1.1 Principles (SIT)

Chairwork is first and foremost grounded in the notion of self-multiplicity: that the self contains a variety of “mindsets,” “modes,” “subpersonalities,” or “I-positions.” Whether these parts of the self represent autonomous subselves (the hard multiplicity view), transient states of mind (the modest multiplicity view), or are purely metaphorical (the soft multiplicity view) is hotly contested. Nonetheless, these parts of the self are capable of meaningful information exchanges. For example, self-criticism describes a conflictual interaction between parts of the self, wherein one part of the self attacks and coerces other parts (Gilbert & Irons, 2005). Finally, parts of the self and their dialogical relationships are believed to play a role in many forms of psychopathology (Dimaggio et al., 2010; Lazarus & Rafaeli, in press). Working directly with parts can, therefore, bring about transformation.

1.2 Processes (SAT)

The principles of chairwork beget three complementary processes when facilitating chairwork. First, relevant parts of the client’s self are placed in different chairs (separation). Next, these parts are brought to life (animation) either through embodiment (the client changes seats and enacts the part, speaking in the first-person) or personification (the client imagines the part is held in an empty chair and relays its statements in the third-person). Finally, these parts are encouraged to converse with one another or the therapist to bring about change (talk).

1.3 Procedures

1.4 Process skills

Process skills describe the “micro-interventions” that support the facilitation of chairwork, many of which derive from psychodrama and gestalt therapy (e.g., Greenberg, 1979; Moreno, 1946). These include “listening in surround” (e.g., identifying and naming parts as they emerge in the client’s speech), proxemics (e.g., collaborative decision-marking regarding how near or far chairs should be placed from one another), imagery (e.g., visualizing salient features of a part before initiating a dialogue with it), and role reversal (e.g., adopting the perspective of a part or person by moving into its chair).

1.5 Evidence base

Such is the plethora of methods that constitute chairwork that conclusions about its overall effectiveness are difficult to make. Nonetheless, studies indicate it has therapeutic value (Elliott et al., 2004; Pugh, 2021a). For example, two-chair dialogues have been shown to ameliorate self-criticism (e.g., van Maarschalkerweerd et al., 2021), indecision (e.g., Clarke & Greenberg, 1986), problematic anger (e.g., Conoley et al., 1983), interpersonal distress (Paivio & Greenberg, 1995), and symptoms associated with childhood trauma (e.g., Paivio et al., 2010). Other studies indicate that dramatizations are an effective way to modify distressing thoughts and beliefs (e.g., de Oliviera et al., 2012) and develop behavioral skills such as assertiveness (Lazarus, 1966). Interview methods have received comparatively less attention but have produced promising results such as increased insight, motivation, self-compassion, and positive relationships with distressing inner voices (Chua et al. 2021; Longden et al., 2022). Finally, studies suggest that interventions using chairwork are not only effective in the context of psychotherapy but also as a stand-alone intervention (e.g., Trachsel et al., 2012).

1.6 Single session chairwork

There has been a growing interest in the use of brief therapeutic interventions, including single-session therapy (SST). SSTs are predicated on the observation that a proportion of individuals want and make good use of single therapeutic appointments (Hymmen et al., 2013). This is not to say that medium- and long-term therapies can be condensed into single meetings or that one appointment is appropriate for all difficulties. Rather, SSTs are sufficient and satisfactory for some individuals seeking help (Hymmen et al., 2013). It follows, then, that various evidence-based therapies have adopted the single-session frameworks as one model of delivery, including systemic therapy (Westwater et al., 2020), cognitive behavioral therapy (Dryden, 2022), and solution-focused therapy (Perkins, 2006). However, experiential approaches to SST are limited.

Research suggests that chairwork provided during one appointment is feasible and effective (Conoley et al., 1983; de Oliveira et al., 2012; Kramer & Pascual-Leone, 2016; Lee & Tratner, 2021; Traschel et al., 2012). Accordingly, a single-session approach to chairwork appears to have merit. Single session chairwork (SSC) is a newly developed SST which aims to provide individuals with a focused experience of chairwork. Alongside typical procedures such as two-chair dialogues and client-therapist dramatizations, SSC incorporates additional structures to maximize informed choice, collaboration, emotional containment, and consolidation of learning (see Pugh, 2021b). Whilst SSC has received positive feedback, the approach has not yet undergone evaluation with a clinical population. As such, it remains unclear whether SSC is suited to a particular context, client group, or presentation.

1.7 Chairwork and the therapeutic alliance

SSC raises interesting questions about the role of the therapeutic alliance in chairwork. The conservative view has been that chairwork is dependent on a robust therapeutic relationship. For this reason, it is sometimes recommended that therapists avoid using chairwork during initial sessions or until an alliance has been established (Elliott & Greenberg, 2021). If they do not, chairwork is likely to unproductive or potentially counter-therapeutic (i.e., distressing, exposing, or destabilizing for the client). This would imply chairwork is not suited for SSTs. Should chairwork be limited to longer-term psychotherapies?

The alternative perspective is that the therapeutic alliance and therapeutic gains are cyclical and reciprocal: that is, positive changes in therapy create a stronger therapeutic alliance, which leads to further improvements as treatment progresses (Tang & DeRubeis, 1999). Moreover, research suggests that client-therapist “agreement” on the goals and tasks of therapy predicts symptom change in structured therapies such as cognitive behavioral therapy (CBT) and so enhance the therapeutic relationship (Brown et al., 2013). In other words, helpful therapeutic tasks not only drive change but also strengthen the alliance. Could this be true of chairwork? Research is yet to provide an answer. However, SSTs that incorporate chairwork (and in which alliance has not been established) may provide some insights.

2.1 Presenting problem and client description

Hana is a White-British female in her late twenties. Preliminary details regarding her current difficulties were collected via an intake form1 which she completed 1 week before the appointment. In her form, Hana described symptoms of social anxiety which made it difficult for her to “speak up” in groups of people and prevented her from being her “true self” during social interactions. She wondered if her anxiety might be related to distressing events in her childhood, such as “going completely blank” during a song recital and feeling “like an outsider” in social situations. She identified her goal for the session as being more talkative when socializing with her partner’s family. Regarding potential directions for the session, Hana wondered if it would be helpful to work with the part(s) of her that felt anxious so she could better understand their “purpose/function” and “figure out what might help to manage these situations better.”

2.2 Case conceptualization

Opportunities for case conceptualization are limited in SSC due to the brevity of appointments and the limited information collected before the session. Nonetheless, Hana’s intake form was reviewed by the therapist to identify relevant “parts” of herself, their interrelations, and how they might be linked to her difficulties. The therapist developed initial codes for these parts based on patterns observed in Hana’s written answers. These codes were then used to develop a preliminary case conceptualization (or “dialogical hypothesis”) which would guide how the session was initially approached. The dialogical hypothesis was also informed by problematic dialogical patterns observed in psychotherapy (e.g., Dimaggio et al., 2004). Archetypal patterns (or “dialogical dysfunctions”) include “monolithic dialogs” where client feels dominated by a part (e.g., the “depressed mode” in depression) or “conflictual dialogs” in which the client feels caught between polarized voices (e.g., indecision about a course of action).

While reviewing Hana’s intake form, the therapist noted that the following parts might be relevant to her difficulties: the “Anxious Child Self,” “Outsider Self,” “Quiet Self,” “True Self,” and “Partner’s Family.” The therapist’s tentative formulation was that Hana’s social anxiety might relate to conflicts between these parts, most notably her “Anxious Child Self”/”Quiet Self,” and her “True Self.” Hana’s session may, therefore, attempt to initiate a resolution of this split via some form of multi-chair dialogue.

The following section outlines the course of Hana’s session, with an emphasis on relational factors that supported the use of chairwork.

2.3 Course of treatment

Dialogical framing, nontechnical terms, and Hana’s feedback helped create a shared understanding of her difficulties while also socializing her to core principles and processes of chairwork (e.g., self-multiplicity and dialogical interactions between parts of the self). When explaining how chairwork might go about resolving Hana’s inner conflict, the therapist shared examples of his own self-multiplicity and demonstrated how chairwork could be used to work these parts (e.g., “I might move my chair over here and I might speak as my demanding side”). Self-disclosure also sought to normalize and de-pathologise self-multiplicity, whilst illustrating the practical steps of chairwork so Hana could make an informed decision about proceeding.

At the end of the interview, Hana separated from her Protector by moving her chair back to its original position (the “center”). After reflecting on what the Protector had shared, the therapist invited Hana to speak from the part that “wants to speak up” (what she called the “Opinionator”). After moving her chair to a new space, the therapist interviewed the Opinionator regarding its history, intentions, and hopes (that Hana would “open the curtains a little bit and test me out”). As discussed earlier, a benefit of speaking as a part (as opposed to speaking about a part) is the unique ‘action-insights’ this provides into the nature of these mindsets (Kellermann, 1992). Embodiment also provides access to feeling states, thoughts, and memories associated with the part, thereby clarifying its nature. This was evident for Hana: she linked the isolation felt by the Opinionator to a memory of childhood rejection, which helped identify a more vulnerable part connected to social anxiety (the “Unwanted Child”).

After returning to the center once again, guided discovery was used to reflect on the parts that had been met so far. While reviewing the dialogical formulation, Hana noted that her Protector had helped maintain her safety but blocked the Opinionator’s desire for expression and connection. In turn, this had compounded Hana’s sense of being “alone and unwanted” (the feelings of her Unwanted Child). Hana also noted that her Protector had sought to avoid attacks from her Inner Critic, which was often triggered when her Opinionator “spoke up.” During these reflections, the therapist supported reflection and integration of these insights. Hana seemed to value this process as it helped her “connect the dots,” such as how her present way of relating to others linked to past interactions.

This collaborative and reflective stance continued when the therapist proposed taking a 10-min break at the mid-point of session so Hana could “process what’s gone on” and “think about where we need to go next.” This would also ensure that Hana’s insights, needs, and preferences continued to guide the session.

Following the break, Hana felt it was important to work with her Unwanted Child. With her consent, the focus of the session then shifted to facilitating a dialog with this part. The therapist adopted a more directive stance at this point to facilitate this conversation: Hana was asked to reorientate her seat and speak to her Unwanted Child as if she were held in a second chair. These prompts appeared to give Hana the containment and direction needed to immerse herself in the task, as well as scaffolding the encounter.

The expression of unmet needs is often transformative during two-chair dialogues, allowing for the provision of care-giving and care-receiving as the client reverses roles (Bell, 2022). As the dialogue progressed, Hana adopted a more parental role towards her Unwanted Child—soothing and comforting this part—which resulted in a shift towards greater self-compassion, acceptance, and integration. At the end of the dialogue, Hana reflected on the insights she had gained: although she “hadn’t felt wanted back then,” it didn’t mean she had to go through her adult life being so inhibited. Instead, she could choose to take her Unwanted Child self with her and care for her.

The final stage of the session involved Hana adopting a “witnessing” position to help her reflect on and process the work she had undertaken: Hana was asked to “metaphorically and literally step back” from the chairs/parts of her self and observe them from a decentered perspective. This involved Hana standing beside her screen as if she was sharing the therapist’s viewpoint (“like we are both looking at the chairs”). To enhance separation from these parts and attenuate her emotional arousal, the therapist began with a brief grounding exercise in which Hana slowed her breath and connected with the qualities of self-witnessing (curiosity, care, and non-judgemental acceptance). Speaking as a witness to the session, Hana then summarized (in the third-person) what should be taken from the meeting and ways she could support herself going forwards (Hana as Witness: “She [Hana] can put her arms around her [the Unwanted Child]… to remember that she has grown up and she’s not still that girl, and that the times have changed”).

2.4 Outcome

Hana completed a feedback form approximately 7 days after the single session. Overall, she was pleased with the outcome of SSC: she rated the appointment as “exceeding expectations” and “fully meeting my goal for the session.” Regarding her broader difficulties with social anxiety, she rated this as ‘fairly resolved’. Hana also completed the session rating scale (SRS), which is a brief and well-researched measure of four dimensions of the therapeutic alliance (respect and understanding; relevance of the goals and topics; client-practitioner fit; overall alliance) (Miller et al., 2003). She rated all four items as “10” (the highest score).