Profile: Dr Matthew Pugh Talks Chairwork In CBT
Matthew Pugh is a clinical psychologist and senior therapist in an NHS eating disorders service. He is also the author of Cognitive Behavioural Chairwork, and is co-founder of Chairwork.co.uk – a chairwork research and training centre. He sat down with Psychology Tools to talk about how his personal experiences have shaped his professional life, what drives his interest in chairwork, and his thoughts on what makes speaking to a piece of furniture so powerful.
The road to CBT and chairwork
What was your route into clinical psychology initially?
Growing up with parents who were doctors played a big role in wanting to join a helping profession. Unfortunately, I struggled with my mental health throughout my teens. I saw a few counsellors and psychologists during that time, some which were helpful and some which were actively unhelpful. I decided to train as a clinical psychologist in the hope these events might help me to help others, and do my part to ensure others had better experiences of therapy than I did.
What kind of clinical roles have you held since qualifying?
My first qualified post was in an NHS eating disorders service, where I’ve continued to work for the last 10 years. I’m also an honorary clinical lecturer with University College London, where I teach and provide supervision. Outside of my NHS work, I run a private practice in Buckinghamshire and co-direct a chairwork training centre with my colleague, Tobyn Bell.
How did you become interested in chairwork and what was it that made you realize how effective it could be as an intervention?
I was introduced to chairwork in 2013 by Scott Kellogg and was blown away its power. In a particularly memorable workshop, a brave therapist agreed to speak with his father using an empty chair. By the end of this conversation, almost everyone in the room was moved to tears, myself included. I was staggered. How could speaking to a piece of furniture be so powerful? From that moment onwards, I was hooked on chairwork. Little did I know that, several years later, I would use the chairs to speak to my own father during emotion-focused therapy training. I wasn’t able to say goodbye to him before he died, so talking with him again brought me a lot of comfort and closure. I’m incredibly grateful to the therapist who helped me have this conversation.
You’ve either had training in, or had experience of many types of therapeutic models (CBT, schema therapy, EFT, CFT )… so why did you write your book about chairwork within a CBT framework?
CBT was my main therapeutic modality throughout training and post-qualification. When I began studying chairwork, I was surprised to find these methods appeared in CBT textbooks fairly often, but they were never described in detail. I knew there was something special about chairwork and I wanted to feel more confident incorporating it into CBT, so I began reviewing the CBT and chairwork literature from top to bottom, to clarify when, how, and why cognitive therapists used these interventions. What started as a small data search has since spiraled into a journey through psychodrama, personal construct therapy, gestalt therapy, voice dialogue, emotion-focused therapy, and other approaches. Seven years later, I’m still on that journey. I hope that sharing what I’ve learned will benefit therapists across orientations, including cognitive therapists.
Here-and-now interactions between parts of the self
Can you explain what chairwork is?
Chairwork represents a collection of experiential interventions which utilize chairs, their positioning, movement, and dialogue. Broadly speaking, the aim of chairwork is to facilitate here-and-now interactions between parts of the self, including internalized representations of other individuals, in order to bring about change. In other words, chairwork invites individuals to speak directly to, rather than about, the issues they bring to therapy. This can be a powerful and sometimes liberating experience.
How does chairwork work and how is it used?
Chairwork rests upon a small number of principles, processes, procedures, and process-skills, which I call the ‘pillars’ of chairwork. The principles of chairwork are that the ‘self’ is composed of numerous parts, selves, or voices, that these parts are capable of meaningful, dialogical exchanges of information, and that these interactions both create and can transform the mind and emotional experience. The processes of chairwork map onto these principles. Chairwork begins with a decision about which parts of the client we want to work with. Next, we concretize and bring these parts to life through personification or embodiment by the client or therapist, and finally, we facilitate interactions with these self-parts. How therapists go about facilitating these interactions depends upon their use of process-related facilitation skills, such as ‘doubling’ for the client.
In terms of its applications, chairwork tends to take the form of specific ‘procedures’. Imagine we’re working with a self-critical client. We could ask this individual to imagine that an empty seat represents their inner critic and to move it somewhere in the room which captures its significance and their relationship with it. This is called a ‘depiction’ insofar as the chairs are used to map out the client’s internal world. Next, we could ask the client to change seats and speak as their inner critic, so that we can ask it questions like, “where do you come from?” and “what are you trying to achieve?” This is an ‘interview’ style of chairwork and can be helpful to explore the functions of self-parts. A two-chair ‘dialogue’ might then follow, in which the client switches between two chairs, speaking as and responding to their inner critic, in order to resolve this internal conflict. During this enactment, it might become apparent that the client’s self-criticism stems from painful childhood experiences. We might ask the client to ‘disclose’ these experiences in a second chair to explore and help concretize the idea that these traumatic events are important, but do not define the self. With their consent, we might then dramatize one of these memories through role-play, so that the client has an opportunity to confront their critical parent and soothe their child self. Finally, chairwork might end with the client standing up and ‘witnessing’ the work they have done. This type of vertical chairwork is similar to decentering in that it helps individuals step back, defuse, and process events from a self-distanced perspective.
Are there times you’ve used chairwork in your personal life?
I use it quite a lot. My daughter was born with severe gastric problems, meaning that she slept very little and cried almost continuously. Those first few months were far from the idealized parenting scenes I’d expected! On a particularly bad night, I imagined myself taking part in an enactment Zerka Moreno called the ‘psychodramatic baby’. I visualized two chairs in front of me: one holding my daughter and another holding the quiet, contented baby I’d imagined having. I began by describing this idealized baby out loud. “You are the perfect baby I wanted. You don’t cry. You’re always smiling”, and so on. Then a funny thing happened. I realized that I didn’t want to be talking to this imaginary baby anymore – what I wanted was to be holding my own daughter. Something fundamental had shifted inside of me. I’d let go of my fantasy of parenthood and connected with my daughter in an even deeper way.
Which types of scenario does chairwork suit best?
Chairwork can be used in almost any clinical scenario, but is particularly helpful when conflicts exist between parts of the self. This might include conflicts between a part which wants to stop a behavior and a part which doesn’t, a part which is highly critical and a part which feels criticized, unfinished business between the self and another person, and so on. Bringing these polarized self-parts to life and allowing them to speak to one another can help individuals understand the two sides of the conflict better and, hopefully, resolve it. Chairwork can also be a very helpful way to strengthen new parts of the self, using actions and the body. My colleague and good friend, Tobyn Bell, is doing fascinating research in this area, exploring how chairwork can help individuals develop their ‘compassionate self’.
Can you give an example of a goal you might work towards using chairwork within CBT?
Chairwork can be a really helpful way to strengthen clients’ belief in the healthy cognitions they’ve developed through cognitive restructuring. Let’s say a client has completed a thought record but is only 60% convinced of the accuracy of their new, balanced thought. We could invite that client to participate in a two-chair dialogue between the negative automatic thought and the healthy thought. As the client switches between the seats, responding and counter-responding to their negative thought, conviction in the new cognition will hopefully increase. Alternatively, the therapist might speak as the negative thought and support the client in presenting compelling counter-arguments. My experience has been that when individuals defend their healthy thoughts in this way, they become stronger and more memorable. Afterwards, clients will often say, “The thought record we did was helpful, but the chair-thing really stuck out in my mind.”
You have talked about how experiential interventions like chairwork can be especially effective in bringing about head-level and heart-level belief change. Can you tell us about why you think this is the case?
Theories like Interacting Cognitive Subsystems and Cognitive-Experiential Theory suggest that head-level beliefs and heart-level beliefs are linked to different information-processing systems. Talk-based interventions like guided discovery are good at bringing head-level change through analytic processing, but not so good at bringing about heart-level change. It’s as if this second system speaks a different, experiential language. Both of these theories converge on the idea that multisensory experiences involving emotion, the body, and imagery are often the most effective way to access and communicate with this heart-level system. Chairwork seems to tick all of these boxes. Other cognitive theories suggest that therapy is not so much about changing beliefs, but developing new, more helpful, and memorable mental representations. One thing we can be fairly sure about is that chairwork is a very memorable way of working.
Given the current challenges we’re all experiencing, can chairwork be delivered effectively online?
Absolutely. I’ve found chairwork works just as well online, although it may need a little adaptation. We’re just published a paper in which experts shared their experiences of tele-chairwork and most agreed: remote chairwork is often just as effective as face-to-face chairwork. Personally, I’ve found it helpful to revert back to the principles and processes of chairwork when working online. At its most basic, chairwork involves just three steps: choosing a part of the client to work with, bringing it to life, and then initiating an interaction with it. If therapists apply these ideas flexibly and creatively, online chairwork becomes much less daunting.
In your experience as a supervisor and trainer, what are some of the mistakes or difficulties that can arise when novice therapists work with clients using chairwork interventions?
A question that often comes up during our workshops is, “How do I introduce chairwork into therapy sessions?” There can be a temptation to present chairwork in a detailed or cautious way, but this risks the client overthinking or disqualifying the idea prematurely. It’s often more helpful to introduce chairwork confidently and concisely: “I’d like to try this thing. It sounds strange but I think it could help. Shall we give it a go? I’ll help you do it.” That said, I feel it’s important that therapists present chairwork as an invitation, not an instruction. Clients have every right to decline these methods, which itself provides important information for the therapist. A second question which often comes up is “Can I and should I use chairwork with such and such an issue?” My answer is almost always “Yes!” Chairwork was born in psychodrama, which views spontaneity and creativity as important therapeutic resources. So, be creative! And if you need some guidance or inspiration, revert to the principles, processes, and procedures of chairwork to help steer you.
Are there any areas of working with chairs that clients find harder to grasp?
Most clients ‘get’ chairwork pretty quickly, once the initial weirdness passes and the therapist has given them a little direction. That said, there are a couple of missteps that sometimes occur. The first is when the client starts to disengage from the dialogue, either by speaking to the therapist or slipping out of role. It’s important that the therapist guides the client back to process if they start to drift: “Rather than saying that to me, try saying it to the critical side, over there”. Self-consciousness can be another obstacle. Clients sometimes experience chairwork as a performance for the therapist or worry about getting it wrong. Either way, this limits their immersion in the process. Doubling can be really useful when this happens. By offering empathically-attuned first-person statements to repeat aloud, the therapist helps keep the client emotionally involved and anchored in the dialogue.
Over the time that you’ve been interested in this area, what about your approach has changed the most?
I was very procedurally-focused when I started using chairwork. “For this particular difficulty, I should use this particular enactment, with this many chairs, delivered in this particular way.” This helped me learn chairwork, but over time I’ve become more interested in the dialogical process. “What self-parts play a role in this issue? What’s the nature of their relationship? How can I bring this to life using chairs?” Moving away from procedures and towards processes has helped me use chairwork in a more flexible and creative way. I’ve also come to appreciate the unique contribution which each therapeutic approach brings to chairwork. Psychodramatic chairwork highlights the value of spontaneity and doubling when using chairs. Emotion-focused chairwork shows the importance of tracking the client’s emotional experience during enactments and following their pain. Schema therapy beautifully illustrates how therapists can involve themselves in a dialogue, while compassion-focused therapy demonstrates the importance of embodiment when strengthening new self-parts.
Sharing ideas with others
Sadly, a majority of clinical psychologists never publish. What motivates you to carry out and publish research?
It is a shame that so few psychologists write. Therapists on the ground are often in the best position to develop ideas and test interventions given their clinical experience. I think the main obstacle is that so few clinical posts offer protected time for research. When I began writing, I did this almost entirely outside of my 9-5 job, which was often exhausting. What motivates me? I think there’s a part of me which gets really excited about sharing ideas with other people. I also feel that if I’m going to promote chairwork, I have an obligation to investigate it and contribute to its research-base. Being part of a network of therapists who love chairwork also helps. We keep each other excited about the work we’re doing – which is important when you’re working on your sixth draft or a paper gets rejected!
What role does research play in what you do?
I’m pleased it’s becoming an increasingly big role. I’ve supervised trainee clinical psychologists pursuing chairwork-related projects for a few years and love it. It’s great introducing new therapists to chairwork and seeing them grow in skill and confidence. So, if you’re a therapist or a trainee and have an interest in researching chairwork, please get in touch with us! Securing grants has also meant that I now have more dedicated time for writing about chairwork. There are some other things in the pipeline which are too early to talk about, but I’m confident there will be lots more chairwork-related studies published by our research group over the next few years.
Research-wise, what’s the most interesting thing you’re working on at the moment?
I’m involved in a few different projects which are exploring how chairwork can be used to treat eating disorders. One particular study is exploring whether talking with the internal eating disorder ‘voice’ using the voice dialogue method is helpful. Talking with voices has shown a lot of promise amongst individuals with psychosis, so it’s really exciting to bring this approach into another therapeutic setting. I’ve also been developing and piloting a single-session approach to chairwork for some time, which aims to give individuals a safe and focused experience of chairwork. The feedback so far has been positive.
What is it that you’re most interested in finding out? (e.g. whether an intervention works, the mechanism by which a problem works …)
Where to start! Researchers like Leslie Greenberg and Robert Elliott have done an amazing job of establishing not only the effectiveness of emotion-focused chairwork, but also clarifying how it brings about change. We desperately need more task analytic research like this in the other therapies, like schema therapy and CBT. I’m also interested in establishing whether there are common factors in chairwork. Do therapists across orientations agree on any shared mechanisms of action underlying chairwork, and do these hold up in experimental conditions? We also need more research exploring the micro-processes of chairwork. For example, a recent study by Irismar Reis de Oliveira and colleagues suggested that chairwork is more effective when clients enact parts of the self in different chairs, rather than staying in the same chair. This raises a question about whether movement and embodiment make a unique contribution to the chairwork. Perhaps this is what distinguishes chairwork from other experiential interventions like imagery rescripting. There’s a lot to investigate!
Finally, where can readers learn more about chairwork?
Our website (www.chairwork.co.uk) has a library of chairwork training webinars and free written guides which are available for download. Tobyn and I also provide online and in-house chairwork training workshops throughout the year on topics including general introductions to chairwork, cognitive behavioral chairwork, compassion focused chairwork, using chairwork in clinical supervision, and many others. I’ve written a book on cognitive behavioral chairwork for the Routledge’s ‘Distinctive Features’ series, which also includes chapters on using chairwork in other approaches including compassion focused therapy, schema therapy, motivational interviewing, and positive psychotherapy.