Matthew Pugh

Central and North West London NHS Foundation Trust · Vincent Square Eating Disorders Service

Background Many individuals perceive Anorexia Nervosa (AN) as a part of their personal identity. Externalisation of the problem is a practice that is often taken up within NICE recommended treatments for AN. Dominant understandings of externalisation are that this practice involves making the “problem” a separate entity, external to the individual....

Objective To synthesise young person and family member perspectives on processes of change in family therapy for anorexia nervosa (AN), including systemic family therapy and manualised family-based treatments, to obtain an understanding of what helps and hinders positive change. Method A systematic search of the literature was conducted to identif...

Although prevalent among those given a diagnosis of anorexia nervosa (AN), the internal anorexic voice (AV) is little understood. This study aimed to explore the AV’s role in the development and maintenance of AN from a new perspective – that of the AV itself. Nine women with a diagnosis of AN participated. Data was collected via dialogical enquiry...

Objective: To synthesise young person and family member perspectives on processes of change in family therapy for anorexia nervosa (AN), including systemic family therapy and manualised family-based treatment, to obtain an understanding of what helps and hinders positive change. Method: A systematic search of the literature was conducted to identif...

Background: Many individuals perceive anorexia nervosa (AN) as a part of their personal identity. Externalisation involves making the “problem” a separate entity, external to the individual. It is an attitude taken by the client and family, stimulated by the therapist to build engagement with treatment and supportive relationships around the indivi...

Voice hearing experiences are commonly reported by patients with anorexia nervosa (AN) and are associated with negative outcomes. The “eating disorder voice” (EDV) can be understood within relational frameworks. Relating therapy (RT) has offered encouraging outcomes when targeted at voice hearing experiences transdiagnostically but has not been eva...

Chairwork is a central component in Compassion Focused Therapy (CFT). Despite its importance, there has been no prior research on the relational factors underpinning the application of chairwork in CFT. There is also a general paucity of research on the role of the therapeutic relationship in chairwork across modalities. This paper analyses data fr...

"Chairwork" is a collection of experiential methods that utilize movement between chairs and dialogue with parts of the self to bring about change. Because of their emotionally intense nature, therapists often assume that a robust therapeutic relationship is a prerequisite for these tasks. However, it could be said that chairwork also supports the...

Single session therapy (SST) is an increasingly popular approach to mental health treatment that aims to address clients' presenting difficulties in a single appointment. However, experiential approaches to SST are limited. In this paper I describe the theory and practice of "chairwork"-an integrative, action-focused method of intervention centred...

The majority of psychotherapeutic approaches work on the basis that addressing what is “wrong” with individuals will facilitate recovery. Positive therapies adopt a different approach, demonstrating that adaptive change can be achieved by addressing well-being and what is “right”. Unfortunately, research indicates the effectiveness of positive psyc...

A proportion of individuals given an eating disorder diagnosis describe the experience of an eating disorder ‘voice’ (EDV). However, methods for working with this experience are currently lacking. Voice Dialogue (Stone & Stone, 1989) involves direct communication between a facilitator and parts of the self to increase awareness, understanding, and...

Chairwork refers to a collection of experiential interventions which utilise chairs, their positioning, movement, and dialogue to facilitate therapeutic change. Chair-based methods are used in several models of psychotherapy, including cognitive behavioural therapy (CBT). However, little is known about cognitive behavioural therapists’ use and atti...

Aplicación de la terapia centrada en las emociones para trabajar con la "voz anoréxica" dentro de la anorexia nerviosa: una breve intervención Los tratamientos existentes para la anorexia nerviosa (AN) han producido resultados insatisfactorios. La investigación sugiere que muchas personas con AN experimentan una "voz" interna que esta relacionada c...

Objective: Recent years have seen a significant and rapid increase in the provision of tele-therapies. Chairwork methods such as empty-chair dialogues and role-play represent a “common” category of therapeutic interventions which are utilized in many psychotherapeutic approaches. However, guidelines for facilitating chairwork in tele-therapy are cu...

[Published in BPS Psychotherapy Section Review (2020), 65, 12-23]. Many individuals with eating disorders make reference to an internal eating disorder ‘voice’ or ‘self’ (EDV/S): a phenomenon which is poorly understood. This paper reviews conceptual and empirical literature relating to the EDV/S. Criticisms and controversies surrounding such experi...

Recent years have seen the emergence of process-based therapies which seek to target evidenced-based psychological processes through the application of evidence-based procedures. Chairwork represents an increasingly popular collection of experiential methods which utilise chairs, their positioning, movement, and dialogue to bring about change. In a...

Action-based methods such as behavioural experiments, role-play and (by extension) ‘chairwork’ are powerful techniques recommended in core supervisory texts for cognitive behavioural therapy (CBT). Despite this, experiential methods are seldom used by supervisors, suggesting that supervision often drifts from a ‘doing process’ to a ‘talking process...

The Dialogical Interview Schedule for Eating Disorders (DIS-ED) is a semi-structured approach to dialoguing with the internal eating disorder ‘voice’ or eating disorder ‘self’ (EDV/S). The DIS-ED is inspired by a number of approaches, principally the Voice Dialogue method (Stone & Stone, 1988), as well as Psychodrama (Moreno, 1987), Ego State Ther...

Objective The coronavirus pandemic has led to a dramatically different way of working for many therapists working with eating disorders, where telehealth has suddenly become the norm. However, many clinicians feel ill equipped to deliver therapy via telehealth, while adhering to evidence‐based interventions. This article draws together clinician ex...

Coaching practice is dominated by discussion. This is at odds with theories of cognition and adult learning which emphasise experiential processes in stimulating beneficial changes in thought, feeling, and behaviour. In this practice-focused article, we make the case for an integrative and experiential approach to coaching which is informed by dial...

Research indicates that good quality supervision, like good quality ST, should involve the ‘head’ (case discussion), ‘heart’ (experiential processes), and ‘hands’ (doing). Action-experiential supervisory methods refer to a collection of active procedures involving simulated interactions with other individuals (e.g. one’s clients), parts of the self...

Reappraisal strategies such as ‘thought challenging’ and ‘cost-benefits analysis’ are a hallmark of cognitive therapy, but sometimes fail to bring about lasting changes in the cognitive-affective structures underlying psychopathology. Modern theories of information processing suggest that experiential, action-based interventions such as chairwork m...

Schema therapy integrates techniques from cognitive, behavioural, gestalt, and psychodynamic approaches to treat complex and treatment-resistant psychological difficulties. Experiential interventions such as imagery rescripting and chairwork are amongst the most effective methods for bringing about schema-level change and have been centralised in s...

Ambivalence and impoverished motivation to change are common obstacles in schema therapy for eating disorders (ST-ED). Drawing upon theories of cognition and emotion, this chapter describes a multi-modal approach to conceptualising and resolving ambivalence in schema therapy (ST). The chapter begins by discussing the nature of ambivalence in eating...

Cognitive Behavioural Chairwork: Distinctive Features provides a practical, accessible, and concise introduction to both the theory and practice of chairwork - one of the most powerful and exciting methods of intervention in cognitive behavioural therapy (CBT) - and is the first book to synthesise its many applications in CBT and allied therapies....

Ambivalence about change is a common obstacle in psychotherapy. Motivational interviewing (MI) is a popular person-centred approach which aims to elicit and reinforce intrinsic motivation to change, but also has been associated with theoretical and empirical limitations. Drawing upon theories of cognition and emotion, this paper provides an integra...

Many individuals diagnosed with eating disorders describe their disorder as being represented by an internal 'voice'. In line with cognitive models of voice-hearing, previous research has identified associations between voice appraisals and eating psychopathology in anorexia nervosa. Whether these findings generalise to other eating disorder subtyp...

Individuals with anorexia nervosa often describe experiencing an internal “voice” of their disorder, which previous research has associated with multiple dimensions of eating pathology. This pilot study examined whether eating disorder measures use invoice characteristics at the outset of outpatient therapy predicted changes in disordered eating ov...

A chair can be many things, writes Matt Pugh, a cognitive behaviour psychotherapist at the Vincent Square Eating Disorders Service in London...

Recent years have seen increased interest in the use of experiential techniques within cognitive behavioural therapy (CBT). Chairwork techniques such as empty-chair and two-chair interventions are popular therapeutic tools which originate from the psychodrama and gestalt schools of psychotherapy. Despite a growing body of evidence, however, such te...

The efficacy of Cognitive Behavioral Therapy–based Guided Self-Help for mild to moderate bulimia and binge eating disorders has been well supported. However, limited research has explored in-depth individual experiences of this treatment approach. In-depth semi-structured interviews were conducted with 4 individuals who had completed Cognitive Beha...

Matthew Pugh on the use and potential of chairwork.

Chairwork represents an assembly of versatile experiential interventions which have been incorporated into many evidence-based psychotherapies. This narrative review explores the applications, efficacy and mechanisms of action of chairwork techniques utilised in cognitive and behavioural therapies. Relevant literature was acquired through research...

Key practitioner message: Experiences of an internal 'anorexic voice' are common in anorexia nervosa. Clinicians should consider the role of the voice when formulating eating pathology in anorexia nervosa, including how individuals perceive and relate to that voice. Addressing the voice may be beneficial, particularly in more severe and enduring f...

Eating disorders are characterised by high levels ambivalence. Unfortunately, limited evidence exists for the effectiveness of traditional motivational techniques. Experiential interventions such as chairwork have a long legacy in eating disorders and have produced promising results. Accordingly, they may be a useful tool for enhancing motivation i...

Objective: Internal "anorexic voices" are commonly described by individuals with eating disorders. This study examines whether the perceived power and nature of that voice are related to eating pathology in anorexia nervosa. Method: Sixty-three women and one man with an ICD-10 diagnosis of anorexia nervosa participated in this study (mean age =...

Poor treatment outcomes have fuelled calls for the development of novel maintenance models of anorexia nervosa. Experiences of an internal ‘anorexic voice’ are often reported in eating disorders but remain little understood. This article reviews anorexic voice research and examines how these experiences may be implicated in the persistence of eatin...

Whilst cognitive-behavioural therapy has demonstrated efficacy in the treatment of eating disorders, therapy outcomes and current conceptualizations still remain inadequate. In light of these shortcomings there has been growing interest in the utility of schema therapy applied to eating pathology. The present article first provides a narrative revi...

Although empathy is considered by many to be fundamental to psychotherapeutic practice, little is known about how working with an interpreter may affect empathy in clinical work. Accordingly, the present study aims to provide an exploration of mental health professionals' experiences of empathy in clinical work with an interpreter. A qualitative me...