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Objective: To determine the relationship between length of time spent expressing highly aroused emotion and therapeutic outcome. Method: Thirty-eight clients (14 male, 24 female) between the ages of 22 and 60 years (M = 39.5, SD = 9.71), treated for depression with experiential therapy, were rated on working alliance and expressed emotional arousal (with the Client Expressed Emotional Arousal Scale) in their three highest arousal sessions. Among the clients, 34 were of European ethnicity, 2 were of Asian ethnicity, 1 was of Latino ethnicity, and 1 was of Caribbean--Canadian ethnicity. Clients were administered the short form of the Working Alliance Inventory following their 4th therapy session and also completed, pre- and posttherapy, the Beck Depression Inventory (BDI), the Global Severity Index (GSI) of the Symptom Checklist--90--Revised (SCL-90-R), the Inventory of Interpersonal Problems, and the Rosenberg Self-Esteem Scale. Results: Hierarchical regressions showed that a nonlinear pattern of expressed emotional arousal predicted outcome significantly above the alliance. This combination predicted 30% of outcome variance on the BDI and 24% on the GSI (p < .01). An optimal frequency (25%) of highly aroused emotional expression was found to relate to outcome, with deviation from this optimal frequency predicting poorer outcome. Conclusions: Too much or too little emotion was found to be not as helpful as a moderate amount. It was concluded that expressed emotional arousal in experiential therapies has a more intricate relationship with therapeutic outcome than has previously been shown and that it is moderate amounts of heightened emotional arousal that improve predictions of therapeutic outcome. Keywords: psychotherapeutic process, expressed emotional arousal, working alliance, depression DOI: 10.1037/a0018401

In this study, we measured emotional processing and the alliance across 3 phases of therapy (beginning, working, and termination) for 74 clients who each received brief experiential psychotherapy for depression. Using path analysis, we proposed and tested a model of relationships between these 2 processes across phases of therapy and how these processes relate to predict improvement in the domains of depressive and general symptoms, self-esteem, and interpersonal problems after experiential treatment. Both therapy processes significantly increased across phases of therapy. Controlling for both client processes at the beginning of therapy, working phase emotional processing was found to directly and best predict reductions in depressive and general symptoms, and it could directly predict gains in self-esteem. Within working and termination phases of therapy, the alliance significantly contributed to emotional processing and indirectly contributed to outcome. Surprisingly, beginning therapy alliance (measured after Session 1) also directly predicted all outcomes. Furthermore, only clients' beginning therapy process predicted reductions in interpersonal problems. Therefore, although the proposed theory of change was supported, clients' beginning therapy processes may constrain clients' success in experiential treatment and in particular their outcomes in some problem domains related to depression. Keywords: emotional processing, alliance, depression, experiential psychotherapy, psychotherapy process DOI: 10.1037/a0017059

Follow-up data across an 18-month period are presented for 43 adults who had been randomly assigned and had responded to short-term client-centered (CC) and emotion-focused (EFT) therapies for major depression. Long-term effects of these short-term therapies were evaluated using relapse rates, number of asymptomatic or minimally symptomatic weeks, survival times across an 18-month follow-up, and group comparisons on self-report indices at 6- and 18-month follow-up among those clients who responded to the acute treatment phase. EFT treatment showed superior effects across 18 months in terms of less depressive relapse and greater number of asymptomatic or minimally symptomatic weeks, and the probability of maintaining treatment gains was significantly more likely in the EFT treatment than in the CC treatment. In addition, follow-up self-report results demonstrated significantly greater effects for EFT clients on reduction of depression and improvement of self-esteem, and there were trends in favor of EFT, in comparison with CC, on reduction of general symptom distress and interpersonal problems. Maintenance of treatment gains following an empathic relational treatment appears to be enhanced by the addition of specific experiential and gestalt-derived emotion-focused interventions. Clinical and theoretical implications of these findings are presented. Keywords: depression, emotion, experiential therapy, follow-up, relapse prevention

This study compared the effectiveness of emotion-focused therapy (EFT) involving gestalt empty-chair dialogue in the treatment of individuals who were emotionally injured by a significant other with therapy in a psychoeducation group designed to deal with these injuries. In addition, this study examined aspects of the emotional process of forgiveness in resolving interpersonal injuries and investigated the relationship between letting go of distressing feelings and forgiveness. A total of 46 clients assessed as having unresolved, interpersonal, emotional injuries were randomly assigned to an individual therapy treatment of EFT or a psychoeducation group. Clients were assessed at pretreatment, posttreatment, and 3-month follow-up on measures of forgiveness, letting go, depression, global symptoms, and key target complaints. Results indicated that clients in EFT using empty-chair dialogue showed significantly more improvement than the psychoeducation treatment on all measures of forgiveness and letting go, as well as global symptoms and key target complaints. Keywords: interpersonal injuries, forgiveness, letting go, emotion-focused therapy, psychoeducation

The purpose of this study was to examine observable moment-by-moment steps in emotional processing as they occurred within productive sessions of experiential therapy. Global distress was identified as an unprocessed emotion with high arousal and low meaningfulness. The investigation consisted of 2 studies as part of a task analysis that examined clients processing distress in live video-recorded therapy sessions. Clients in both studies were adults in experiential therapy for depression and ongoing interpersonal problems. Study 1 was the discovery-oriented phase of task analysis, which intensively examined 6 examples of global distress. The qualitative findings produced a model showing: global distress, fear, shame, and aggressive anger as undifferentiated and insufficiently processed emotions; the articulation of needs and negative self-evaluations as a pivotal step in change; and assertive anger, self-soothing, hurt, and grief as states of advanced processing. Study 2 tested the model using a sample of 34 clients in global distress. A multivariate analysis of variance showed that the model of emotional processing predicted positive in-session effects, and bootstrapping analyses were used to demonstrate that distinct emotions emerged moment by moment in predicted sequential patterns. Keywords: emotional processing, emotion-focused therapy, distress, task analysis, change mechanisms

Emotion-focused therapy regards the client's problems as indications that the inner dialogue among voices of the self has become fractious, often because one or more voices have developed emotion schemes that are based on maladaptive emotions. The goal of therapy is to transform such maladaptive emotions into more adaptive ones. The therapist's interventions focus on facilitating the client's process of dialogue among the voices of the self and guiding the client toward experiencing of adaptive emotions. These new experiences contribute to a dynamic shift in the relation among the voices. A case study illustrates how a male client's rage and hopelessness transformed into assertiveness and tenderness as the various voices learned to respect and help each other within the self. Keywords: emotion-focused therapy; multiple voices; psychotherapy; emotions; experiential therapy

This article reviews the process and outcome research on emotion in psychotherapy. Four distinct types of emotion processes are identified in the literature as useful in therapy, depending on a client's presenting concerns: emotional awareness and arousal: emotional regulation, active reflection on emotion (meaning making), and emotional transformation. Research findings are summarized to highlight the practical implications of these different emotion processes to psychotherapy. A range of selected treatments from different therapeutic orientations are addressed collectively as different types of emotion-focused, experiential therapies and are compared on the basis of how they work with emotion in session. Keywords: emotion: psychotherapy: process: outcome: change mechanisms

Early-, middle-, and late-phase client emotional arousal, perceptual processing strategies, and working alliance were examined in relation to treatment outcome on 4 measures in 32 clients who previously underwent experiential therapy for depression. Hierarchical regression analyses relating these variables to outcome indicated that results varied depending on the therapeutic process, phase of treatment, and outcome measure involved in the analyses. Mid-therapy arousal predicted improvements in self-esteem, whereas mid- and late treatment perceptual processing predicted reductions in client interpersonal dysfunction. Emotional arousal in conjunction with perceptual processing during mid-therapy predicted reductions in depressive and psychopathological symptomatology better than either of these variables alone. The implications of these findings for psychotherapy research and practice are discussed. Keywords: psychotherapeutic process and outcome, major depression treatment, emotions, perception, working alliance

This study explored the importance of early and late emotional processing to change in depressive and general symptomology, self-esteem, and interpersonal problems for 34 clients who received 16-20 sessions of experiential treatment for depression. The independent contribution to outcome of the early working alliance was also explored. Early and late emotional processing predicted reductions in reported symptoms and gains in self-esteem. More important, emotional-processing skill significantly improved during treatment. Hierarchical regression models demonstrated that late emotional processing both mediated the relationship between clients' early emotional processing capacity and outcome and was the sole emotional-processing variable that independently predicted improvement. After controlling for emotional processing, the working alliance added an independent contribution to explaining improvement in reported symptomology only.

This article reports the development of a marker-based method for rating assimilation in psychotherapy with a case study of a woman Sarah, who was treated for depression with process-experiential psychotherapy. To increase the rigor of the qualitative case study methodology, independent judges rated passages--taken out of context and randomly ordered--from the qualitative analysis. The authors examined levels of training required to make quantitative judgments by comparing ratings from 4 graduate students and 4 undergraduate students. Pooled reliabilities of the 2 groups of raters were high (.90 and .84), and the estimated reliability of single graduate student raters was acceptable (.70). Consistent findings across a series of related case studies are reviewed to address the generalizability of the findings.

This study related the process of the resolution of unfinished business with a significant other to therapeutic outcome in a population of 26 clients who suffered from various forms of interpersonal problems and childhood maltreatment. Clients were treated in emotion-focused, experiential therapy with gestalt empty-chair dialogues. Those clients who expressed previously unmet interpersonal needs to the significant other, and manifested a shift in their view of the other, had significantly better treatment outcomes. The presence of the specific process of resolution in the clients' empty-chair dialogues was also found to be a better predictor of outcome than the working alliance. Degree of emotional arousal was found to discriminate between resolvers and nonresolvers.

The formation and maintenance of a positive working alliance is fundamental to the success of experiential therapy. Experiential therapists face a special challenge insofar as they must constantly consider whether to direct the therapeutic process more actively or remain more closely within the clients' own frame of reference. This requires that experiential therapists be acutely aware of the alliance with their clients on a moment-to-moment basis during the session. In this article ruptures to the alliance, comprising breakdowns in the agreement between clients and therapists as to the goals and tasks of therapy during the early and middle phases of treatment, are identified and explored. As ruptures are often covert processes, methods of detecting their occurrence during the session are presented. Finally, experiential techniques for forging, maintaining, and repairing the alliance between clients and therapists are discussed and illustrated. Keywords: experiential therapy; working alliance; alliance ruptures; relationship conditions; empathy

The research approach I recommend involves the intensive analysis of concrete-change performances using both intensive observation and measurement of in-session behavior, as well as the investigation of participants' subjective recall of their experience. The goal is to build models of client-change processes and the therapist interventions that set these in motion. Examples of research efforts to study the allowing of emotional pain, the process of interruption of emotion, and the process of resolution of hopelessness are given.

The authors present a marker-based method for tracking the assimilation of a previously outcast voice into the self, conceived as a community of voices. In a qualitative assimilation analysis of the case of Jan, a woman whose depressive symptoms abated in process experiential psychotherapy, the authors tracked 2 major themes, excerpted 43 relevant passages, and rated each passage on the Assimilation of Problematic Experiences Scale (APES). Ratings by 3 independent raters who used a marker-based APES manual were highly correlated with the investigators' consensus ratings. APES ratings tended to increase across sessions, as expected in successful therapy. The authors present passages to illustrate the assimilation of a voice of neediness and weakness by Jan's dominant superwoman voice and the assimilation of a voice of rebellion and assertiveness by Jan's dominant good-girl voice, yielding a more complex and flexible community.

This special section has a dual focus. One is on psychotherapy change research. The other is to explicate an approach to develop a program of research that builds on 2 aspects of scientific discovery: decomposition of observed phenomena and localization of specific elements that may combine to produce a complex whole. These aspects are considered within an ordered framework of 8 steps in the development and testing of a model, moving from discovery to model construction, validation, and prediction of complex outcomes. Studies on psychotherapy change processes were selected, after a masked review, to represent different levels in developing a program of research. Although it is argued that the early steps of decomposition and localization are important when developing a program of research, current editorial practices in first-tier journals, including the Journal of Consulting and Clinical Psychology, typically consider this type of study to be too preliminary for a scientific archival journal. Should this practice be revisited?

The steps of a task-analytic research program designed to identify the in-session performances involved in resolving lingering bad feelings toward a significant other are described. A rational-empirical methodology of repeatedly cycling between rational conjecture and empirical observations is demonstrated as a method of developing an intervention manual and the components of client processes of resolution. A refined model of the change process developed by these procedures is validated by comparing 11 successful and 11 unsuccessful performances. Four performance components - intense expression of feeling, expression of need, shift in representation of other, and self-validation or understanding of the other - were found to discriminate between resolution and nonresolution performances. These components were measured on 4 process measures: the Structural Analysis of Social Behavior, the Experiencing Scale, the Client's Emotional Arousal Scale, and a need scale.

A study proposed a two-dimensional scheme for classifying observational coding on the basis of content meaning and code type. However, the systematic task-analytic approach for observational coding involves understanding of both the nature and process of change. It includes modeling of context-specific, and in-situation process since any variations in the process yields crucial information about change in psychotherapy. The focus is on the process occurring at a particular moment in a particular environment than just the nature of change mechanisms.

This article presents 3 different studies of in-session changes in emotionally focused couples therapy (EFT). Studies of in-session conflict events demonstrate both that couples' conflict interaction at the end of treatment is more affiliative and interdependent than at the beginning of treatment and that peak session conflict interaction is deeper in level of experience and more affiliative than the interaction in poor session conflict episodes. In addition, events beginning with intimate, affective self-disclosure by one partner were found to involve greater affiliation in spouses' responses to the self-disclosure than in a control event not involving self-disclosure. The possible change processes in EFT are discussed in light of these results.

The emphasis on transference in analyzing therapeutic relationships can be misleading because of the difficulty in distinguishing between transference and real relationship, particularly at the conceptual level and at the level of measurement. The overinclusiveness of the concept of transference also presents a point of contention. To resolve these problems, criteria for transference such as notions of distortion and truth should be replaced with notions of dysfunctionality and intersubjectivity.

The importance of facilitating productive therapeutic processes to gain access to overregulated primary adaptive emotional experience is discussed. In addition to describing common two- and three-step emotion sequences involved in change, this article presents the more complex sequences involved in facing emotional pain. Key aspects of facing pain are allowing the experience of 'brokenness,' or a 'shattering' of the self, feeling the associated painful emotions, and processing them to completion. This promotes a transformation in view of self, world, and other. A case example and some general principles of emotional change are given. [C] 2001 John Wiley & Sons, Inc. J Clin Psychol 57:197-211, 2001. Keywords: change principles; emotion regulation; pain; process sequences

Present stages of development and preliminary validation of a self-report instrument for measuring the quality of alliance, the Working Alliance Inventory (WAI). The measure is based on Bordin's (1980) pantheoretical, tripartite (bonds, goals, and tasks) conceptualization of the alliance. Results from three studies were used to investigate the instrument's reliability and validity and the relations among the WAI scales. The data suggest that the WAI has adequate reliability. The instrument is reliably correlated with a variety of counselor and client self-reported outcome measures. Nontrivial relations wre also observed between the WAI and other relationship indicators. These results are interpreted as preliminary support for the validity of the instrument. Although the results obtained in hte reviewed studies are encouraging, the high correlations between the three subscales of the inventory bring into question the distinctness of the alliance components.

Accurately identifying another person's emotional state is an ability that may be necessary for a psychotherapist to empathize with a patient and that may be required for obtaining valid and reliable psychotherapy process ratings in research. Accuracy of identifying emotions and of rating emotional intensity expressed by a patient was studied in a comparison of 36 experienced therapists and 36 undergraduate psychology students who intended to become psychotherapists. Representative segments of a psychotherapy session were presented in one of three ways to tease apart the relative importance of verbal and nonverbal cues in making accurate ratings. Accuracy was judged against ratings supplied by two experienced and prestigious clinicians based on the same therapy sample. Results indicated that although therapists were more accurate than nontherapists in identifying emotions, they did not differ in the accuracy of rating emotional intensity. Moreover, accuracy of ratings was found to be less reliant on verbal cues among psychotherapists than among nontherapists. Finally, levels of participants' personal awareness of their own emotions had a positive impact on the accuracy of identifying specific emotions but not on the accuracy of rating their intensity.