are feeling or suggest to them what theyre feeling, but we suggest to them ways that they might use to better connect with or process their own feelings. For example, guiding clients to pay attention to whats going on in their body or to speak to somebody in an empty chair, Im making suggestions that I think will help clients process their emotions in particular ways so Im being quite directive in process but not in content. DS: It seems like empathy is a real core feature in EFT and that a therapist needs to establish empathy first and then build off of that. In a lot of clinical training programs empathy is not something that tends to be part of training. LG: Yes, youre right. I think thats the greatest tragedy. When I was in graduate school I started from day one in training in empathy and that was what my fundamental training was. At York University I run a fourth year counseling course and it has a lab component that is two hours per week and that s all empathy training. I also have graduate students in their first year do their practicum that is based on empathy and empathy training. I really believe empathy is fundamental and the waves of fads in training are amazing to watch. Its one of the great losses because it used to be that empathy was being taught and trained in many programs and now thats just disappeared completely mainly with the dominance of CBT as an empirically-supported treatment. Somehow the emphasis on empathy has just been lost. Rapport is what is talked about in CBT. Rapport is not empathy. DS: I agree. Empathy is really an essential skill for therapist and I doubt anyone could be an effective therapist without having good empathy skills. I also think many people dont appreciate just how difficult it is to learn how to truly listen to clients. LG: Exactly. Empathy is the most critical skill. From the base of empathy you can also understand the tension between following versus leading. Its really crucial to first have these following or listening skills before you get into leading. It took me many years before I started integrating the two. Many students in training and therapists in general want to lead, they want to do something, but the real skill is to listen, to be present and to really hear whats going on. So ideally I would like to have students do two years of basic empathy training and just be in that listening mode before they begin to do more active interventions. Its very difficult to listen really clearly and then to listen to affect. Listening to emotion is very important.

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DS: Clearly the therapist ability to listen and listen to affect is critical in the EFT model. Given that, do you think its important for students in training to be in therapy themselves? LG: I think its very beneficial, particularly when working with emotions. Its an a-rational process so you cant just teach people rationally how to work with emotions without them actually experiencing the emotions themselves. To tell people that avoidance of emotions is not good and that experiencing pain is useful you have to really experience that facing your own pain has been useful for you, as the therapist, to believe it. There are certainly a lot of rational reasons for thinking experiencing pain would not be helpful. I think experiential learning is important. Nowwhetherthatsthroughpersonaltherapyorsomeformoftrainingthatinvolves experiential aspects I think is very important. I do think that to be a good therapist, personal therapy is probably highly beneficial. DS: One thing that Ive noticed in supervising beginning therapist is that they often collude with the client in avoidance of negative emotions. The beginning therapist seems to not want to make the client feel bad and doesnt seem to appreciate the importance of the client experiencing negative emotions in therapy. LG: Exactly. I do find that with my students that those who have been in therapy haveadeeperappreciationandalsotheyarenotdoingthatsortofthingofcolluding or trying to help the person feel good and stay away from difficult things. DS: If a student didnt want to go to therapy, for whatever reason they had, what would you recommend to them in place of personal therapy? LG: Thats an interesting question. Well, in my book, Emotion Coaching, I have a number of experiential learning exercising that people could do on their own. Im not a great fan of self-help books but there are certain books that propose how you can work on this for yourself with awareness training. Things like mediation and personal reflection kinds of experiences are useful. One doesnt need to be in therapy in order to increase awareness. So there are other ways to accomplishing this through personal relationships, focusing, self-reflection, etcetera but it is a matter of always working on oneself to always be more aware. DS: Do you think theres an ideal type of client for EFT? LG:Theidealclientissomeonewhoisalreadyabletosymbolizetheirowninternal experience so that they take very readily to this process. But clients who probably benefit greatly are those who some would call alexithymic, who dont have the ability to put words on their emotions. These individuals could benefit a lot from learning this kind of process but theyre not the ideal client. Basically, EFT applies to people who are good for therapy in general and that means that they are not too hostile, avoidant, and dont have severe personality issues, such

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as borderline personality and self-harming behaviors. These individuals are not the ideal clients for really any type of therapy. DS: Given that, what would you suggest for someone who is highly avoidant of emotions? LG: Ive been quite impressed with aspects of the dialectical -behavior therapy approach for people with severe problems. I think the idea of an intense psychoeducational program, where you put people in a classroom and you teach them about the importance of facing emotions and they are given homework exercises. At the same time the client is in therapy where what they are learning in the classroom is being put into practice in a more intense manner in a validating relationship. I think the problem is that if you dont have the educative piece you spend a lot of time on the front end of therapy trying to educate clients and that changes the nature of the relationship between the client and the therapist. A therapist cant really be empathic because they have to teach and kind of convince and persuade. So if it is broken into two components that run in parallel that would be my suggestion for working with more avoidant clients. For example, people with more psychosomatic disorders are often quite avoidant and I think you need to teach them on the one hand, but then you need a really empathic, nurturing relationship to help them do the work and do it with another person. If you just do the homework outside the context of a relationship this does not recognize as important the role of the empathic relationship in helping us deal with our own affects. Its not just an individual skill, its actually a relational phenomenon-the dyadic regulation of affect. DS: I asked you about how you thought EFT has changed over the years, where do you see the EFT model going? LG: Well, first let me go back for one moment to say something about how EFT has changed. The biggest change has been its explicit focus on affect. EFT didnt start with its focus being explicitly on emotion. So thats been one of the big changes, to bemoreandmoreclearonitsfocusonemotion.IntermsofwherewillEFTgo,well, what I think would be important to do is expand its empirical evaluation in relation to other populations. Weve mainly worked with depression and interpersonally based problems but working with anxiety and eating disorders would be good populations to expand EFT to. Also, moving into more preventive domains of developing emotional awareness training modules for use with adolescences and young adults. This training would have to be done at an experiential level, but the goal would basically be helping people become more emotionally intelligent. Not in the global sense of do you have intelligence but how do you actually use your emotion intelligently. Enhancing peoples skills and abilities in emotion awareness, utilization and transformation. So moving into preventive domains will be important. In terms of the couples therapy, I think theres room for more development theoretically. Weve dealt a lot with affiliation and attachment but not a lot with power, definition of reality and autonomy issues.

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In the circumplex model both affiliation and autonomy are important. Weve sort of dealt with only a one dimension of affiliation but Im very interesting in the affect related to power, dominance, and autonomy and thinking about how to work with people in relationships dealing with these more autonomy related emotions. DS: Theres seems to be a lot of emphasis on manualized treatments, particularly ones that are empirically-supported. Whats your view of manualized treatments? LG: Actually I think the phase of manuals is now dying. The move has been that way and funding has required it but I think there are mounting criticisms on the deficiencies of manualization, so I think the romance with manuals is about to be finished. We were sort of in a position of writing some type of manual but I dont think you can manualize a complex interaction. I think manualization is easier in CBT approaches, which are more much psychoeducational, dydactic and much more explicit. So you can manualize things that are less interactive and more dydactic. However, I think there is some benefit to manuals because it forces one to specify what one does. I also think you could think about first generation manuals but were now probably onto third generation manuals, which are the manuals that are attempting to get more flexible and more complex. I think specification of what the therapist does or tries to do is a good thing but I thing that overly rigid manualization doesnt really work. I do think the efforts to continue to specify what the therapists do and write some sort of complex flexible manual is a good thing and its generating fourth and fifth generation manuals that are more flexible. That is important. For example, weve developed a manual that is more marker guided so it doesnt state do this rather it states if this, then this. If a client is in a particular state, then this type of intervention would be most appropriate. So this is the kind of thing that gives you flexibility. DS: On a broader topic, how do you envision the field of psychotherapy in the future? LG: Ive never been much of a prognosticator. I say moving toward integration. This is a hope but I think a prediction as well. Eventually I think we will integrate but more immediately I think we are on the cusp of moving toward an ABC therapy, which is an affective behavioral cognitive therapy and integrating these three elements. But I think that still doesnt do enough justice to the psychoanalytic and motivational components, which are so complex they are very difficult to specify and manualize. But eventually Ido see the field moving to much greater integration and then that would be a biological, affective, behavioral, cognitive, motivation, interactional, social kind of integration. My hope would be that eventually students would come into programs and they wouldnt be trained in different therapies but instead they would train in how to work with affect, cognition, behavior, and interaction. They wouldnt be taught

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cognitive therapy, object relations therapy. There wouldnt be schools. Instead, there would be processes being taught. DS: Do you see that being far into the future? LG: Yes, I dont think were there yet. DS: How do you think managed care has affected psychotherapy? LG: Well in Canada we dont have managed care but I think its been the wo rst blow to therapy thats occurred in the short time therapy has been around because its only been around 50 or 60 years. I have a wonderful anecdote; it is a Canadian one. A hospital administrator who is an M.B.A. came in and took over the running of the hospital and he called the head of psychology and said, I see that the average time of contact between patient and doctor in the hospital is 8 minutes but in psychology its one hour. Could you reduce it to 8 minutes? This highlights the administrator perspective over the function of what therapists are doing. So managed care is just how to be quicker, more efficient, more effective without any attention to what it is that is being done. Managed care has favored brief interventions that are highly specified and I think it has damaged the development of psychotherapy quite severely. DS: What do you think about prescription privileges for psychologists? LG: At first I was quite in favor of them and I saw the conflict as a power fight between psychology and psychiatry. However, after speaking to some friends of mine, most of whom are psychiatrists, I now think that maybe getting prescription privileges for psychologists would produce more of a headache than it is really worth. I think its not such a desirable thing to get into. I think it changes the role of the psychologist. I was of the opinion that its a fairly simple process to give prescriptions but if you have to start getting into the full range of complexities in order to rule out all kinds of medical factors and so on it just detracts from doing your central psychological interventions, so Im not so in favor of it. Its not something I would push for. DS: What recommendations would you give to beginning psychotherapists? LG: For people really interested in psychotherapy I dont think the academic establishment is the best way of getting experience. I do think having a good theoretical background is good but this is sort of the broader question of the split between research and practice, and the two are not always so close. For a student I think getting training in empathy and getting supervised clinical experience are the two most important things in training to be a psychotherapist. I would emphasize getting lots of good supervision. I still think that the best form of training is through supervision. Unfortunately, especially in the CBTtype programs, I think studentsdontgetenoughhandsonexperiencewithrealclientswhoarecomplex. Students need supervision beyond doing manual guided treatments, applied to

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all kinds of cases to deal with a full complexity of things. So I think its how to get training thats doing real psychotherapy and good supervision and for students to seek that out the best they can. DS:IagreewithyouthatmanyPh.D.clinicaltrainingprogramsemphasizeresearch at the expense of clinical training. Do you think that this emphasis has changed the type of people applying to Ph.D. clinical programs? LG: Yes. It certainly changes people who pursue it into being that kind of person, with a research focus. The European model is actually a lot better. In Europe they are looking at creating standards for the whole of Europe. Basically their program for psychotherapy is that you get the M.A. degree and then you do two to three years of specialized training in psychotherapy. A Ph.D. is a research degree but not a practice degree. I think we have this extreme confounding in that you need a Ph.D. to be a registered psychologist, and you need to be a registered psychologist to practice. What were really tr ained to do is research and not practice. I think theres a problem in that people that are more interested in practice probably do seek other ways of training, so they do Psy.D. programs and so on. DS: Or they state that they are interested in pursuing research to gain admittance to Ph.D. clinical programs but what they really desire is to be a clinician. LG: Exactly. The Psy.D. program was an attempted solution to this problem but I dont think it solved it, although I dont know that much about Psy.D. programs because we dont have them in Canada. Ideally you wouldnt need a Ph.D. in order to be a registered practitioner and you would have some other form of real training that was appropriate to practice and then a Ph.D. would truly be a research degree. I dont see that happening but thats how it is in Europe and its actually a better model. DS: Ive asked you a lot of questions and Im wondering if theres anything you feel would be important to add. LG: Well, related to this last topic, I do think theres a human encounter in therapy and the human element thats very undervalued and underemphasized in a Ph.D.type training environment. Ultimately, therapy is an encounter between two people and its a very personal experience. I think therapy transcends scientific study or some of the elements transcend scientific study,and thenits not valued sufficiently or paid sufficient attention. I believe in the scientific, investigative component but its how to get a balance between both the human, interpersonal perspective and the scientific, investigative perspective and to value them both. Whereas now its more valuing of the scientific, objective perspective and devaluation of the more human helping perspective and this is unfortunate. It would be best to integrate these two perspectives with respect for both.

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REFERENCES
Greenberg, L. S. (in press). Emotion coaching. Washington, DC: American Psychological Association Press. Greenberg, L. S. (2001). Emotion-focused therapy: Coaching clients to work through their feelings. Washington, DC: American Psychological Association Press. Greenberg, L. S., & Johnson, S. (1988). Emotionally focused couples therapy. New York: Guilford Press. Greenberg, L. S., & Paivio, S. (1997). Working with emotion in psychotherapy. New York: Guilford Press. Greenberg, L. S., Rice, L., & Elliott, R. (1993). The moment by moment process: Facilitating emotional change. New York: Guilford Press. Horvath, A., & Greenberg, L. S. (Eds.). (1994). The working alliance: Theory, research and practice. New York: Wiley. Rice, L., & Greenberg, L. S. (Eds.). (1984). Patterns of change: An intensive analysis of psychotherapeutic process. New York: Guilford Press.