ChapterPDF Available

Research on humanistic-experiential psychotherapies

Authors:

Figures

Content may be subject to copyright.
Final version published as: Elliott, R., Watson, J., Greenberg, L.S., Timulak, L., & Freire, E. (2013).
Research on humanistic-experiential psychotherapies. In M.J. Lambert (Ed.), Bergin & Garfield‘s
Handbook of psychotherapy and behavior change (6th ed.) (pp. 495-538). New York: Wiley. ©Wiley.
This is a post-print version and may not exactly replicate the final version. It is not the copy of record.
Chapter 13
Research on Humanistic-
Experiential Psychotherapies
Robert Elliott, Leslie S. Greenberg, Jeanne Watson,
Ladislav Timulak, and Elizabeth Freire
We acknowledge the contributions of the many colleagues who sent us information on their research; we ask them
to continue sending omitted or new studies. The outcome meta-analysis was supported in part by a grant to RE and
EF from the British Association for the Person-Centred Approach.
This review covers approaches to psychotherapy generally referred to as
humanistic or experiential. These therapies are part of the main tradition of
humanistic psychology (see Cain & Seeman, 2002), with major subapproaches
being person-centered therapy (PCT; e.g., Rogers, 1961), gestalt (e.g., Perls,
Hefferline & Goodman, 1951), emotion-focused (EFT, also known as process-
experiential; Greenberg, Rice, & Elliott, 1993), existential (e.g., Yalom, 1980),
psychodrama (J. Moreno & Moreno, 1959), focusing-oriented (Gendlin, 1996),
expressive (Daldrup, Beutler, Engle, & Greenberg, 1988), and body-oriented
(Kepner, 1993). In addition, humanistic-experiential psychotherapies (HEPs) are
often used as generic relationship control conditions by researchers from other
theoretical orientations under store-brand labels such as supportive or
nondirective.
Although these approaches have varied somewhat in technique and
conception over the course of their historical development, in their contemporary
expressions they nevertheless share several distinctive theoretical assumptions.
Most important among these is the centrality of a genuinely empathic and prizing
therapeutic relationship. In the HEPs, the therapeutic relationship is seen as
potentially curative. Each persons subjective experience is of central importance,
and, in an effort to grasp this experience, the therapist attempts to enter
empathically into the client’s world in a way that goes beyond usual relationships
or the subject-object dichotomy. Being allowed to share another persons world is
viewed as a privilege, and all HEPs reject the idea that the relationship between
2
the client and the therapist can be reduced to an unconscious repetition of previous
attachments. Rather, they generally share the view that an authentic but
boundaried relationship with the therapist provides the client with a new,
emotionally validating experience.
HEPs also share a focus on promoting in-therapy client experiencing,
defined as the holistic process of immediate, ongoing awareness that includes
perceiving, sensing, feeling, thinking, and wanting/intending. Thus, methods that
deepen or stimulate client emotional experiencing are used within the context of
an empathic facilitative relationship. Commitment to a phenomenological
approach flows directly from this central interest in experiencing. People are
viewed as meaning-creating, symbolizing agents, whose subjective experience is
an essential aspect of their humanity. In addition, the experiential-humanistic view
of functioning emphasizes the operation of an integrative, formative tendency,
oriented toward survival, growth, and the creation of meaning. Moreover, all
HEPs are united by the general principle that people are wiser than their intellect
alone. Internal tacit experiencing is seen as an important guide to conscious
experience, fundamentally adaptive, and potentially available to awareness when
the person turns attention internally within the context of a supportive
interpersonal relationship. Interpersonal safety and support are thus viewed as key
elements in enhancing the amount of attention available for self-awareness and
exploration. HEPs are also consistently person-centered. This involves genuine
concern and respect for each person. The person is viewed holistically, neither as a
symptom-driven case nor as a diagnosis.
Recent developments in the HEPs include a revival of research on person-
centered therapy (PCT) and continued study of focusing-oriented (Gendlin, 1996)
and emotion-focused approaches (Greenberg et al., 1993). Like gestalt therapy,
these newer approaches use experiments in directed awareness to help focus and
concentrate attention on unformed experience and to intensify its vividness. For
example, focusing-oriented therapy emphasizes the creation of new meaning by
focusing awareness on bodily feelings, while EFT integrates person-centered and
gestalt therapy traditions, emphasizing both the relationship and the process of
reflection on aroused emotions to create new meaning. In practice, these and other
process-guiding contemporary approaches strive to maintain a creative tension
between the person-centered emphasis on creating a genuinely empathic and
prizing therapeutic relationship, and a more active, task-focused process-
facilitating style of engagement that promotes deeper experiencing and consequent
meaning creation. Although coming from a different tradition, “third generation”
cognitive-behavioral therapy (CBT), such as mindfulness-based cognitive therapy
(Segal, Williams, & Teasdale, 2001), acceptance and commitment therapy (Hayes,
Strosahl, & Wilson, 1999), and compassion-focused therapy (Gilbert, 2009) have
expanded to have much in common with HEPs.
3
A continuing key point of contention within the humanistic-experiential
psychotherapies, however, is the degree to which therapists should act as process-
experts by offering ways clients can work more productively on particular types of
problems (process guiding). All HEPs are process-guiding to a certain extent,
but EFT and gestalt are more so, while PCT and so-called supportive or
nondirective therapies attempt to minimize process guiding.
In this chapter we focus on research published since our previous reviews
(Elliott, Greenberg, & Lietaer, 2004; Greenberg, Elliott, & Lietaer, 1994), which
covered research published between 1978 and 2001, plus additional earlier
research on HEP outcome that we have been able to track down. A key element of
the chapter is a meta-analysis of nearly 200 HEP outcome studies (through 2008)
and a survey of the use of the approach with different client groups. In addition,
we offer a meta-synthesis of qualitative research on these therapies (cf. Timulak,
2007), and provide a narrative review of recent quantitative research on change
processes in HEPs. Finally, we once again apply the criteria for designating
psychotherapies as empirically supported, originally proposed by the Society of
Clinical Psychology (Division 12, American Psychological Association; see Task
Force on Promotion and Dissemination of Psychological Procedures, 1995) and
subsequently modified by Chambless and Hollon (1998). We realize that these
criteria are controversial (e.g., Elliott, 1998), but use them here because they are
the clearest such guidelines available and are widely recognized.
Because of space limitations and the increasing amount and range of
research this survey is not exhaustive. In particular, we have not reviewed research
on the therapeutic alliance, child psychotherapy, and on measure development (but
see Cooper, Watson, & Hölldampf, 2010, for reviews of these topics). In addition,
we have chosen not to review research on the growing number of related
integrative approaches, such as emotion-focused psychodynamic approaches (e.g.,
Fosha, 2000), motivational interviewing (Lundahl, Kunz, Brownell, Tollefson, &
Burke, 2010), and “third wave” CBT (e.g., Gilbert, 2009; Hayes et al., 1999; Segal
et al., 2001).
As noted in our previous review (Elliott et al., 2004), although clear
progress has taken place in the past 20 years, including increasing numbers of
studies on specific client populations, additional programmatic empirical research
on humanistic-experiential therapies is still needed.
4
Are Humanistic-Experiential
Therapies Effective?: A Meta-
Analysis
In North America and Europe, economic pressures on mental health
services and scientific-political trends toward treatment standardization have led to
the development of guidelines calling for certain psychological treatments to be
officially recognized as effective, reimbursed by insurance, and actively promoted
in training courses, at the expense of other treatments (e.g., Task Force on
Promotion and Dissemination of Psychological Procedures, 1995; Meyer, Richter,
Grawe, von Schulenburg & Schulte, 1991; National Collaborating Centre for
Mental Health, 2009). To date, these guidelines have not been kind to the HEPs,
and have in effect enshrined widely shared preconceptions about the perceived
ineffectiveness of these approaches as supposed scientific fact and health care
policy. Although research on HEPs has rapidly expanded over the past 20 years
(see previous reviews in Cain & Seeman, 2002; Cooper et al., 2010; Elliott et al.,
2004), they continue to be overlooked or dismissed, as in the NICE Guidelines for
Depression and Schizophrenia (National Collaborating Centre for Mental Health,
2009, 2010).
Understandably, humanistic-experiential therapists (e.g., Bohart, O’Hara, &
Leitner, 1998; Schneider, 1998) have responded to these challenges with alarm.
Although philosophical assumptions and methods of the evidence-based practice
movement have been and continue to be challenged, our strategy here is to look
instead at the existing research evidence, which has sometimes been neglected in
the controversy. In fact, as we show, a substantial and rapidly growing body of
research data supports the effectiveness of HEPs.
We report here the latest of a continuing series of meta-analytic reviews of
HEP quantitative outcome research, substantially updating earlier reports (Elliott,
1996, 2002; Elliott et al., 2004; Greenberg et al., 1994). The present analysis
includes more than 5 times the number of studies analyzed in Greenberg et al.’s
(1994) original review, from 35 to 195, including 77 studies not included in our
most recent review (Elliott et al., 2004). Eleven of these studies were published
prior to 1970; 25 came from the 1970s; 36 from the 1980s; 63 from the 1990s; and
60 from the first decade of the 2000s. These studies offer evidence for a revival of
outcome research on HEPs. We have included all the studies we could locate and
analyze through 2008 (unfortunately, the accelerating pace of the research has
currently outstripped our ability to keep up with it beyond that date).
5
At this point, the analysis includes pre-post effect size data from 199
different samples of clients seen in some form of HEP, drawing from 186 studies
(involving a total of 14,206 clients). In terms of controlled studies with wait-list or
no-treatment conditions, there are 62 comparisons, from 59 studies (involving
2,149 therapy clients and 1,988 controls); 31 of these were randomized control
trials (RCTs). As for comparative studies, in which HEPs were compared to other
treatments, there are 135 comparisons, derived from 108 samples of clients in HEP
in 100 different studies, 82 of these RCTs (n = 6,271 HEP clients, 7,214 clients in
non-HEP therapies). Finally, there are 9 comparisons between more versus less
process-guiding HEPs (7 studies, 264 clients).
The pre-post therapy samples were categorized into six clusters: (1) 74
involved person-centered therapy (PCT) in a relatively pure form; (2) 33 focused
on generic versions of HEP most commonly referred to as supportive or
nondirective; (3) 34 studies examined task-focused, integrative emotion-focused
therapies (EFT, also known as process-experiential), including emotionally
focused therapy for couples (EFT-C); (4) new in this review, we analyzed 10
studies of existentially oriented supportive-expressive group therapy for medical
populations (e.g., cancer); (5) finally, 43 samples of clients received other HEPs
(gestalt therapy, psychodrama, focusing-oriented, encounter, or integrative); and
(6) five got treatments that mixed HEP with some other kind of treatment such as
medication or advice. The average length of therapy was 20 sessions (sd: 21, range
2–124); the average number of clients studied was 70 (sd: 240; range 5– 2,742).
For the pre-post effects sample, researcher theoretical allegiances were most
commonly pro-HEP (65%), while for comparative studies this figure was only
31%.
For each study, characteristics of the treatments, clients, therapists or the
studies were rated to estimate the contribution of these features to effect size. For
example, internal validity was coded, with one group pre-post uncontrolled open
clinical trials rated as “0”; one group wait list own control designs as “1”; two
group nonrandomized designs as “2”; and two group randomized controlled trials
(RCTs), given a “3” rating.
Standardized pre-post differences (d) were used for effect size (ES)
calculations using standard estimation procedures (e.g., Smith, Glass, & Miller,
1980) and D/STAT (Johnson, 1989). ESs were calculated for each subscale of
each outcome measure used, then averaged across subscales within measures for
each of three assessment periods: posttherapy, early follow-up (less than a year),
and late follow-up (a year or longer). For pre-post effect sizes, measure effects
were first averaged, then across the three assessment periods to yield an overall
value for each treatment in each study. In addition, standard corrections for small
sample bias and inverse error (based on sample-size) weighting formulas (Hunter
& Schmidt, 1990) were applied to these ESs in order to obtain more precise
estimates of overall effect. Analyses of controlled and comparative effect sizes
6
compared mean overall pre-post effects between control or comparative treatment
conditions, with positive values assigned where the HEP treatment showed a
larger amount of change. In addition, random-effects significance testing (Wilson
& Lipsey, 2001), using the Comprehensive Meta Analysis software package was
combined with equivalence analyses (Rogers, Howard, & Vessey, 1993) for key
comparisons, using .4 sd, as previously proposed by Elliott, Stiles, and Shapiro
(1993), as a demarcation between a small and a medium effect size This is useful
for defining the minimum clinically interesting difference, relevant to individual
clinical practitioners, who see small numbers of clients at one time. Next, we
analyzed for heterogeneity of effects using Cochrane’s Q, which tests for whether
the overall effect estimate is compromised by significant between-study
variability. Finally, we estimated the proportion of the between study variation due
to true variability as opposed to random error by using the I2 statistic (Higgins,
Thompson, Deeks, & Altman, 2003). (Higgins et al. [2003] recommend
interpreting I2 values of 25%, 50%, and 75% respectively as small, medium, and
large.)
In addition, when examining particular client populations (e.g., depression),
we applied the Chambless and Hollon (1998) revised criteria for designating level
of empirical support. According to their formulation, studies are generally
expected to meet certain quality criteria: (a) reasonable sample size (n > 25 per
group); (b) use of treatment manual or adherence checks; (c) a specific client
population defined by reliable, valid inclusion criteria; (d) use of reliable, valid
outcome measures, including measurement of targeted client difficulties; (e)
appropriate data analysis (e.g., direct comparisons, evaluation of all outcome
measures). The three levels of efficacy are defined as:
1. Possibly efficacious: One controlled study in absence of conflicting
evidence.
2. Efficacious: In at least two independent research settings, the treatment is
either (a) superior to no treatment or another treatment, or (b) equivalent
to an established treatment using studies of reasonable size (n > 25 per
group). With conflicting evidence, the preponderance of the well-
controlled studies supports the treatment.
3. Efficacious and specific: In at least two independent research settings,
the treatment must have been shown to be statistically significant and
superior either (a) to a nonbona fide treatment (e.g., a “placebo”) or (b)
to an alternative bona fide treatment. With conflicting evidence, the
preponderance of the well-controlled studies supports the treatment.
7
Total Pre-post Change in Humanistic-
Experiential Therapies
Table 13.1 summarizes pre-post effects for all studies for which these could
be calculated. The unweighted average pre-post effect (d), across the 199
treatment samples and assessment periods, was .96. This exceeds the .8 standard
cited by Cohen (1988) as a large effect size. The data clearly indicate that clients
maintained or perhaps even increased their immediate posttreatment gains (d =
.95) over the posttherapy period, with slightly larger effects obtained at early (1
11 months; 1.05) and late (12+ months; 1.11) follow-ups. Weighting effects by
inverse error (a function of sample size) produced a virtually identical overall
mean ES of .93 (95% confidence interval: .86 to 1.00).
Table 13.1 Summary of Overall Pre-Post Change, Controlled and Comparative
Effect Sizes
n
m
sd
Prepost Change ES (mean g)
By assessment point:
Post
181
.95
.61
Early follow-up (1–11 mos.)
77
1.05
.65
Late follow-up (12+ mos)
52
1.11
.68
Overall (mES):
Unweighted
199
.96
.61
Weighted (dw)
199
.93
.04a
Controlled ES (vs. untreated
clients)b
Unweighted mean difference
62
.81
.62
Unweighted m diff, RCTs only
31
.81
.68
Experiential mean pre-post ES
59
1.01
.68
Control mean pre-post ES
53
.19
.32
Weighted
62
.76
.06
Weighted m diff, RCTs only
31
.76
.10a
Comparative ES (vs. other
treatments)b
Unweighted mean difference
135
–.02
.53
Unweighted m diff, RCTs only
113
–.02
.53
Experiential mean pre-post ES
124
.98
.62
Comparative treatment mean pre-
post ES
124
1.02
.69
Weighted mean difference
135
.01
.03a
Weighted m diff, RCTs only
113
–.01
.04a
8
Comparative ES (more vs. less
process-guiding experiential)b
Unweighted
9
.33
.51
Weighted by n
9
.14
.18a
Note. Hedges g used (corrects for small sample bias). Weighted effects used inverse variance
based on n of clients in humanistic-experiential therapy conditions.
aStandard error of the mean given for weighted effects.
bMean difference in change ESs for conditions compared, except where these are unavailable;
positive values indicate pro-HEP or pro-process guiding results.
Controlled Studies on the
Effectiveness of Humanistic-
Experiential Therapies
Pre-post effects do not tell us whether clients in HEPs fared better than
untreated clients, and thus make it difficult to infer that therapy was responsible
for changes made by clients. They have also been reported to produce generally
larger effects than control group comparisons (Lipsey & Wilson, 1993). Therefore,
we examined control-referenced effect sizes (differences between pre-post ESs) in
the 62 treated groups in which HEPs were compared to wait-list or no-treatment
controls. The unweighted mean controlled effect size for these studies (Table 13.1)
was also large, .81, a value only slightly less than the mean pre-post effect of .96.
In contrast, the average pre-post effect for the 53 untreated conditions (the number
for which data were available) was .19, only a fifth the size of the effect for clients
in HEPs. The weighted effect (dw) was .76 (CI: .64 to .88) and moderately
heterogeneous (Q = 162.8; p < .001; I2 = 62%). The same unweighted and
weighted results held when only the 31 randomized studies were analyzed. From
this pattern of results, three conclusions can be drawn: (1) there is a strong causal
relationship between HEP and client change; (2) the controlled effects are highly
consistent with the pre-post effects, and suggest that about 80% of the pre-post
gains reported for clients in HEPs can be attributed to the therapy (including both
client and therapist within-therapy factors), as opposed to external or nontherapy
factors; (3) these results hold, regardless of whether RCT designs are used or not,
thus supporting the internal validity of the nonrandomized controlled studies, as
well as the much larger body of one-group pre-post studies.
9
Comparative Outcome Research on Humanistic-
Experiential Versus Other Therapies
While impressive, the pre-post and controlled effect-size analyses reported
do not address the issue of comparative treatment effectiveness, which is central to
continuing discussions about mental health policy, the effectiveness of HEPs and
the sources of their effects. For this, we analyzed 135 comparisons between HEPs
and other therapies. The average unweighted difference in pre-post effects was
.02, indicating no overall difference (see Table 13.1). Weighting by inverse error
produced comparable but moderately heterogeneous results (dw = .01; CI: .05 to
.07; Q = 305.1, p < .001; I2 = 56%). Once again, analyzing only the 113
randomized effects produced nearly identical results (see Table 13.1). In 81 (60%)
of the comparisons, pre-post change in clients in HEPs vs. non-HEPnon-HEPs
were within.4 standard deviation of each other, a value proposed as the minimum
clinically interesting difference in effects (Elliott et al., 1993). The heterogeneity
in comparative effect sizes was evidenced by the fact that in 28 comparisons
(21%) clients in the non-HEP treatment did substantially better (comparative
effect size < .4 sd) than clients in HEP, while HEP clients did substantially better
(> .4 sd) in the remaining 26 (19%) comparisons.
Particularly noteworthy recent mixed sample outcome studies are the two
studies by Stiles and colleagues (2006, 2008) comparing person-centered, CBT,
and psychodynamic therapies in primary care settings, with very large naturalistic
U.K. samples (Stiles, Barkham, Mellor-Clark & Connell, 2008; Stiles, Barkham,
Twigg, Mellor-Clark & Cooper, 2006). In both studies, the studies approximated
RCTs in spite of the lack of randomization, because clients in all three treatments
were statistically identical at pre- and posttest yet showed large amounts of pre-
post change.
Equivalence Analysis
Applying random effects model significance testing (Wilson & Lipsey,
2001) and equivalence analysis to this and other treatment comparisons made it
possible to demonstrate statistical equivalence between HEPs and non-HEPs.
These analyses are summarized in Table 13.2, with equivalence analyses given in
the “95% Confidence Interval,” “Different from 0,” and “Different from |.4|
columns. If the “Different from 0” column is “No” and the “Different from |.4|
column is “Yes,it means that the confidence interval includes zero but neither
+.4 or .4, indicating that the mean comparative effect demonstrated statistical
equivalence. In addition, because of the large sample sizes for most of the
equivalence analyses, we adopted the following conventions for interpreting the
practical or clinical implications of these and later results: Equivalent: within .1
10
sd of zero (greater than .1 and less than .1); “Trivially Different”: between .1 and
.2 sd from zero; “Equivocal”: between .2 and .4 sd from zero; “Clinically
Better/Worse”: at least .4 sd from zero.
Table 13.2 Overall Comparisons Between HEPs and non-HEPs
n
dw
SE
95% CI
Diff:
0
Diff:
<|.4|
Resulta
Whole Data set
HEP vs. non-HEP
135
.01
.03
-.05 to .07
No
Yes
Equivalent
HEP vs. CBT
76
-.13
(-.03)b
.04
-.21 to -.06
(-.11 to .05)
Yes
(No)
Yes
Trivially
worse
(Equivalent)
HEP vs. non-CBT other
therapies
59
.17
(.06)
.05
.08 to .27
(-.04 to .16)
Yes
(No)
Yes
Trivially
better
(Equivalent)
RCTs only
HEP vs. non-HEP
113
-.01
.04
-.09 to .07
No
Yes
Equivalent
HEP vs. CBT
65
-.14
(-.02)
.05
-.24 to -.05
(-.11 to .08)
Yes
(No)
Yes
Trivially
worse
(Equivalent)
HEP vs. non-CBT other
therapies
48
.15
(.04)
.06
.04 to .27
(-.08 to .17)
Yes
(No)
Yes
Trivially
better
(Equivalent)
Note. dw: weighted comparative effect size (difference between therapies weighted by inverse
variance); SE: standard error for the comparative effect sizes, random effects model; 95%CI: 95%
confidential interval; Diff: 0 : mES statistically significantly different from zero; Diff: <|.4| : mES
statistically significantly smaller than minimum clinical practical value of .4 sd. HEP: humanistic-
experiential psychotherapy; CBT: cognitive-behavioral therapy.
aResultrefers to the practice implications of obtained value of mES: Equivalent: within .1 sd of
zero (greater than .1 and less than .1); “Trivially (worse/better)”: between .1 and .2 sd from zero;
“Equivocally (worse/better)”: between .2 and .4 sd from zero; “Clinically worse/better”: at least .4 sd
from zero.
bValues in parenthesized italics are results of analyses controlling for researcher allegiance,
performed when uncontrolled differences had been obtained.
In the case of the overall comparison between HEPs and non-HEPs, not
only was the obtained .01 value within the specified “equivalent” range, but this
practical equivalence was also supported statistically by its confidence interval
including zero but not .4 or .4 sd. In other words, on the basis of this sample, it
can be concluded that HEPs are in general, equivalent to other treatments in their
effectiveness. This result has been a consistent result of our earlier meta-analyses
(e.g., Elliott et al., 2004) and appears to be quite stable at this point. Nevertheless,
this consistent near-zero figure conceals statistically significant variability in
effects, as indicated by a Cochrane’s Q of 305.15 (p < 0.001); in addition, the
estimated proportion of true between study variability (I 2) was 56%, considered to
11
be a medium-size value. This means that examination of possible moderators of
comparative outcome effects is called for (Lipsey & Wilson, 2001).
HEPs Versus Cognitive-Behavioral Therapies (CBTs)
A significant center of controversy involves widely held assumptions to the
effect that HEPs are inferior to cognitive-behavioral treatments. The comparative
studies analyzed above did not exclusively use CBT (76 out of 135 comparisons).
Therefore, it can be argued that the effects of the CBT were watered down by the
inclusion of comparisons involving other types of therapy (most often “treatment
as usual,” psychodynamic, or integrative).
To clarify this issue, we undertook a series of further equivalence analyses
(see Table 13.2). These analyses indicated that, for the subsample of 59
comparisons analyzed here, HEPs showed slightly larger pre-post effects than
non-CBT treatments, an advantage of .17 sd, statistically significant but trivial for
clinical purposes: it would take at least 10 clients receiving HEP rather than a non-
CBT therapy for one additional client to benefit (cf. Furukawa, 1999). By the same
token, 76 studies comparing HEPs to CBT revealed a comparable but opposite
mean difference of.13, in favor of CBT. This effect was statistically significant
but also too trivial to serve as a guide for individual practitioners, although when
considered from an epidemiological point of view it could be seen as meaningful.
Next, we examined the 113 randomized comparisons separately in order to see if
these findings held up when only RCTs were analyzed (see Table 13.2): The
results were virtually identical.
Of considerable importance to practitioners and policy makers is the fact
that statistically controlling for researcher allegiance or bias diminishes the small
differences that have been reported. There was, in fact, a relatively high rate of
negative researcher allegiance (44%) in these studies, and also a large negative
correlation (r = .49; n = 135; p < .001) between researcher allegiance and
comparative effect size. Therefore, we ran additional analyses statistically
controlling for researcher allegiance, by removing variance in comparative ESs
due to this variable. When this was done (see Table 13.2, values in italics), these
statistically significant but trivially small treatment differences disappeared. Thus,
these data support the claim that HEPs have been found to be practically and
statistically equivalent to CBT in effectiveness. Researcher allegiance in
comparative outcome studies continues to confound the interpretation of
differences found between treatments generally (e.g., Luborsky et al., 1999).
CBT Versus HEP Subtypes
In this meta-analysis, our larger sample enabled us to examine our data
more closely than in previous meta-analyses, in order to see if we could
12
understand better the statistically significant but trivially small advantage of CBT
over HEPs. In order to do this, we looked at the four types of PCE therapy for
which there were at least two comparative studies: PCT, supportive treatments,
EFT, and other HEPs. The results of these analyses are given in Table 13.3, which
reveal:
1. Supportive therapies appeared to be equivocally less effective than CBT
(total sample: n = 37; dw = .27; CI: .4 to .13; RCTs: n = 35; dw =
.25; CI: .4 to .11). As Table 13.3 indicates, the confidence intervals
for these differences fall below zero (it is statistically significantly
worse than CBT) and at the minimum clinically interesting value of .4.
Furthermore, these values are moderately inconsistent, with statistically
significant Q values and I2 of around 40%, indicating further within
group differences needing to be explored. Further investigation of the
supportive therapies revealed them to be watered down, typically non
bona fide versions of PCE therapies, commonly used by CBT
researchers, especially in the United States; in fact, when researcher
allegiance was controlled for, the weighted effect dropped to .01 (CI:
.16 to .13). We have included these here as part of our inclusive search
strategy, because they meet our inclusion criteria and because they have
been widely researched.
2. The supportive subgroup of HEPs appeared to be responsible for the
small (“trivial”) advantage of CBT over the remaining HEPs. When the
supportive treatments were removed, the result was a relatively
consistent equivalence finding for the total sample (n = 39; mES = .06;
Q = 48.1, p > .1; I2 =21%) and for RCTs (n = 30; mES = .03; Q = 39.6,
p > .05; I2 = 27%).
3. PCT appeared to be consistently, statistically and practically equivalent
in effectiveness to CBT (22 studies, including 17 RCTs, with effect
sizes of .06 and .1 respectively and Q’s with p > .5), even without
controlling for researcher allegiance.
4. Although based on only six studies (5 RCTs), EFT for individuals or
couples appeared to be statistically and clinically more effective than
CBT, with an effect size of .53 (.51 for the RCTs). However, controlling
for researcher allegiance lowered the weighted effect to an equivocal,
nonsignificant .21 (CI: .19 to .61.)
5. Other HEPs were trivially worse than CBT overall (10 studies; ES =
.17; Q = 6, p > .5) but equivalent for the RCT subset (7 studies, ES =
.06). (This was a consistent finding with Q’s having p > .5, and
remained even after controlling for researcher allegiance.)
Table 13.3 Equivalence Analysis: Comparisons Between CBT and Type of HEP
n
dw
SE
95% CI
Diff:
0
Diff:
<|.4|
Resulta
PCT vs. CBT
22
(17)
-.06
(-.10)
.02
(.06)
-.11 to -.01
(-.23 to -
.02)
Yes
Yes
Equivalent
(Trivially worse)
Supportive vs.
CBT
37
(35)
-.27
(-.25)
.07
-.41 to -.13
(-.40 to -
.11)
Yes
No
Equivocally worse
EFT vs. CBT
6
(5)
.53
(.51)
.2
(.23)
.13 to .93
(.06 to .97)
Yes
No
Clinically better
Other HEP vs.
CBT
10
(7)
-.17
(.06)
.10
(.12)
-.37 to .03
(-.30 to .18)
No
Yes
Trivially worse
(Equivalent)
Low process-
guiding vs. CBT
59
(52)
-.16
(-.19)
.04
(.05)
-.23 to -.08
(-.29 to -
.09)
Yes
Yes
Trivially worse
High process-
guiding vs. CBT
17
(13)
.04
(.12)
.12
(.13)
-.2 to .27
(-.15 to .38)
No
Yes
Equivalent
(Trivially better)
More vs. less
Process-guiding
9
(8)
.14
(.08)
.18
(.19)
-.21 to .5
(-.30 to .44)
No
No
Trivially better
(Equivalent)
Note. For table column abbreviations, see notes for Table 13.2. HEP: humanistic-experiential;
CBT: cognitive-behavioral therapy; PCT: person-centered therapy; EFT: emotion-focused therapy.
Low process-guiding: PCT + Supportive; high process-guiding: EFT + other experiential +
supportive-expressive group.
aEquivalent: within .1 sd of zero (greater than .1 and less than .1); “Trivially (worse/better)”:
between .1 and .2 sd from zero; “Equivocally (worse/better)”: between .2 and .4 sd from zero;
“Clinically worse/better”: at least .4 sd from zero.
bValues in parenthesized italics are results of analyses of randomized studies.
High Versus Low Process-Guiding Humantistic-
Experiential Therapies
As noted earlier, HEPs such as gestalt, EFT, and focusing encourage the
therapist to act as a process expert or guide by offering the client different ways of
working in the session at different times. This stand has sometimes proven to be
controversial (eg., Brodley, 1990), so it is useful to examine what our meta-
analytic data have to say about this issue. As shown in Table 13.3, in general,
HEPs low on process-guiding (i.e., PCT and supportive therapies) were trivially
worse than CBT for the whole sample (n = 59; mES: .16) and for RCTs (n = 52,
mES: .19), while high process-guiding therapies (EFT, other HEP) were
equivalent to CBT for the total sample (n = 17; mES = .04) and trivially better for
RCTs (n = 13, mES = .12). On the other hand, in the nine comparisons (eight
randomized) where more process guiding therapies (e.g., EFT, gestalt) were
compared directly to less process guiding therapies (most commonly PCT), the
824
comparative effect sizes for the more process-guiding approaches was only
trivially better (and equivalent for RCTs) and not particularly consistent (total
sample: mES = .14; CI: .21 to .5; Q = 16.9, p < .05; I2 = 53%; RCTs: mES = .08;
CI: .3 to .44; Q = 14.3, p < .05; I2 = 51%.). It is worth noting that process-guiding
exists along a continuum, so that different studies have compared pairs of HEPs at
different points on the spectrum, making it difficult to integrate the results.
Researcher allegiance effects also likely play a role here. Clearly, more research is
needed to explore this key issue.
Outcome for Different Client
Problems: Differential Treatment
Effects
Investigation of HEPs for specific client presenting problems or disorders
has blossomed over the past 20 years. The three lines of evidence (pre-post,
controlled, and comparative studies) are summarized in Table 13.4 for six
commonly studied relatively coherent types of client problem, evaluated both
relative to zero and for bench-marking purposes to the whole sample. In brief, the
largest amount of evidence and the strongest support for HEPs have been found
for depression, relationship problems, coping with chronic medical problems (e.g.,
HIV, cancer), habitual self-damaging behaviors (substance misuse, eating
disorders), and psychosis. There is also considerable, but more mixed, evidence
supporting the application of these approaches with anxiety. In this section, we
provide meta-analytic evidence, summarize key recent studies, and evaluate the
status of HEPs as empirically supported treatments for these six particular client
problems.
Table 13.4 Effect Size by Selected Client Problems/Disorders
Problem/Disorder
Prepost ES
Controlled ES
Comparative ES
n
dw ± 95%CI
n
dw ± 95%CI
n
dw ± 95%CI
Depression
34
1.23 ±
.23*(+)
8
.42 ±. 36*(=)
37
-.02 ± .15(=)
Relationship/inter
personal/trauma
23
1.27 ±
.21*(+)
11
1.39 ± .4*(+)
15
.34 ±.27*(+)
Anxiety
20
.94 ± .22*(=)
4
.50 ± .34*(=)
19
-.39 ± .16*(-)
Medical/physical
25
.57 ± .27*(-)
6
.52 ± .34*(=)
24
-.00 ± .11(=)
Psychosis
6
1.08 ±
.17*(=)
--
--
6
.39 ± .29*(+)
Habit/substance
misuse
13
.65 ± .26*(-)
2
.55 ± .39*(=)
10
.07 ± .23(=)
Total sample
(used for bench-
marking)
201
.93 ± .08*
62
.76 ± .12*
135
.01 ± .06
Note. *p < .05 in null hypothesis test against ES = 0; ns refer to number of client samples (pre-post
ESs) or comparisons with other conditions (controlled and comparative ESs). Benchmarking results
vs. total sample: (=): confidence interval includes benchmark value; (+): confidence interval is
above bench-mark value; (-): confidence interval is below benchmark.
Depression
There are more studies of depression in our data set than any other client
presenting problem, with the strongest evidence provided by pre-post and
comparative treatment studies. We found 34 samples of clients (from 27 studies; n
= 1,287 clients) for whom pre-post effects could be calculated, most commonly
PCT (10 samples), supportive (9 samples), or EFT (8 samples). The weighted
mean pre-post effect size across these 34 samples was large (dw = 1.23, CI: 1.0 to
1.45).
On the other hand, the eight controlled comparisons with no treatment or
waitlist controls provided a somewhat weaker but still statistically significant
weighted effect in the small to medium range (weighted controlled ES: .42; 95%
confidence interval: .06 to .78), including two outliers (Maynard et al., 1993;
Tyson & Range, 1987), the only two negative controlled effects in the data set as a
whole, both small sample studies using nonbona fide group interventions.
The 37 HEP versus non-HEP comparisons (from 23 studies, n = 755 and
1,261 respectively; most commonly CBT) support an equivalence conclusion
(mean comparative dw: –.02; CI: .16 to .13). In fact, substantial (> |.4|) positive
and negative comparative results were evenly balanced (positive: 8; negative: 10;
neutral: 19).
824
Four of the comparisons between more and less process guiding HEPs
involved depressed clients. These studies showed a consistent, reliable and
clinically significant advantage for more process guiding approaches like EFT
(Goldman, Greenberg, & Angus, 2006; Greenberg & Watson, 1998) or gestalt
therapy (Beutler et al., 1991; Tyson & Range, 1987), with a weighted comparative
ES of .44 (confidence interval: .10 to .78).
Two clusters of evidence on depression are worth noting: First, there are
three well-designed RCTs testing EFT for depression (Goldman et al., 2006;
Greenberg & Watson, 1998; Watson, Gordon, Stermac, Kalogerakos & Steckley,
2001) comparing EFT to other therapies in the treatment of major depressive
disorder, using medium-size samples and conducted by two different research
teams. In particular, Goldman et al. (2006) found that EFT had significantly better
outcomes (including very low relapse rates) when compared to PCT. Watson et al.
(2003) found equivalent, and on some measures better, results than CBT. Second,
there are four well-designed RCTs of PCT for perinatal depression with medium
to large sample sizes that either show superiority to treatment as usual (Holden,
Sagovsky, & Cox, 1989; Morrell et al., 2009; Wickberg & Hwang, 1996), or no
difference in comparison to CBT (Cooper, Murray, Wilson & Romaniuk, 2003) or
short-term psychodynamic therapy (Cooper et al., 2003; Morrell et al., 2009). Both
of these clusters of well-controlled studies meet Chambless and Hollon’s (1998)
criteria for efficacious and specific treatments.
Key new studies since our last review include the Cooper et al (2003) and
Morrell et al. (2009) studies with perinatal depression, mentioned above, and two
studies by Mohr and colleagues on depression in a medical population (Mohr, et
al, 2005; Mohr, Boudewyn, Goodkin, Bostrom, & Epstein 2001), to be discussed
later. The other substantial study is Stice, Burton, Bearman, and Rohde (2006;
Stice, Rohde, Gau, & Wade, 2010), in which adolescents with mild to moderate
depression were randomized to one of four conditions: supportive group therapy
versus CBT group therapy versus CBT bibliotherapy versus controls. Participants
seen in supportive therapy showed benefits comparable to those in CBT out to 2-
year follow-ups and did much better than control group clients.
Relationship and Interpersonal Difficulties
Of all client presenting problems, HEPs appear to be most consistently
effective for clients presenting with either specific unresolved relationship issues
or more general interpersonal difficulties. The largest number of the 24 studies
included in our meta-analysis addressed specific relationship problems, generally
within the context of couples therapy (10 studies, e.g., Denton, Burleson, Clark,
Rodriguez & Hobbs, 2000). However, there were also smaller clusters of studies
on general interpersonal difficulties, generally treated individually (six studies,
e.g., Grawe, Caspar, & Ambühl, 1990); and specific emotional injuries, treated
825
either individually or in couples (five studies, e.g., Greenberg, Warwar, &
Malcolm, 2010; Makinen & Johnson, 2006). Finally, we found three studies that
focused on posttrauma difficulties or formally diagnosed PTSD, with some (e.g.,
Szapocznik et al., 2004) including substantial portions of clients with this
diagnosis. The strongest evidence was for EFT-C (emotion- or emotionally
focused therapy for couples), developed by Greenberg and Johnson (1988). We
found 23 samples of clients (from 21 studies; n = 467 clients) for whom pre-post
effects could be calculated, most commonly EFT-C (10 samples), EFT for
individuals (6 samples), PCT (3 samples), and other HEP (4 samples). The
weighted mean pre-post effect size across these 23 samples was large but quite
variable (dw = 1.27, CI: .96 to 1.58; Q = 96.9, p < .001; I2 = 77%). Effects were
somewhat (but not significantly) larger for therapies delivered in couple or family
format (n = 13; dw = 1.50, CI: 1.11 to 1.90) versus being carried out individually
(n = 10; dw = .97, CI: .53 to 1.41).
The 11 controlled comparisons (7 of them RCTs, 7 studies on EFT-C) with
no treatment or waitlist controls provided a very large weighted effect (dw = 1.39;
CI: .99 to 1.79), with all controlled effects being substantial and positive.
There were 15 controlled comparisons (from 13 studies) of clients seen in
HEPs (n = 250) versus non-HEPs (n = 327), most commonly CBT or
psychoeducational interventions. The overall weighted effect was moderately
heterogeneous but points to the superiority of HEPs over non-HEPs for relational
difficulties (comparative dw = .34; CI: .07 to .62; Q = 39.1, p < .001; I2 = 64%).
Seven of the 15 comparative effects were substantial (> |.4|) and positive, with no
substantial effects favoring the alternative treatment. For the eight comparisons
involving EFT (both couples and individual), the weighted effect (dw = .69; CI: .32
to 1.06) was significantly larger than for the five comparisons involving PCT (dw
= .08; CI: .30 to .13). Both forms of EFT appeared to be highly effective: EFT
for couples for addressing relational injuries (3 studies; dw = .88; CI: .16 to 1.92),
and EFT for individuals with unresolved interpersonal issues or abuse suffered by
individuals (5 studies; dw = .62; CI: .26 to .97). In addition, whether the non-HEP
was CBT or psychoeducation made relatively little difference: versus CBT the
weighted effect was .34 (6 studies; CI: .15 to .83); the value for comparisons with
psychoeducation was .51 (n = 4; CI: .10 to 1.13).
EFT for couples has long been included in lists of empirically supported
treatments for marital distress (e.g., Baucom, Mueser, Shoham, & Daiuto, 1998);
however, our meta-analytic data indicate that EFT for individuals is efficacious
and specific for unresolved relationship issues, including emotional injuries
(Greenberg, Warwar, & Malcolm, 2008; Souliere, 1995) such as unresolved abuse
survivor issues (Paivio et al., 2001; Paivio, Jarry, Chagigiorgis, Hall, & Ralston,
2010).
826
Four recent studies not in our meta-analysis support and extend the results
reported here. Two of these underscore and develop the results already reported:
Greenberg, Warwar, and Malcolm (2010) offered promising results for an EFT
couples approach specific to emotional injury and forgiveness. Paivio and
associates (2010) extended earlier results with EFT for individuals who had
experienced childhood abuse (62% met criteria for PTSD), finding that EFT with
empty chair work produced better outcomes but more dropouts than EFT without
chair work. Two other recent pilot studies opened up new areas for working with
relational difficulties but were at the same time consistent with the overall findings
for this client population: In an initial uncontrolled study, McLean and colleagues
(2008) provided promising evidence that EFT-C can help couples improve their
relationship and reduce psychological distress in the face of advanced breast
cancer. Also, in a newly located study, Miller (1999) found that a PCT group was
as effective as a social learning theory-based CBT group for reducing dating
violence in at-risk young people with histories of observing domestic violence or
committing dating violence themselves. (See anxiety section below for discussion
of the evidence on PTSD.)
Anxiety
Research on HEPs for anxiety, most commonly the application of
supportive therapies with panic/agoraphobia or generalized anxiety disorder, is
much more mixed than is the case for depression, but is strongest for pre-post and
controlled studies. We found 20 samples of clients (n = 19 studies, 305 clients) for
whom pre-post effects could be calculated, mostly supportive (8 samples of
clients), PCT (6 samples), and other HEP (5 samples), carried out in studies where
there was a negative researcher allegiance (14 samples). Anxiety disorders studied
included panic/agoraphobia (6 samples), generalized anxiety disorder (6 samples),
phobias (usually chronic or complex; 6 samples), and mixed anxiety (2 samples).
The weighted mean pre-post effect size for the 20 sets of anxious clients was .94
(CI: .73 to 1.16), quite near the bench-mark for the entire sample of pre-post
effects (see Table 13.4). Although the confidence intervals all overlapped, pre-post
effects varied significantly across type of HEP (Q = 8.17; p < .05), with effects for
supportive treatments somewhat smaller (dw = .66; CI: .40 to .92) than for PCT (dw
= 1.0; CI: .71 to 1.28) or other HEP (dw = 1.41; CI: .84 to 1.97).
There were only four controlled studies, all with relatively small samples (<
25); these showed a controlled effect size of .5 (CI: .17 to .83) a medium effect
size slightly but not statistically significantly less than the bench-mark value of .76
for the entire sample.
Of the six client population clusters we are reviewing for comparative
effects in this chapter, HEPs fared most poorly with anxiety problems, with a
mean comparative effect size of.39 (CI: .55 to .23) across 19 comparisons
827
with non-HEP. This is consistently, moderately and significantly in favor of the
non-HEPs, almost all some form of CBT. Nine of the 18 comparative effects with
CBT substantially favored CBT (<.4), with none favoring an HEP. In
comparisons with CBT, there was very little variation (dw = .42 to .36) across
type of HEP (supportive, PCT, other).
Applying the Chambless and Hollon (1998) criteria to specific types of
anxiety disorder, the picture is clearest for generalized anxiety disorder, where six
of nine comparisons substantially favored CBT, including studies by two
independent research teams (Bond, Wingrove, Curran, & Lader, 2002; Borkovec
et al., 1987; Borkovec & Costello, 1993; Borkovec & Mathews, 1988); the other
three comparisons showed equivocal results (Blowers, Cobb, & Mathews, 1987;
Borkovec & Mathews, 1988; Stanley, Beck, & Glassco, 1996). Here, the
preponderance of the evidence, both in terms of overall effect size (dw = .44) and
numbers of studies and independent research teams, clearly favors CBT. The
picture for panic/agoraphobia was somewhat more complicated: Two of the 6
comparisons favored CBT over HEP (from independent research teams: Beck,
Sokol, Clark, Berchick, & Wright, 1992; Shear, Houck, Grenno, & Masters,
2001), with one comparison favoring medication over HEP (Shear et al., 2001),
and three having equivocal results (Craske, Maidenberg, & Bystritsky, 1995;
Shear, Pilkonis, Cloitre, & Leon, 1994; Teusch, Böhme, & Gastpar, 1997).
Nevertheless, the weighted effect for panic/agoraphobia was.39 (CI: .75 to
.04). Thus, it can be said that for panic that the preponderance of the evidence
somewhat favors CBT over HEP. Finally, for the three comparative studies of
phobia, either complex or chronic phobia (Grawe, 1976; Johnson, 1977) or social
phobia (Cottraux et al., 2000) all reported equivocal comparative effects (dw =
.15).
At the same time, we found substantial pre-post effects for the great
majority of anxiety studies, indicating that HEPs for anxiety meet Chambless and
Hollon’s (1998) criteria as possibly efficacious, while also suggesting that CBT
may be somewhat more specific and efficacious. This apparent moderate CBT
advantage is likely due to two possible factors. To begin with, it is likely to be due
in part to researcher allegiance effects: When allegiance-controlled effects were
analyzed, the difference, though still statistically significant, shrank to .21 (CI:
.38 to .05). In addition, it now seems likely to us that anxiety disorders may
respond somewhat better to more structured treatments that include a
psychoeducation component, such as CBT, as opposed to the predominantly
nondirective forms of HEPs that have so far been studied. Interestingly, two recent
studies of GAD point to potential benefits from adding forms of HEP to CBT:
Newman et al. (2011) combined either supportive-nondirective therapy or
interpersonal emotion processing therapy to CBT on a session-by-session basis;
they reported no significant differences at post or follow-up but large pre-post
effects for the two treatments combined (d = 1.86). In addition, Westra and Dozois
828
(2006) found that adding three sessions of motivational interviewing (adapted for
anxiety) prepared clients better for subsequent CBT and was associated with better
treatment response and posttherapy maintenance of gains.
In our clinical experience, clients with significant anxiety difficulties
frequently have a problem with the lack of structure of typical of nondirective
therapies, often asking directly for expert guidance. For this reason, several of the
authors of this chapter are currently conducting studies on the effectiveness of
EFT with generalized anxiety (Watson, Timulak) or social anxiety (Elliott); Elliott
and colleagues (2010) have reported promising initial results from their study in
progress comparing PCT and EFT to each other and to published CBT outcome
benchmarks. For now, our advice for humanistic-experiential therapists is to
discuss the issue with clients, to consider adding process guiding elements to their
therapy, or to provide information about the role of trauma or emotional processes
in panic attacks (e.g., Wolfe & Sigl, 1998).
Finally, it is worth noting that although there is good evidence that HEPs,
especially EFT, are effective with relational/interpersonal difficulties and even the
long term sequelae of childhood trauma reviewed in the previous section, there is
little research on PTSD per se. Further, the results reviewed here for other anxiety
disorders are not encouraging as a basis for extrapolating to PTSD. It is
particularly difficult to generalize from these various studies examined here to full
blown or nonrelationally focused PTSD, especially PTSD due to combat (e.g.,
Ragsdale, Cox, Finn, & Eisler, 1996). Further research on HEPs for PTSD is
urgently needed.
Coping With Chronic Medical Conditions
The use of HEPs to help clients coping with chronic or life-threatening
medical illnesses has burgeoned in the past 20 years, with studies more than
tripling since our 2004 review. Our 2008 meta-analysis sample turned up 29
studies (n = 1145 clients). The most common form of HEP studied was
supportive-expressive group therapy, an existential-experiential treatment
developed by Spiegel, Bloom, and Yalom (1981), which was the subject of 12
studies in our meta-analysis. Person-centered and supportive therapies were each
examined in seven studies. Coping with a broad range of medical conditions has
now been investigated, the most common being cancer, both early stage/remitted
(7 studies) and late stage/metastatic (7 studies); however, autoimmune disorders
such as lupus, MS, and rheumatoid arthritis are now being investigated (5 studies),
and the meta-analysis also includes two studies each for gastrointestinal problems
(IBS, colitis, Crohn’s), HIV-positive status, and pain (back- and head-ache) as
well as four studies of other conditions (kidney, vitiligo, cardiac rehabilitation,
sleep problems). Of the studies, 17 (59%) were carried out by researchers with a
favorable researcher allegiance, and 17 were in a group format (see also the review
829
by Burlingame et al., examining group psychotherapy, this volume). The overall
weighted mean pre-post effect size across the 25 samples for which pre-post
effects could be calculated was medium in size but highly inconsistent (dw = .57,
CI: .3 to .84; Q = 195.1, p < .001; I2 = 88%). Statistically significant pre-post
effects (dw) were found for autoimmune conditions (.68; CI: .08 to 1.29), early
stage cancer (.55; CI: .28 to .83), early/late cancer combined (.62; CI: .18 to 1.05),
and other medical conditions (.42; CI: .09 to .75).
There were six controlled studies versus no treatment/wait list, on diverse
client populations (early stage cancer, cardiac, kidney, vitiligo); overall, these
showed a fairly consistent medium effect size of .52 (CI: .19 to .86; Q = 7.5, NA;
I2 = 33%), although the effects for the three older studies of early/remitted cancer
were smaller and not statistically significant (dw = .36; Dircks, Grimm, Tausch, &
Wittern, 1982; Katonah, 1991; van der Pompe, Duivenvoorden, Antoni, Visser, &
Heijnen, 1997).
There were 19 comparative studies, including 24 comparisons to non-
HEPs. All but three comparisons were randomized (88%) and all but two used
bona fide treatments (92%). The most common HEPs were PCT (9 comparisons),
supportive (7 studies) and supportive-expressive groups (7 studies); HEPs were
most often applied to helping clients cope with autoimmune disorders (7 studies),
cancer early/remitted or late/metastatic (4 studies each), HIV positive status (3
studies). The most common non-HEPs were CBT (11 studies) and treatment as
usual (8 studies). Researcher allegiances were roughly evenly divided (pro: 42%;
con: 46%; neutral 13%).
The overall comparative effect was a clear and highly consistent
equivalence finding (dw = .00; CI: .11 to .10; Q = 27.7, NS; I2 = 17%). Only
three comparisons substantially (> .4) favored non-HEPs therapies, two of these
from the same study (Machado, Azevedo, Capanema, Neto & Cerceau, 2007;
Mohr et al., 2001). Twenty effects were within .4 of each other, while one effect
favored an HEP (Spiegel et al., 1981). Furthermore, there were no differences in
comparative effects between PCT, supportive, and supportive-expressive group
therapies (between groups Q = 1.85, NS). However, there was a trend for
comparisons with CBT (dw = .13; CI: .29 to .02) to be slightly larger than
comparisons with other non-HEP treatments (dw = .07; CI: .07 to .21; between
groups Q = 3.47; p = .06). Furthermore, there were clear differences between
different medical conditions (Q = 15.4, p < .01), with the strongest comparative
effects for coping with advanced cancer (dw = .28; CI: .10 to .47). HEPs appeared
to do less well with autoimmune conditions when compared to non-HEPs (dw =
.22; CI: .44 to .01, p = .06), as illustrated particularly in the two studies of Mohr
and colleagues (2001, 2005) on clients with MS and depression.
Given the diversity of medical conditions and treatments studies, it is
difficult to apply the Chambless and Hollon (1998) criteria to this set of studies.
830
Nevertheless, from these data, it appears that HEPs are efficacious treatments for
helping clients cope with a variety of medical conditions, based on (a) their
superiority to no treatment control conditions; and (b) their general equivalence to
an established treatment (CBT).
However, a word of caution is in order: A recent search turned up at least
20 more studies on HEPs on this topic, about half of them on cancer, with the rest
on a variety other medical conditions, especially cancer, HIV, chronic pain,
rheumatoid arthritis, and so on. This is certainly an indicator of the vitality of this
area of research on HEPs; but there is a strong possibility that these additional
studies will modify the conclusions that can be made about HEP for medically ill
populations. This is particularly true for supportive-expressive group therapy for
cancer, which has been the subject of intense scientific scrutiny over the past 10
years, including a recent failure to replicate by the originator of the approach
(Spiegel et al., 2007) and a large Canadian multicenter trial on the use of
supportive-expressive group therapy to improve quality of life for women with
metastatic breast cancer, which failed to show a benefit over a no treatment/usual
care control (Bordeleau et al., 2003). This led a recent Cochrane review (Edwards,
Hulbert-Williams, & Neal, 2008) to conclude, “There is insufficient evidence to
advocate that group psychological therapies (either cognitive behavioural or
supportive-expressive) should be made available to all women diagnosed with
metastatic breast cancer.”
The reviewers did, however, note that there was some positive evidence on
psychological (as opposed to medical) outcome variables, especially in the short
term. For now, the search continues for promising client subpopulations (e.g.,
estrogen-negative breast cancer; Spiegel et al., 2007) and target variables (e.g.,
fear of disease progression, relationship variables, treatment decision making). It
is also worth noting that the new comparative outcome data appear to support our
main conclusion of outcome equivalence between HEP and CBT for coping with
breast cancer. However, the main issue here appears to be whether any
psychosocial treatmentCBT or supportive-expressive group therapy included
can improve survival rates and psychological adjustment with breast cancer, either
early stage or metastatic. We hope that further research now in progress will
clarify this important issue.
Psychosis
The use of HEPs for clients diagnosed with psychosis, including
schizophrenia, has become controversial, particularly in the United Kingdom,
where the latest version of the Department of Health’s treatment guidelines
(National Collaborating Centre for Mental Health [NICE], 2010) effectively
banned the practice via the following negative recommendation: “Do not routinely
offer counselling and supportive psychotherapy (as specific interventions) to
831
people with schizophrenia” (p. 290). This proclamation has had the effect of
wiping out a United Kingdom tradition of offering person-centered counseling to
individuals living with psychotic processes, documented by Traynor, Elliott, and
Cooper (2011), and marked by the recent advances, including the addition of
special methods for making psychological contact with clients when they are in
psychotic states (Dekeyser, Prouty, & Elliott, 2008).
The full NICE 2010 guideline includes extensive documentation from the
evidence survey on which the recommendation was supposedly based. Thus, it
was not difficult for us to carry out a quick, rough analysis of the evidence from
the nine studies comparing the supportive treatments (defined in the document as
person-centered in orientation) to CBT in the NICE 2010 evidence survey (see
Appendix 16D): Contrary to the strongly negative guideline, the data reported in
the evidence survey instead point to a trivially small superiority for CBT over
supportive counseling: mean d = .19; mean relative risk ratio = 1.08. In addition,
these overall mean effects were characterized by large standard deviations (.59,
.32 respectively), indicating substantial heterogeneity. In fact, there are many
instances in the NICE data summary where supportive treatments actually did
substantially better than CBT (e.g., Tarrier et al., 2000, at 19-month follow-up).
Two possible interpretations of these data appear to fit the evidence better than
that drawn by the NICE committee: First, supportive treatments are almost as
effective as CBT, even without the benefit of recent focused treatment
development efforts and even when carried out by researchers with an anti-HEP
theoretical allegiance. Second, more conservatively, the data are too inconsistent
to warrant any overall conclusions at the present moment.
Although the committee defined supportive counseling as person-centered,
the NICE 2010 evidence base is a mixture of different approaches, not all of them
HEPs. Nevertheless, our meta-analysis data set does contain six studies (mostly
RCTs) of patients with schizophrenic or psychotic diagnoses for which pre-post
effect sizes could be calculated (Coons & Peacock, 1970; Dekeyser et al., 2008;
Eckert & Wuchner, 1996; Serok & Zemet, 1983; Tarrier et al.,1998; Teusch,
1990), involving a total of 209 clients seen in treatments explicitly labeled as
nondirective, gestalt, or PCT, including a promising recent form of PCT called
pre-therapy. Clients were seen in both inpatient and outpatient settings and in a
mixture of individual and group formats and evaluated on a range of measures,
including symptom and life functioning ratings. The weighted pre-post effect size
for these six studies was 1.08 (CI: .51 to 1.65). Although uncontrolled, these
effects nevertheless demonstrate very large pre-post effect sizes with this chronic
and severely distressed clinical population.
Second, although there were no studies comparing an HEP to a no-
treatment or wait-list control condition, we did locate five comparative treatment
RCTs (Coons, 1970; Dekeyser, 2008; Serok, 1983, 1984; Tarrier 1998), providing
six comparisons to non-HEPs and a total of 170 patients (75 in HEP). The HEPs
832
were explicitly labeled as nondirective, gestalt, or pre-therapy; the non-HEPs were
most commonly labeled as treatment as usual, but one study each involved CBT
or exercise. The mean comparative effect size across the six comparisons was .39,
in favor of HEP (CI: .10 to .67). This is a moderately large, fairly consistent
controlled effect size that supports the effectiveness of HEP versus standard care
for clients with schizophrenia or other psychotic diagnoses, and contrasts strongly
with results of the studies reviewed by the NICE review committee.
Probably the safest conclusion here is that, based on existing evidence,
HEPs appear to be, in Chambless and Hollon’s (1998) terms, possibly efficacious.
In other words, they are promising but require further development and outcome
research, especially in light of developments in both the HEP approaches (e.g.,
new pre-therapy and process-guiding treatments, see Traynor et al., 2011) and in
CBT (the advent of new person- or acceptance-based forms of CBT for
schizophrenia, e.g., Chadwick, 2006).
Habitual Self-Damaging Activities
Recurrent self-damaging activities such as substance misuse and eating
disorders are the subject of an emerging body of evidence using a wide variety of
HEPs, including 13 studies already in our meta-analysis, with 15 samples (total n
= 413) of clients focusing on recurrent, self-damaging habit difficulties,
predominantly substance misuse (11 samples of clients) and eating difficulties (3
samples). (There was also one study on Tourette’s syndrome; Wilhelm et al.,
2003.) The weighted pre-post effect was .65 (CI: .39 to .90). Effects were
comparable for substance misuse (dw = .68; CI: .36 to .99) and eating difficulties
(dw = .62; CI: .12 to 1.11).
There were two controlled studies of substance misuse (Sellman, Sullivan,
Dore, Adamson, & MacEwan, 2001; Washington, 2001) versus no treatment or
wait-list controls, with a weighted effect of .55 (CI: .17 to .93). Nine studies (7
RCTs, 10 comparisons of clients) compared a range of HEPs (supportive and other
HEP were most common) to other treatments, most often CBT (6 studies). The
weighted comparative effect was .07 (CI: .15 to .30), indicating that HEPs and
non-HEPs for habit difficulties were equivalent in effectiveness. For the six
comparisons with CBT, the value was .03 (CI: .41 to .35), an equivalence
finding in terms of effect size but including the |.4| boundary. Six of the
comparisons involved treatments for substance misuse; the weighted effect for
these comparisons was .16 (CI: .05 to .38). Finally, there were three comparisons
between HEPs and CBT for substance misuse (dw = .16; CI: .27 to .60). Seven of
the 10 comparative effects were relatively small (<|.4|). However, two studies
both on alcohol problemsproduced effects that substantially (> .4) favored HEPs
(Jacobs & Bangert, 2005; Wetzel et al., 2004). The one study on Tourette’s
833
(Wilhelm et al., 2003) yielded a very strongly negative comparative effect (<.8)
for a comparison between supportive therapy and CBT.
Overall, the preponderance of the current evidence, including both
controlled and comparative treatment lines of evidence, indicates that HEPs meet
the ChamblessHollon standards as an efficacious treatments for substance misuse
(i.e., problems with alcohol and cocaine): Consistent with our meta-analysis, they
have been shown to be superior to no treatment controls (two good-size,
independent RCTs: Sellman et al., 2001; Washington, 2001); at the same time, the
comparative treatment evidence (2 independent n > 25 studies) indicates that they
are either equivalent or superior to an already established treatment, CBT
(Washington, 2001; Wetzel et al., 2004). The evidence on the use of HEPs for
eating difficulties, however, remains equivocal at this point: there are only two
small studies of overeating (Holstein, 1990; Kenardy, Mensch, Bowen, Green, &
Walton, 2002), with equivocal, no difference results. As for Tourette’s syndrome,
supportive therapy might be inferior to CBT (specifically, habit reversal), but so
far there is only a single, negative researcher allegiance, small n study (Wilhelm et
al., 2003).
Our meta-analysis missed at least one noteworthy recent study of an HEP
for eating difficulties, a good-size German-language RCT by Schutzmann,
Schutzmann & Eckert (2010), in which person-centered therapy had better results
than guided self-help for bulimia. In addition, an EFT group treatment on a sample
of 12 bulimic clients was associated with statistically significant decreases in the
frequency of binge episodes, improvements in eating disorder related
psychopathology, depression, alexithymia, emotion regulation, self-esteem,
general psychiatric distress, and self-efficacy (Wnuk, 2009).
A more significant omission is that we have not to date included research
on motiviational interviewing (also known as motivational enhancement therapy,
Miller & Rollnick, 2002), described as a directive form of client-centered therapy,
adapted for clients who engage in patterns of self-damaging activity such as
excessive drinking. This approach is often quite brief (< 3 sessions) and mixes
PCT with significant information and feedback, making it difficult to categorize in
spite of its clear roots in HEP and its large evidence base. Fortunately, a recent
meta-analysis by Lundahl et al. (2010) provides up-to-date, comprehensive
coverage of 119 controlled and comparative studies of motivational interviewing
for a variety of habitual self-damaging activities (about 80% substance misuse),
including 35 wait-list controlled studies, with an overall mean effect of .32 (CI:
.22 to .42); 42 comparisons with nonspecific treatment as usual (dw = .24; CI: .17
to .31); and 39 comparisons with specific evidence-based alternative treatments
(primarily 12-step or CBT; dw = .09; CI: .01 to .18). These results are roughly
comparable to ours, especially for the comparative studies.
834
Qualitative Outcomes in Humanistic-
Experiential Psychotherapies
The increased use of qualitative methods in the field of psychology
generally, and for psychotherapy research specifically (see McLeod, this volume)
has produced enough findings examining outcome to allow for a “meta-analytic”
style of review (see Timulak, 2009). Timulak and Creaner (2010) recently
conducted a qualitative meta-synthesis of qualitative studies on HEPs, covering
outcome descriptions from 106 clients participating in a variety of HEPs (such as
EFT and PCT). The data collection method most typically used was a posttherapy
(follow-up) interview, such as the client change interview (Elliott, Slatick, &
Urman, 2001).
Timulak and Creaner (2010) reported 11 categories that offered a
comprehensive conceptualization of the outcomes reported by clients in individual
HEPs (see Table 13.5). They found that many of the qualitative outcomes in the
original studies corresponded with humanistic-experiential theories of therapy
outcome. For instance, healthier emotional experiencing, empowerment,
resilience, and increased self-awareness are traditionally emphasized as potential
outcomes of HEPs (cf. Greenberg, 2010). It is interesting to note that the clients in
these therapies also reported outcomes that are likely to be shared with other
approaches to therapy such as mastery of symptoms (CBT) or improved
interpersonal functioning and insight (psychodynamic approaches).
Two findings are, however, of particular interest. One of them is increased
self-compassion. Though it resonates with the traditional concept of self-
acceptance (cf. Rogers, 1961), it also captures the uniquely, warm, emotional
quality of this type of self-relating. The other interesting finding is that of
appreciating vulnerability as an outcome of therapy. This finding stands in quite
the opposite position to the mainstream focus on symptom relief. Though
unexpected, it is fully compatible with HEP theories, which place an emphasis on
authentic being. Authentic being is not necessarily free of suffering and pain.
However, clients apparently still appreciate that overcoming the avoidance cutting
them off from fulfilling their needs in life is worth the risk of pain and suffering.
The finding that some clients prefer settling for no change rather than risking pain,
however, illustrates that this process may not be that straightforward or always
pursued by clients in therapy (cf. Lipkin, 1954). What is interesting is that only
two of the reviewed studies included negative outcomes of therapy. These
included nonresolution of the problem(s) that led clients to seek therapy, feeling
overwhelmed, feeling harmed by the therapist, disappointment over not being
understood by the therapist, and, interestingly, fear of changing and a consequent
increase in emotional restriction thereby preventing change.
835
Timulak and Creaner’s (2010) qualitative meta-synthesis of outcomes in
HEPs is one of the first of its kind, so it may be too early to draw firm conclusions
from it. However, an independently conducted qualitative meta-synthesis by
Elliott and colleagues (Elliott, 2002b) that also included unpublished studies, as
well as recent case studies that also included qualitative assessment of outcome
(e.g., Stephen, Elliott, & Macleod, 2011) draw very similar conclusions.
Table 13.5 Qualitative Outcomes/Effects Reported in Timulak and Creaner (2010)
Qualitative Meta-Synthesis
Main Meta-
Category
Meta-Categories
Primary Studies Findings
A. Appreciating
experiences of self
1. Smoother and
healthier emotional
experiencing
Hopefulness (Klein & Elliott, 2006), peace
and stability (Klein & Elliott, 2006), emotional
well-being, greater sense of energy (Klein &
Elliott, 2006); calmer, at peace (Elliott,
2002a; Lipkin, 1954); improved mood,
optimism (Elliott et al., 1990); general
openness to own feelings (Elliott et al.,
1990); ability to express and contain feelings
(Dale, Allen, & Measor, 1998); feeling more
free and easy, more light and lively (Lipkin,
1954) (4/8; i.e., 4 out of 8 studies on
individual therapy)
2. Appreciating
vulnerability
Permission to feel the pain (Rodgers, 2002);
transparency (dropping barriers and
defenses) (Rodgers, 2002); honest with self
(Elliott, 2002a; Rodgers, 2002); open to
change (Elliott, 2002); awareness of being
old, process of grieving, grieving is undoing
problematic anger/anxiety (Elliott, 2002); self-
acceptance of existential isolation (Dale et
al., 1998) more tolerant of difficulties and set-
backs (Elliott et al., 2009) (4/8)
3. Experience of
self-compassion
Self-esteem, self-care (Klein & Elliott, 2006),
improved self-esteem (Elliott et al., 1990);
engagement with self (experiencing support
from within) (Rodgers, 2002); valuing self
(Dale et al., 1998) (4/8)
4. Experience of
resilience
restructuring (recycling the bad things)
(Rodgers, 2002); insight first painful then
feeling better (Lipkin, 1954) (2/8)
5. Feeling
empowered
Self-confident, strength within (Rodgers,
2002; Klein & Elliott, 2006; Lipkin, 1954);
General sense of well-being: health, energy,
activities (Klein & Elliott, 2006), newfound or
improved abilities to act (Klein & Elliott,
2006); improved general day-to-day coping
(Dale et al., 1998); giving self credit for
836
accomplishments, try new things, reading
(Elliott, 2002); improved ability to cope (Elliott
et al., 1990); preparing to take action to deal
with problems (Elliott et al., 1990); specific
wishes/attitudes strengthened (Elliott et al.,
1990); being able to make decision, gaining
control over life (Lipkin, 1954; Rodgers,
2002; Timulak, Belicova & Miler., 2010); able
to stand up for self, more initiative instead of
fear of doing things (Lipkin, 1954) (7/8)
6. Mastering
symptoms
Can cross bridges, can fly (Elliott et al.,
2009); symptoms went one by one, sudden
relief (Lipkin, 1954) (2/8)
7. Enjoying change
in circumstances
Improved nonrelationship aspects of life
independent of therapy (Elliott et al., 1990;
Elliott, 2002a) (2/8)
B. Appreciating
experience of self
in relationship with
others
1. Feeling
supported
Feeling respected by children, seeking
support group (Klein & Elliott, 2006). Note:
Reported changes in others’ view of self
(Elliott et al., 1990); people tell me I am a
nicer person (Elliott et al., 2009). In many
studies attributions to therapy/therapist as
providers of support (3/8)
2. Enjoying
interpersonal
encounters
Better interpersonal functioning (all,
romantic, family) (Klein & Elliott, 2006);
reordering relationships (Dale et al., 1998);
being able to cope with reactions of others
(Timulak at al., 2009); increased
independence/assertion (Elliott et al., 1990);
increased positive openness (Elliott et al.,
1990); improved relationships (Elliott et al.,
1990); better relationship with my spouse,
more tolerant (Elliott at al., 2009) (5/8)
C. Changed view
of self/others
1. Self-insight and
self-awareness
Development of meaning and understanding
of abuse, learning from therapy (Dale et al.,
1998; Lipkin, 1954); more aware and true to
myself (Klein & Elliott, 2006); realizations
about self (Elliott et al., 1990); enlightened
(problem fitting in like a glove), better
understanding self (I am not in the dark, I can
do something about it), seeing patterns
(Lipkin, 1954) (4/8)
2. Changed view of
others
See other viewpoints (Klein & Elliott, 2006);
being more interested in others (Timulak et
al., 2009); changes in client views and
attitudes toward others (Elliott et al., 1990);
accepting parent faults (Timulak at al., 2009)
(3/8)
837
Note. From. (2010). “Qualitative meta-analysis of outcomes of person-centred/experiential
therapies,by L. Timulak & M. Creaner, 2010, in M. Cooper, J. C. Watson, & D.
Hölledampf (Eds.), Person-centred and experiential psychotherapies work, Ross-on-
Wye, United Kingdom: PCCS Books, pp 75-76. Copyright Ladislav Timulak and Mary
Creaner, 2010, Adapted with permission.
Qualitative Process Research on
Humanistic-Experiential
Psychotherapies
For this review we looked for qualitative research on HEPs and included all
process studies identified by searching PsychInfo using combination of the key
words humanistic/experiential/client-centered/emotion-focused therapywith
qualitative process research(we also included some studies referenced in the
selected studies). We located 22 studies on HEPs that included a relevant
qualitative research element. (We did not include studies that focused solely on the
therapists’ opinions about or experiences of therapy, e.g., Geller & Greenberg,
2002, studies that used traditional content analysis, e.g., Lietaer, 1992, or studies
that used exclusively nominal scales with preset categories, e.g., Nicolo et al.,
2008.)
Client General In-Session Experiences of
Therapy
Qualitative studies of psychotherapy often focus on client experiences of
therapy, either in general or in particular aspects (client-identified significant
events studies are discussed separately). A landmark in research on client
experiences was the work of Rennie (1990, 1992, 1994a, 1994b), who interviewed
14 clients of predominantly humanistic (person-centered and Gestalt) therapists
about one of their recent therapy sessions. The interview (Interpersonal Process
Recall, IPR; Elliott, 1986) was assisted by a recording of the session and clients
were encouraged to stop the tape at any point where they remembered something
meaningful happening; they were asked to describe the recalled experience.
Clients’ accounts were then analyzed using a version of grounded theory analysis
(Rennie, Phillips, & Quartaro, 1994). Rennie documented many interesting
phenomena, including showing how clients in the therapy session were engaged in
a twofold process of pursuing personal meaning for themselves while also
838
monitoring the therapist. Clients evaluated therapist interventions in terms of their
compatibility with client plans or strategies for the session. The clients were also
deferential toward the therapists (they did not confront them with criticism) and
preferred to tolerate therapist shortcomings rather than challenge them. Most of
the findings reported by Rennie have since been replicated by others, for example,
Moerman and McLeod (2006), who used the IPR method with six clients who
took part in person-centered counseling for alcohol-related problems.
A variation of Rennie’s method was used by Watson and Rennie (1994),
who investigated client experiences during evocative unfolding, an EFT
intervention. Using IPR, eight clients with interpersonal problems were
interviewed about their experiences during unfolding interventions. The authors
reported that during this intervention clients were involved in creating a symbolic
representation of their experiencing of the puzzling situation, reflectively
examining their own experience and achieving new realizations that led to revision
of self-concepts and understandings. These processes were either helpful and
flowing, with the interaction between the client and the therapist being
collaborative, or else they were hindering, in which case the flow was interrupted
and the client felt confused by the therapist. The authors also noted that the
intervention led to more new realizations and revisions of the self-concept when
accompanied by client emotional experiencing along with curiosity and interest in
recalling and re-examining disturbing material.
Client Retrospective Experiences of Helpful and
Hindering Aspects of Therapy
Several recent studies of HEPs used client interviews given at the end of
therapy to study helpful aspects of therapy (Knox, 2008; Lillie, 2002; Meyers,
2000; Rodgers, 2002; Schnellbacher & Leijssen, 2009). Overall, research on client
experiences of helpful aspects of HEPs studies underscores the central importance
of the relational qualities offered by the therapist, not only for client perceived
safety in the relationship but also for the client perceived personal change. These
studies show that therapist empathic skills may play a central role in fostering the
development of insight and a new self-understanding in clients, and that clients
appreciate having a space devoted to tracking their own experiencing and
expression of feelings. Additionally, clients appear to be reflective and to
intentionally follow their own agenda, an observation still not adequately stressed
in the theoretical literature. These studies also show that therapist misattunement
(either from active misunderstanding or superficial interaction) may threaten the
therapeutic work, and that this misattunement may not be pointed out to the
therapist (cf. Rhodes, Hill, Thompson, & Elliott, 1994), although it can be
tolerated by at least some clients.
839
Research on Helpful and Hindering Events
Helpful and hindering significant events studies represent a unique genre of
research often using mixed methods. Significant events research focuses on the
most helpful or hindering client-identified events in therapy sessions, which are
subsequently studied in-depth by using the client descriptions to locate the event
on the session recording. The recording of the event is then played back for the
client and therapist in order to learn about their experience of the event (Elliott,
1985; Timulak, 2007, 2010). Given that the events are chosen by the client (as
opposed to the researcher or the therapist), this type of research fits well with the
humanistic-experiential paradigm, which gives voice to the client’s felt
experience.
Studies of helpful and hindering events (Grafanaki & McLeod, 1999, 2002;
Timulak & Elliott, 2003; Timulak & Lietaer, 2001; Timulak et al., 2010), like
those on client perceived outcomes and retrospective experiences just reviewed,
show the importance of both fostering client safety in therapy and also its potential
fragility. They also show that therapist skills at facilitating relational, empathic,
and experiential processing can help the client to bear emotional pain, bring new
awareness and insight, and help bring about a new sense of empowerment. These
in-session events may thus be memorable experiences that can lead to a lasting
impact. In these studies clients typically experienced the quality of relationship as
a mutual encounter that had an enduring impact. For some it improved the
therapeutic relationship and for others it was a moment of personal change. In
general, the therapist’s skillful clarification, guidance, compassionate presence,
interpersonal affirmation, and awareness-promoting communication of empathic
understanding contributed to helpful impacts, but sometimes private inner work by
the client played an important role as well. In hindering events client vulnerability
and occasionally therapist anxieties played role.
Qualitative Change Process Case Studies
Several qualitative studies examined processes perceived by clients to bring
about change in HEPs. The most typical strategy for this kind of research was the
intensive case study (for instance, Elliott’s, 2002a, Hermeneutic Single Case
Efficacy Design), which collects a mixture of quantitative and qualitative process
and outcome data from several sources while also offering a qualitative analysis of
causal links between the therapy outcome and therapeutic processes. By means of
this analysis Stephen, Elliott, and Macleod (2011) captured the connections
between an improvement of a client with social phobia and her participation in
PCT, while Elliott (2002a) reported on the change processes in EFT for a client
diagnosed with bipolar disorder. The studies identified, for instance, the
importance of client experience of connection on a human level, increase in
840
awareness of their own needs, support offered, and credit attributed to the therapist
for bringing the client to experiences that the client would normally have avoided.
Several studies have analyzed HEP cases using the Assimilation of
Problematic Experiences protocol (Stiles, 2002). Assimilation analysis tracks
clients on a 7-stage stage model, in which the main foci of therapy are analyzed on
a continuum ranging from being warded-off, through insight into their nature until
they are mastered. The method uses the Assimilation of Problematic Experiences
Scale (APES) as a qualitative framework for understanding the change process in
therapy. APES was applied to three cases of EFT for depression (Brinegar, Salvi,
& Stiles, 2008; Honos-Webb, Stiles, Greenberg, & Goldman, 1998; Honos-Webb,
Surko, Stiles, & Greenberg, 1999) and one case of PCT for depression (Osatuke,
Glick, Stiles, Shapiro, & Barkham, 2005). The studies highlighted several
interesting findings. For instance, a comparison of a successful versus an
unsuccessful case (Honos-Webb et al., 1998) not only revealed more advanced
assimilation of problematic issues in the successful case, but also showed that the
successful case sustained a clear focus of therapy, while the unsuccessful one did
not. The same successful case was re-analyzed by a somewhat different team
(Brinegar et al., 2008) who found that the change (assimilation of problematic
experiences) could be conceptualized as assimilation of two important
empowering voices.
Another assimilation analysis of successful EFT (Honos-Webb et al., 1999)
and PCT (Osatuke et al., 2005) cases showed a major change process to be the
clientsgradual recognition of their own needs and the empowerment they
experienced from standing up for self. Although assimilation analysis focuses on
client change processes, careful reading of these cases along with the comments of
the researchers (e.g., Osatuke et al., 2005) indicates that therapist affirmation of
the client’s previously disowned needs often played a crucial role in the change
process.
Interestingly, one of the successful EFT cases analyzed using an APES
framework (Brinegar et al., 2008; Honos-Webb et al., 1998) was also analyzed
using the innovative moments coding system framework (Gonçalves, Mendes,
Ribeiro, Angus, & Greenberg, 2010). This analysis, though using a different
conceptual framework, converged with the assimilation analysis, reporting that the
client’s protest moments, in which she reclaimed her needs, allowed her to create a
distance from significant others by whom she felt let down.
It is obvious that various theoretical frameworks such as assimilation of
problematic experiences or similar theory-laden studies (e.g., Stinckens, Lietaer, &
Leijssen’s [2002] study on resolution of inner criticism) can be used to illustrate
changes clients undergo in therapy. These changes might, however, just be
accompanying epiphenomena that correspond with progress in therapy, but may
not necessarily capture the core causal processes in change. Indeed, the more
841
open-ended Hermeneutic Single Case Efficacy Design studies had greater
difficulty in identifying clear, unambiguous links. Regardless of this, it seems that
all of the reported case studies and the change processes tracked in them suggest
that change comes via (a) the therapist responding to the client’s core hurt/pain;
(b) mobilization of the client’s previously obscured unmet needs (typically to be
respected, close, or secure); (c) the therapist offering compassion and affirmation
to those unmet needs, as well as the client’s self-compassion or protective
anger/determination. These observations, reported by a variety of teams, are in line
with recent work on change processes using a task analytic approach (e.g.,
Pascual-Leone & Greenberg, 2007).
Limitations of Qualitative Research on
Humanistic-Experiential Therapies
Qualitative research on HEPs gives voice to client (and therapist)
experiences of therapy and also provides a flexible framework that can facilitate
studying the complexity of therapeutic change processes. Nevertheless, it is useful
to be aware that these studies were conducted with clients with unrelated
presenting issues, such as mood and anxiety disorders, and alcohol misuse, and
may thus represent different underlying change processes. Also, there seems to be
a lack of qualitative studies that use HEP theoretical frameworks for interpreting
change processes and client experiences. For instance, the richness of APES
studies (which use a rather trans-theoretical framework) illustrates how
theoretically informed investigations of HEPs might look. As qualitative research
is still a relatively recent development, the quality of studies reviewed here varied
widely. Further attention needs to be devoted to raising standards in this area of
research (cf. Elliott, Fischer, & Rennie, 1999; Chapter 3, this volume).
Quantitative Process Research on
Humanistic-Experiential
Psychotherapy
Research on the process of change is foundational to HEP approaches, as
research clinicians within this approach have tried to specify the therapist and
client processes that contribute to successful outcomes. Historically the focus of
this research agenda has been on general therapeutic relationship conditions or
attitudes as delineated by Rogers (1959) and on client experiencing (Gendlin,
1981). This has changed over time to a more differentiated focus on therapist
842
interventions and techniques and client processes that are related to change in
psychotherapy.
Process-Outcome Research on the Therapeutic
Relationship
Since Rogers (1957) first articulated his hypothesis about the necessary and
sufficient conditions of therapeutic change, much evidence has accumulated.
Recent comprehensive reviews collected in Norcross (2011) Psychotherapy
Relationships that Work provide an up-to-date summary of the broad base of
evidence supporting these therapist relational conditions, including Elliott, Bohart,
Watson, and Greenberg (2011) on empathy; Farber and Doolin (2011) on positive
regard and affirmation; Kolden, Klein, Wang, and Austin (2011) on
congruence/genuineness, and Horvath, Del Re, Flückiger, and Symonds (2011) on
the therapeutic alliance generally. Subsequently, the task force on the therapeutic
relationship designated therapist empathy as “demonstrably effective”; positive
regard as “probably effective”; and congruence/genuineness as “promising but
insufficient research to judge” (Norcross & Wampold, p. 424).
The research collected and meta-analyzed in the Norcross (2011) review
volume comes from a broad range of therapies, mostly not from the HEP tradition.
For example, only 8 out of 59 (14%) of the studies reviewed by Elliott et al.’s
(2011) empathy-outcome meta-analysis focused on HEPs. The mean weighted
correlation for these eight studies was .26, statistically significant, highly
consistent (I2 = 9%) and in line with the overall value of .30 for the entire sample
of 59 studies. HEPs are grouped under “other treatments” in the Farber and Doolin
(2011) and Kolden et al. (2011) reviews of positive regard and genuineness
respectively, but appear to comprise only a tiny proportion the studies reviewed.
Moreover, several methodological weaknesses have been identified in this
body of quantitative process-outcome research on the impact of the relationship
conditions on outcome. In an earlier, unsystematic review, Sachse and Elliott
(2002) noted that the facilitative conditions did not yield consistent results for all
clients and client problems, as some clients seem to benefit and others not. Other
methodological problems are failure to assess clients for incongruence (as
originally proposed by Rogers, 1957); poor sampling methods; small sample sizes;
different rating perspectives; inadequate levels of the therapeutic conditions;
restricted range of measurement of the relationship conditions; possible nonlinear
effects; low measurement reliability; and inconsistencies in the experience levels
of the therapists (Watson, Greenberg, & Lietaer, 2010). Notwithstanding these
methodological problems, the accumulated evidence to date points to a moderately
strong relationship between the therapeutic conditions and outcome, although the
relationship may be somewhat more complex than initially thought.
843
Among others, Lambert and Barley (2002) attributed the decline of research
on the relationship conditions to the ascendancy of the therapeutic alliance
construct. Nevertheless, the links between outcome, therapist empathy, and the
working alliance are some of the most highly evidence-based findings in the
psychotherapy research literature (Elliott et al., 2011; Horvath et al., 2011;
Lambert, 2005). In an attempt to distinguish the two constructs Watson and Geller
(2006) examined relationships among clients’ ratings of the Barrett-Lennard
Relationship Inventory (BLRI; Barrett-Lennard, 1962), psychotherapy outcome,
and the working alliance in CBT and EFT. Overall, client reports of therapist
positive regard, unconditionality, empathy, and congruence on the BLRI
correlated .72 with clients’ self-reports of the working alliance, pointing to the
possibility of conceptual overlap. Nevertheless, client ratings of the four
relationship conditions were predictive of treatment outcome on a wide range of
outcome measures. The impact of the relationship conditions on outcome appeared
to be mediated by therapeutic alliance for three out of four outcome measures,
consistent with a model of the relationship conditions as instrumental in
facilitating formation of a therapeutic bond and agreement on goals and tasks.
There were no significant differences on client ratings between CBT and EFT
therapists on therapist empathy, unconditionality, and congruence, but clients in
EFT reported feeling more highly regarded by their therapists than clients in CBT.
Subsequently, McMullen and Watson (2005) examined differences between
therapist and client behaviors in high and low alliance sessions in EFT and CBT.
They found that in contrast to EFT therapists, CBT therapists taught more and
asked more directive questions, while EFT therapists offered more support.
However, therapists in both CBT and EFT provided more support during low-
alliance than high alliance sessions. Interestingly, clients in EFT were rated as
expressing more disagreement with therapist responses, and showing greater
resistancein low-alliance sessions than clients in CBT.
However, process-outcome research supporting the role of therapist-offered
relational conditions does not tell us what mediates the relation between therapist
relational conditions and outcome. In order to address this question, Watson and
her team have been investigating the role of the facilitative conditions and
specifically empathy in the change process. Building on Barrett-Lennard’s (1997)
suggestion that therapist empathy leads to increased self-empathy, Steckley and
Watson (Steckley, 2006; Steckley & Watson, 2000) examined this hypothesis in
clients who were treated for major depression with either CBT or EFT. They
found that client ratings of therapist empathy predicted improvements in client
posttherapy attachment styles, as clients became less insecure and more self-
accepting and protective of themselves. These changes were also associated with
positive outcomes, accounting for moderate to large amounts of variance (42% to
70%). A subsequent study showed that empathy was an active ingredient of
change. Watson and Prosser (2007) examined the complex relationship between
844
empathy, affect regulation, and outcome using path analysis, reporting that the
effect of therapist empathy on outcome was mediated by changes in clients’ affect
regulation. These more recent studies continue to provide additional evidence and
support for the role of the clients’ experience of the therapeutic relationship in
promoting positive outcomes in psychotherapy.
Research on Specific Therapeutic Tasks
Research on specific therapeutic tasks continues to be a fruitful line of
inquiry for understanding the relationship between tasks and client processing
during sessions, and also for deepening our understanding of the steps necessary
for facilitating client change in therapy.
Two-Chair Dialogue for Conflict Splits
Intensive analyses of the client change processes in the two-chair dialogue
task in EFT and Gestalt therapies, originally led to the development of a model of
the essential components of resolution of splits (Greenberg, 1979, 1983) that
subsequently received empirical validation (Greenberg & Webster, 1982; Sicoli &
Halberg, 1998; Whelton & Greenberg; 2000). More recently, Shahar and
colleagues (2011) examined the efficacy of two-chair dialogue task at times of
stress with nine clients who were judged to be self-critical. The intervention was
associated with clients becoming significantly more compassionate and reassuring
toward themselves, and to significant reductions in self-criticism and symptoms of
depression and anxiety. Effect sizes were medium to large, with most clients
exhibiting only low and nonclinical levels of symptoms at the end of therapy, and
maintaining these gains over a 6-month follow-up period.
Empty Chair Dialogue for Unfinished Business
The empty chair task has been found to be more effective in resolving
unfinished business than empathy using measures of both in-session process and
session outcome (Greenberg & Foerster, 1996). Clients rated by observers as
resolving their unfinished business reported significantly greater improvement in
symptom distress, interpersonal problems, target complaints, affiliation toward
self, and degree of unfinished business (Greenberg & Malcolm, 2002). More
recently in a study of the resolution of interpersonal, emotional injuries, EFT was
found to be more emotionally arousing than a psychoeducational treatment.
However, the reported in-session emotional arousal did not relate directly to
outcome in either group. The authors suggested that this finding probably reflects
the fact that emotional arousal may signal different processes at different times
(Greenberg et al., 2008). For example, emotional arousal at one point in therapy
845
may be a sign of distress and at another point a sign that the client is actively
working through distress (Greenberg & Watson, 2006; Kennedy-Moore &
Watson, 1999).
Paivio et al.’s (2010) recent study comparing two forms of EFT for trauma
is also relevant here: In one condition (“imaginal confrontation”), clients were
required to use empty chair work, that is, to speak directly to the perpetrator of
their abuse or important nonprotective others in the empty chair. In the other
condition (“empathic exploration”), clients instead spoke to the therapist about the
perpetrator/nonprotective other. Clients in both forms of EFT showed substantial
pre-post gains. Clients using empty chair, showed more pre-post change; however,
they also dropped out at a higher rate (20% versus 7%), suggesting that it may not
be a good idea to require all clients to use this highly evocative therapeutic task.
Interpersonal Forgiveness
Research on specific therapeutic tasks has occurred within the context of
couples therapy as well as individual therapy. Meneses and Greenberg (2011)
explored how forgiveness unfolds in EFT for couples (EFT-C), using eight cases
where women felt their partners had betrayed them. Forgiveness was defined as a
process involving the reduction in negative feelings and the giving out of
undeserved compassion. A task analysis was performed to rigorously track the
steps leading to forgiveness using videotapes of therapy sessions. A comparison of
those who forgave to those who did not yielded a model of the process of
forgiveness in EFT for couples, from which a process rating system was
developed. Five essential components of the model were found to distinguish
between those who forgave and those who did not: (a) first, the injurer offered
nondefensive acceptance of responsibility for the emotional injury; they then (b)
expressed shame or empathic distress and (c) offered a heartfelt apology; (d) this
was followed by the injured partner showing a shift in their view of the other; and
(e) the injurer expressing acceptance of forgiveness, and relief or contrition.
In a further study, Woldarsky (2011) related the in-session process during
the interpersonal forgiveness task to outcome, based on data from 33 couples who
received emotion-focused couples therapy for an emotional injury (a betrayal)
(Greenberg et al., 2010). The results showed that expressed shame accounted for
33% of the outcome variance in posttherapy forgiveness; the addition of
acceptance explained an additional 9%, while in-session forgiveness explained
another 8%, with the final regression model accounting for 50% of the outcome
variance. These findings lend support to the couples’ forgiveness model (Meneses
& Greenberg, 2011). In addition, the therapeutic process was found to be more
relevant to whether the injured partners forgave their partners than the degree of
distress a couple was experiencing at the start of treatment.
846
Modeling Client Emotional Processing
Emotional processing of global distress is a generic task in EFT, in that
clients often enter therapy with strong or partially blocked but undifferentiated
feelings (i.e., feeling “upset” or “bad”). For this reason, Pascual-Leone and
Greenberg (2007) carried out a task analysis on the emotional processing steps
involved in clients’ resolution of global distress, defined as an unprocessed
emotion with high arousal and low meaningfulness, beginning with a rational-
empirical model. The model hypothesized that in processing their emotions clients
would move from a state of global distress through fear, shame, and aggressive
anger to the articulation of needs and negative self-evaluations; then they would
move on to assertive anger, self-soothing, hurt, and grief as states indicating more
advanced processing (Pascual-Leone & Greenberg, 2007). The model was tested
using a sample of 34 clients. Results showed that the model of emotional
processing predicted in-session outcomes and that distinct emotions emerged
moment-by-moment in predicted sequential patterns.
Intermediate components in the form of personal evaluation and
reevaluation predicted in-session outcomes. Experiences of fear/shame and
statements of negative evaluation about the self (i.e., feeling worthless, frail, or
unlovable) were present in both good and poor outcome cases and could not be
predicted by in-session outcome. However, a heartfelt statement expressing an
existential need to feel valuable, lovable, safe, or alive did predict and often
preceded good within-session outcome (as measured by the Client Experiencing
Scale).
In a subsequent study (Pascual-Leone, 2009) univariate and bootstrapping
statistical methods were used to examine how dynamic emotional shifts
accumulate moment-by-moment to produce in-session gains in emotional
processing. It was found that effective emotional processing was simultaneously
associated with steady improvement and increased emotional range. Good events
were shown to occur in a “two-steps-forward, one-step-backward” fashion, and it
was found that there were increasingly shorter emotional collapses in helpful in-
session events, as compared to unhelpful in-session events where the opposite was
true.
Research on Client Processes
In HEP theories of personality change (Gendlin, 1970; Greenberg & Van
Balen, 1998; Rogers, 1959), depth of experiential self-exploration is seen as one of
the pillars of psychotherapy process and change. During the past 50 years much
research has been done on the relationship between experiential depth and
outcome. Within this context several instruments have been constructed to
847
measure levels of experiential depth, the first ones being Rogers’ Process Scale
(Rogers, Walker, & Rablen, 1960) and Truax’s Tentative scale for the
measurement of depth of intrapersonal exploration (1962; Truax & Carkhuff,
1967). Subsequently, the Client Experiencing Scale (Klein, Mathieu, Gendlin, &
Kiesler, 1969/1983; Klein, Mathieu-Coughlan, & Kiesler, 1986) was developed,
followed by Toukmanian’s Levels of client perceptual processing scale (1986,
1992; Toukmanian & Gordon, 2004) and Sachse’s Processing Mode Scale (1992a;
Sachse & Maus, 1991). Although there are some differences between these scales,
they all describe and measure the level of clients’ involvement in an experiential
process of self-exploration.
Depth of Experiencing and Outcome
Ratings of client depth of experiencing have been related to good outcome
consistently in HEPs (Elliott et al., 2004; Hendricks, 2002). Moreover, clients’
emotional processing in the session has been found to be beneficial across a range
of other therapeutic approaches, including CBT and psychodynamic (Giyaur,
Sharf, & Hilsenroth, 2005; Godfrey, Chalder, Risdale, Seed & Ogden, 2007;
Leahy, 2002). Research on depth of experiencing in therapy has found a consistent
relationship between client experiencing during therapy and outcome: the higher
the experiencing level, the better the therapy outcome (Elliott et al., 2004; Purton,
2004). Although the association between experiencing level and outcome is clear
and consistent, it is not perfect, suggesting that other factors play a role in fruitful
therapy process. In addition, it is simplistic to hold a linear view of the stages of
the experiencing scale (i.e.,the higher the score, the better the process quality of
the exploration process”). Recent investigations of psychotherapy change process
(Angus & McLeod, 2004; Watson, Goldman, & Greenberg, 2007) emphasize that
all narrative modalities, representing the full range of the client experiencing
scale, are important and serve useful functions for clients in exploring their
problems.
Rogers’ process view (1961), however, also predicted that there would be
an increase of experiencing level throughout the course of successful therapy.
Unfortunately, this has not been confirmed in most studies, possibly due to
methodological issues such as sampling problems. Researchers typically measure
experiencing levels at the beginning, middle, and end phases of therapy, but
randomly select segments within and across sessions. Noting this practice, Rice
and Greenberg (1984) originally suggested that as a result key events of the
psychotherapy process were not being investigated. As an alternative sampling
method they selected segments that were linked to clients’ problematic issues.
Subsequently, Goldman, Greenberg, and Pos (2005) found that an increase in
client levels of experiencing from early to late in therapy was a stronger predictor
of outcome than the working alliance.
848
Like the early observations of Rogers (1959) and Gendlin (1970), several
studies have revealed significant differences in the manner in which good and poor
outcome clients refer to their emotional experience during the session, across
different therapeutic approaches (Pos, Greenberg, Goldman, & Korman, 2003;
Watson & Bedard, 2006). Watson and Bedard (2006) found that good outcome
clients in both EFT and CBT for depression, began, continued, and ended therapy
at higher modal and peak experiencing levels during the session than did clients
with poor outcome. Good outcome clients engaged in deeper exploration, referred
to their emotions more frequently, were more internally focused, and examined
and reflected upon their experience to create new meaning and resolve their
problems in personally meaningful ways. In contrast, clients with poorer outcomes
were not as engaged in processing their emotional experience, nor did they reflect
on or pose questions about their experience during the session, to examine it and
try to understand the origins and implications of their experience more fully. As a
result, poor outcome clients did not report important shifts in perspective or
feeling during the session. These findings suggest that processing one’s bodily felt
experience and deepening this in therapy may well be a core ingredient of change
in psychotherapy regardless of approach. However, an alternative interpretation is
that clients who enter therapy with these skills do better in short term therapy than
those who do not enter with these skills. Thus these skills may be an indicator of
clients’ readiness or capacity to engage in short term therapy.
Depth of Experiencing, Emotional Expression and
Processing, and Outcome
Therapy researchers have begun to examine the relationship between
clients’ levels of emotional arousal and outcome. Process-outcome research on
EFT for depression has shown that both higher emotional arousal at mid-
treatment, coupled with reflection on the aroused emotion (Warwar & Greenberg,
2000) and deeper emotional processing late in therapy (Pos et al., 2003), predicted
good treatment outcomes. High emotional arousal plus high reflection on aroused
emotion distinguished good and poor outcome cases, indicating the importance of
combining arousal and meaning construction (Missirlian, Toukmanian, Warwar, &
Greenberg, 2005; Warwar, 2003). EFT thus appears to work by enhancing a
particular type of emotional processing: first helping the client experience, then
accept, and finally make sense of their emotions.
Warwar (2003) examined mid-therapy emotional arousal as well as
experiencing in early, middle, and late phases of therapy. In this study clients who
had higher emotional arousal at mid-therapy were found to have changed more at
the end of therapy. Furthermore, client ability to use internal experience to make
meaning as measured by the Client Experiencing Scale, particularly in the late
phase of treatment, added to the outcome variance over and above middle phase
849
emotional arousal. Thus, this study showed that the combination of emotional
arousal and experiencing was a better predictor of outcome than either index
alone.
It is important to note this study measured expressed as opposed to
experienced emotion. In a study examining in-session client reports of experienced
emotional intensity, Warwar, Greenberg, and Perepeluk (2003) found that client
reports of in-session experienced emotion were not related to positive therapeutic
change. A discrepancy was observed between clients’ reports of in-session
experienced emotions and the emotions that were actually expressed based on
arousal ratings of videotaped therapy segments. For example, one client reported
that she had experienced intense emotional pain in a session; however, her level of
expressed emotional arousal was judged to be very low based on observer ratings
of emotional arousal from videotaped therapy segments.
Pos et al. (2003) suggested that emotional processing late in therapy
mediates between early emotional processing and outcome. Here emotional
processing was defined as depth of experiencing during emotion episodes.
Emotion episodes (Greenberg & Korman, 1993) are in-session segments in which
clients express or talk about having experienced an emotion in relation to a real or
imagined situation. The Client Experiencing Scale was used to rate only those in-
session episodes that were emotionally laden. They found that client early capacity
for emotional processing did not guarantee good outcome, nor did entering therapy
without this capacity guarantee poor outcome. Thus, early emotional processing
skill did not appear as critical as the ability to acquire or increase depth of
emotional processing throughout therapy. In this study late emotional processing
independently added 21% to the explained variance in reduction in symptoms,
over and above early alliance and emotional processing.
Pos, Greenberg, and Warwar (2010) measured emotional processing and
the alliance across three phases of therapy (beginning, working, and termination)
for 74 clients who each received EFT for depression. Using path analysis, a model
of the role of the alliance and emotional processing across different phases of
therapy and how they relate to and predict improvement in depression and other
symptoms, self-esteem, and interpersonal problems at the end of treatment, was
proposed and tested. Both therapeutic alliance and emotional processing
significantly increased across phases of therapy. After controlling for both the
alliance and client emotional processing at the beginning of therapy, client level of
experiencing during the working phase was found to directly and best predict
reductions in depressive and general symptoms, as well as gains in self-esteem.
Within working and termination phases of therapy, the alliance significantly
contributed to emotional processing and indirectly contributed to outcome. In
addition, the alliance, measured after session one, also directly predicted outcome,
and client therapy process at the beginning of treatment predicted reductions in
interpersonal problems. These findings suggest that although the EFT theory of
850
change was supported, the quality of client emotional processing at the beginning
of therapy may constrain their success in a short-term HEP and in particular
resolution of interpersonal problems.
In another study of relations among the alliance, frequency of aroused
emotional expression, and outcome, in EFT for depression, Carryer and Greenberg
(2010) found that the expression of high versus low emotional arousal correlated
with different types of outcome. Moderate frequency of heightened emotional
arousal was found to add significantly to outcome variance predicted by the
working alliance. The majority of process research studies have focused on a
direct linear relationship between process and outcome; however, this study
showed that a rate of 25% for moderate-to-high emotional expression predicted
best outcomes. Lower rates, indicating lack of emotional involvement, represented
an extension of the generally accepted relationship between low levels of
expressed emotional arousal and poor outcome, while higher rates, indicating
excessive amounts of highly aroused emotion, were related to poor outcome. This
suggests that having the client achieve an intense and full level of emotional
expression is predictive of good outcome, as long as the client does not maintain
this level of emotional expression for too long a time or too often. In addition,
frequency of reaching only minimal or marginal level of arousal was found to
predict poor outcome. Thus, emotional expression that does not attain a
heightened level of emotional arousal, or that reflects an inability to express full
arousal and possibly indicates interruption of arousal, appears undesirable, rather
than a lesser but still desirable goal. This complex relationship offers a challenge
to therapists in managing levels of arousal and possibly selecting clients for EFT.
In an intensive examination of four poor and four good outcome cases,
however, Greenberg, Auszra, and Herrmann (2007) did not find a significant
relationship between the frequency of higher levels of expressed emotional arousal
measured over the whole course of treatment and outcome. They measured both
aroused emotional expression and productivity of the expressed emotion, and
concluded that productivity of aroused emotional expression was more important
to therapeutic outcome than arousal alone.
The measure of productive emotional arousal used in the earlier study was
further developed and its predictive validity was tested on a sample of 74 clients
from the York depression studies (Auszra, Greenberg, & Herrmann, 2007).
Emotional productivity was defined as a state of being in contact with and aware
of a presently activated emotion, where contact and awareness were defined as
involving the following necessary features: (a) attending to nonverbal aspects of
experience; (b) symbolization in words; (c) congruence, matching between content
and manner of expression; (d) acceptance, non-negative evaluation; (e) agency,
not experiencing self as a victim of emotion but responsible for it; (f) regulation,
not being overwhelmed; and (g) differentiation, being in a process of developing
more specific meanings. Emotional productivity was found to increase from the
851
beginning to the working and the termination phases of treatment. Working phase
emotional productivity was found to predict 66% of treatment outcome variance,
over and above variance accounted for by beginning phase emotional productivity,
session four working alliance, and high expressed emotional arousal in the
working phase. These results suggest that productive processing of emotion may
be the best predictor of outcome of all process variables studied thus far.
In studies of EFT for trauma (Paivio & Pascual Leone, 2010) good client
process, early in therapy, has been found to be particularly important because it
sets the course for therapy and allows maximum time to explore and process
emotion related to traumatic memories (Paivio et al., 2001). One practical
implication of this research is the importance of facilitating clients’ emotional
engagement with painful memories early in therapy. A study of EFT for trauma
found that therapist competence in facilitating imaginal confrontation using empty
chair work, predicted better client processing. Moreover, when adult survivors of
childhood abuse engaged in empty chair work, it contributed to the reduction of
interpersonal problems, a contribution independent of therapeutic alliance (Paivio,
Holowaty, & Hall, 2004). These important findings are consistent with those
found in research on EFT for depression, which showed deeper levels of
emotional experiencing had a curative effect over and above the alliance (Pos et
al., 2003). Emotional processes have also been studied in the two controlled
studies on resolving emotional injuries and interpersonal difficulties. Emotional
arousal during imagined contact with a significant other was a process factor that
distinguished EFT from a psycho-educational treatment and was related to
outcome (Greenberg et al., 2008; Greenberg & Malcolm, 2002; Paivio &
Greenberg, 1995).
Extending this line of inquiry, Watson, McMullen, Prosser, and Bedard
(2011) recently examined relationships among client affect regulation, in-session
emotional processing, working alliance, and outcome in 66 clients who received
either CBT or EFT for depression. They found that client initial level of affect
regulation predicted their emotional processing during early and working phases
of therapy. Moreover, the quality of client emotional processing in the session
mediated the relationship between client level of affect regulation at the beginning
of therapy and at termination; and client level of affect regulation at the end of
therapy mediated the relationship between client level of emotional processing in
therapy and final outcome, independently of the working alliance. These studies
demonstrate the importance of client emotional processing in the session and
suggest important ways that it can be facilitated by specific therapist interventions,
for example, by facilitating client symbolization, acceptance, owning, regulation,
and differentiation of key emotions.
Finally, recent content analysis studies of client experiences of helpful
factors in therapy (Dierick & Lietaer, 2008; Vanaerschot & Lietaer, 2010) have
shown that processes referring to depth of experiential self-exploration have a
852
central place among the therapeutic ingredients mentioned by clients as helpful
and that these processes discriminate between very good” and rather poor
sessions. In content analysis studies done by Vanaerschot and Lietaer (2007, 2010)
20% to 40% of helpful factor descriptions mentioned by clients could be put under
the following three categories: stimulation and deepening of self-exploration;
focusing on and exploring more deeply; and intensively living through and
experiencing fully.
Therapist Interventions and Client Experiencing
Several studies have investigated the role of therapist interventions in
facilitating client productive engagement in the session. While the Experiencing
Scale (Klein et al., 1986) has mainly been used to investigate client process in
psychotherapy, Sachse has focused on the interaction between therapist and client.
To do so he constructed two parallel scales, respectively for the processing
modes(PM) of the client and the processing proposals(PP) of the therapist
(Purton, 2004; Sachse, 1990, 1992b; Sachse & Elliott, 2002; Takens, 2008). In a
series of empirical studies (Sachse, 1992a; Sachse & Maus, 1991; Sachse &
Elliott, 2002; Sachse & Takens, 2004) showed the impact of therapist proposals on
the depth of clients’ exploration process. Similar to Rogers’ (1961) and Gendlin’s
(1981) early observations about variations in client process, Sachse emphasized
that the results of these micro-analytic studies suggest that the manner in which
therapists respond to their clients can exert a significant influence on client
exploration processes. As some clients may find it quite difficult to clarify, check,
and modify their own feelings, needs, goals, and convictions, therapists can offer
active assistance to support client processing efforts.
Adams and Greenberg (1996) looked at whether therapist experiencing had
an impact on client level of processing. They found that therapist statements that
were high in experiencing influenced level of client experiencing and that depth of
therapist experiential focus predicted outcome. More specifically, if the client was
externally focused and the therapist made an intervention that was targeted toward
internal experience, the client was more likely to move to a deeper level of
experiencing. This study replicates Sachse’s (1990) earlier research and highlights
the importance of the therapist’s role in deepening emotional processes. Given that
client experiencing predicts outcome, and that therapist depth of experiential focus
influenced client experiencing and predicted outcome, a path to outcome was
established that suggests that therapist depth of experiential focus influences client
depth of experiencing, which in turn relates to positive outcome.
A series of studies carried out by Toukmanian and co-workers also
examined the impact of therapist interventions, including attunement,
tentativeness, and meaning exploration, on client level of cognitive and emotional
processing in the session. They found that therapist empathy, attunement, and
853
exploration were each associated with higher levels of client experiencing and
client perceptual processing (Gordon & Toukmanian, 2002), and that therapist
empathy was best predicted by therapist attunement (Macaulay, Toukmanian, &
Gordon, 2007). Moreover, complexity of client manner of processing over the
course of therapy predicted reduction in depression at post treatment
(Toukmanian, Jadaa, & Armstrong 2010).
Narrative processes. Studies led by Angus on client narrative sequences in
EFT have revealed interesting patterns associated with good outcomes (Angus,
Levitt, & Hardtke, 1999), with unique processing patterns associated with good
treatment outcomes (Angus, et al., 1999; Angus, Lewin, Bouffard, & Rotondi-
Trevisan, 2004). Lewin (2001) found that therapists in good outcome in EFT cases
were twice as likely to help clients shift to internal/emotion-focused and reflexive
narrative modes than therapists of clients with poor outcome. Additionally, good
outcome depressed clients initiated more shifts to emotion-focused and reflexive
discourse than poor outcome clients. Clients with good outcome in brief HEP,
spent significantly more time engaged in reflexive and emotion-focused discourse
than did poor outcome clients. These findings provide empirical support for the
importance of emotion and reflexive processes in the treatment of depression.
Moreover high emotional arousal plus high reflection on aroused emotion
distinguished good and poor outcome cases, indicating the importance of
combining arousal and meaning construction (Missirlian et al., 2005; Warwar,
2003). More recently, Boritz, Angus, Monette, and Hollis-Walker (2008) and
Boritz, Angus, Monette, Hollis-Walker, and Warwar (2010) investigated the
relationship of expressed emotional arousal and specific autobiographical memory
in the context of early, middle, and late phase sessions drawn from the York I
Depression Study (Greenberg & Watson, 1998). Hierarchical Linear Modeling
analyses established that there was a significant increase in the specificity of
autobiographical memories from early to late phase therapy sessions and that
treatment outcome was predicted by a combination of high narrative specificity
plus expressed arousal in late phase sessions. However, neither expressed
emotional arousal nor narrative specificity alone was associated with complete
recovery at treatment termination. Specifically, Boritz et al. (2010) found that
recovered clients were significantly more able to emotionally express their
feelings in the context of telling specific autobiographical memory narratives than
clients who remained depressed at treatment termination.
Client Postsession Change and Outcome
A recent study by Watson, Schein, and McMullen (2010) examined the
relationship of client reported postsession change to determine whether it
predicted outcome over and above the therapeutic alliance in a study of 66 clients
treated with EFT or CBT for depression. An updated measure of client postsession
854
change was used, the Client Task-Specific Changes-Revised scale. The measure
showed high internal consistency. Factor analyses showed that the measure
comprised two factors, conceptualized as Behavior Change and
Awareness/Understanding. Client postsession scores increased over the course of
psychotherapy and predicted change in depression at the end of therapy over and
above the therapeutic alliance, explaining an additional 13% of the variance in
outcome on the BDI.
Conclusions
In this latest review of research on humanistic-experiential psychotherapies,
we have once again emphasized outcome research, but have also looked at
qualitative studies of client experiences of outcome and helpful factors, as well as
quantitative investigations of change processes.
Humanistic-Experiential Psychotherapies as
Evidence-Based Treatments
Current mental health politics urgently require continuing collection,
integration, and dissemination of information about the rapidly expanding body of
accumulated outcome evidence, to help deal with challenges to HEPs in several
countries, including the United States, United Kingdom, Germany, and the
Netherlands (to mention only those with which we are most familiar). HEP
outcome research has grown rapidly, with half of the existing studies appearing in
the past 10 years. This has allowed us to pursue increasingly sophisticated analysis
strategies and to break down the evidence by client subpopulation and type of
HEP. We believe that these analyses go a long way toward meeting the demands
implicit in the criteria put forward by various national guideline development
groups (e.g., APA Division 12 Task Force on Empirically Supported Treatments
in the United States; National Institute for Clinical Excellence [NICE] in the
United Kingdom).
Looking at our entire data set of roughly 200 outcome studies, we see that
evidence for the effectiveness of HEPs comes from three separate lines of
evidence and supports the following conclusions:
First, overall, HEPs are associated with large pre-post client change. These
client changes are maintained over early (< 12 months) and late (a year or more)
follow-ups.
Second, in controlled studies, clients in HEPs generally show large gains
relative to clients who receive no therapy, regardless of whether studies are
855
randomized or not. This allows the causal inference that HEP, in general, causes
client change; or rather, speaking from the client’s perspective, we can say that
clients use HEP to cause themselves to change.
Third, in comparative outcome studies, HEPs in general are statistically and
clinically equivalent in effectiveness to other therapies, regardless of whether
studies are randomized or not.
Fourth, overall, CBT appears to have a trivial advantage over HEPs.
However, this effect seems to be due to nonbona fide treatments usually labeled
by researchers as supportive (or sometimes nondirective), which are generally less
effective than CBT. These therapies are typically delivered when there is a
negative researcher allegiance and in nonbona fide versions, and appear to be the
mediator for the substantial researcher allegiance effect that we found. When the
supportive treatments are removed from the sample, or when researcher allegiance
is controlled for statistically, HEPs appear to be equivalent to CBT in their
effectiveness.
Going beyond these general conclusions, we have argued that the existing
research is now more than sufficient to warrant varying positive valuations of HEP
in six important client populations: depression, relationship/interpersonal
problems, anxiety, coping with chronic medical conditions, psychosis, and
substance misuse, even using the fairly strict criteria put forward by Chambless
and Hollon (1998; the successor to the APA Division 12 Criteria).
For depression, HEPs have been extensively researched, to the point where
the claim of empirical support as efficacious and specific (i.e., superior to a
placebo or active treatment) can be supported for them in general (using meta-
analytic data), and more specifically for EFT for mild to moderate depression
(e.g., Goldman et al., 2006; Watson et al., 2003), and PCT for perinatal depression
(e.g., Cooper et al., 2003; Holden et al., 1989).
For relationship and interpersonal problems EFT clearly meets criteria as
an efficacious and specific treatment. These include current relationship problems
among couples, where EFT for couples has long been recognized as an empirically
supported treatment (e.g., Baucom et al., 1998). In our review here, however, we
have also highlighted the use of EFT in both couples and individual formats for
emotional injuries, including childhood abuse trauma (e.g., Greenberg et al., 2008;
Paivio et al., 2010). It is important to note, however, that these studies do not focus
on PTSD.
For helping clients cope psychologically with chronic medical conditions in
general based on the meta-analytic data, it now appears that HEPs meet criteria as
efficacious treatments, based either on their superiority to no treatment control
conditions or on their equivalence to an established treatment (CBT). Supportive
therapy, PCT, and supportive-expressive group therapy have been used with a
856
wide variety of chronic and disabling medical conditions, including most
commonly early and late stage cancer, and autoimmune disorders (e.g., lupus,
MS), but also gastrointestinal problems (e.g., IBS), HIV, chronic pain and others.
To date, the strongest pre-post and comparative effects have been found for
cancer; however, recently reported large studies (e.g., Bordeleau et al., 2003;
Spiegel et al., 2007) have shown weaker effects and point to the continuing need
for further research.
For habitual self-damaging activities, our analysis indicates that HEPs
(primarily supportive and other HEPs) meet the criteria for being efficacious
treatments for substance misuse. (The sample was too small and the results too
equivocal to properly assess the evidence for eating disorders.) These results are
comparable for those of a closely related treatment for substance misuse,
Motivational Interviewing (Lundahl et al., 2010).
For anxiety problems overall, the existing evidence is mixed, but sufficient
to warrant a general continuing verdict of possibly efficacious (at least one study
shows “equivalence” to an established treatment) for panic, generalized anxiety
and phobia (see Borkovec & Mathews, 1988; Shear et al., 1994). However, the
available evidence on treatment of panic and generalized anxiety (but not phobia)
also suggests that HEPs may be less efficacious than CBT. Although this is likely
to reflect researcher allegiance effects, it is also possible that the supportive,
person-centered and other HEPs used so far are less effective than CBT for these
client subpopulations, and that a more process-guiding approach is needed, as
indicated by evidence now emerging from ongoing research (e.g., Elliott &
Rodgers, 2010).
For psychotic conditions such as schizophrenia, we continue to recommend
a cautious verdict of possibly efficacious, in spite of a recent UK guideline contra-
indicating humanistic counseling for clients with this condition (National
Collaborating Centre for Mental Health, 2010). In fact, the comparative evidence
we have reviewed points to the possibility that HEPs may be more effective than
the other therapies to which they have been compared; however, the number and
sample size of the existing studies is relatively small, so we have preferred to err
in the direction of caution here rather than going for a stronger conclusion.
Key Change Processes in Humanistic-
Experiential Psychotherapies
Our review of quantitative and qualitative change process research on HEPs
shows that researchers continue to refine their understanding of the therapist and
client processes that bring about change in therapy. This research uses all four of
the change process research paradigms defined by Elliott (2010), including
quantitative process-outcome, qualitative helpful factors, significant events, and
857
sequential process approaches, in the context of both group and individual case
studies. Over time, the research has moved beyond global therapist facilitative
processes such empathy, positive regard, genuineness and collaboration to more
specific within-session change processes.
Qualitative change process research, for example, reveals the complexity of
clients’ experiences of therapy. Clients have their own agendas, may be
ambivalent about change, and may have doubts about the therapist, all of which
can significantly affect the outcomes of therapy. In successful therapy, the
therapist is seen as reaching out to the client in a way that promotes the client’s
sense of safety, but that also responds to the client’s emotional pain and unmet
needs with compassionate and authentic presence. These needs are affirmed by the
therapist, thus facilitating the development of self-compassion and self-acceptance
as well as self-empowerment grounded in awareness of key emotions and unmet
needs. All this interweaves with the collaborative development of a personally
meaningful client narrative (Angus & Greenberg, 2011).
Furthermore, the use of task analysis to model sequences of particular client
and therapist performances has led to the development of additional models of
processes in individual and couples therapy and has broadened the range of
therapist behaviors and types of interventions that have been shown to facilitate
good outcome. Sequential and process-outcome research on client experiencing
has been extended to look at clients’ cognitive and emotional processing during
the session as well as the quality of their narratives in order to identify productive
client processes in HEPs.
The recent quantitative change process research reviewed here has involved
continuing work on central therapeutic processes such as client experiencing,
emotional expression, and elements of narrative, but has added a new set of
important variables, including emotion episodes, emotional productivity and
differentiation, affect regulation, innovative moments, and autobiographical
memory specificity. These new variables and their associated process measures
are providing more fine-grained tools for understanding how client change occurs.
These conceptual and research tools are generating new, more precise maps of the
change process. Thus, we can see more precise answers emerging to key questions
about productive therapy process:
Question 1: When is client emotional expression most likely to lead to
good outcome? Answer: When it is grounded in specific
autobiographical memories, accompanied by deeper levels of
experiencing, and becomes more regulated and differentiated as it is
explored (research by Greenberg, Angus, Pascual-Leone, and
colleagues).
Question 2: What is the most productive sequence of narrative
exploration in therapy? Answer: Description of external events, leading
858
to initial self-reflection, leading to access to internal experiences, leading
to self-reflection on broader meaning (research by Angus and
colleagues).
Question 3: How do problematic or painful client experiences get
assimilated? Answer: Via an extended sequence over time starting from
warded off or painful awareness, then to problem clarification and
insight, and finally to working through and mastery (research by Stiles
and colleagues).
Question 4: How do new narratives emerge and become established in
client’s lives? Answer: By a spiraling movement between action and
reflection, starting with attempts to change the problem, leading to
reflection on the nature of the old problematic narrative, followed by
active protest or working against the problem, then to emerging re-
conceptualization of self and the process of change, and finally to
carrying out the change in one’s life (research by Gonçalves and
colleagues).
The many ways in which these different lines of theory development and research
run parallel to and complement one another are plain to be seen and point to the
possibility of a larger synthesis with many useful clinical implications.
Recommendations for Research, Practice, and
Training
It is our view that the research reviewed here has important scientific and
practical implications.
First, while the field of humanistic-experiential therapy research has made
substantial progress during the past 10 years, more research is clearly needed,
particularly with client populations where clear recommendations are not yet
possible, such as different types of anxiety, psychosis, particular medical
conditions, and eating disorders, and others. At the same time, more research on
well-studied client problems such as depression are also needed, in order to bolster
or upgrade the existing evidence, which runs the risk of becoming obsolete as
standards for research evidence shift over time (e.g., requiring larger samples,
RCTs, intent-to-treat analyses, and more sophisticated meta-analysis techniques).
Second, from a health care policy point of view, the available outcome data
clearly support the proposition that HEPs are empirically supported by multiple
lines of scientific evidence, including “gold standard” RCTs and recent large
RCT-equivalent practice-based studies in the UK (e.g., Stiles et al., 2006, 2008).
This body of research suggests that the lists of empirically supported or evidence-
based psychotherapies that have been constructed in various countriesthe NICE
859
Guidelines in the United Kingdom or the list of empirically supported treatments
in the United States, for exampleneed to be updated with the type of evidence
we have reviewed. HEPs should be offered to clients in national health service
contexts and other mental health settings, and paid for by health insurance,
especially for the well-evidenced client populations highlighted.
Third, there is an important lesson to be learned from the negative results
we have identified for supportive therapies. For those of us in the HEP tradition,
the moral of this story is that we do not need to be afraid of quantitative outcome
research, including RCTs. Naturally, there are many problems and limitations with
RCTs, just as there are with all research methods. If, however, we insist as a
matter of principle on conscientiously objecting to quantitative outcome research
in general and RCTs in particular, then we create a situation in which we let others
define our reality by constructing watered-down versions of what we do as a
representation of our practice. If we continue to let this happen, then we are going
to be in worse trouble than we already are. For this reason, it is imperative that as
humanistic-experiential therapists we do our own outcome researchincluding
RCTson bona fide versions of our therapies. It is also essential for us to train
more HEP researchers.
Fourth, as for the specific research implications of our review, it certainly
seems to us to illustrate the value of using a wide range of research methods,
qualitative and quantitative, group and single case, to address questions of
therapeutic change, effectiveness and efficacy. At the same time, it is worth noting
that our data indicate that the current emphasis on randomization in controlled and
comparative outcome studies is misplaced: In fact, we found that randomization
made no difference whatsoever in our meta-analysis. Although randomization is a
useful research tool, nonrandomized studies also need to be given significant
weight in integrating research findings.
Fifth, it now appears to us that research alone will not suffice; the
development of treatment guidelines in various countries has in our experience
become increasingly politicized, with powerful interest groups dominating the
committees charged with reviewing the evidence. These groups determine what
counts as evidence, what evidence is reviewed, and how that evidence is
interpreted as a basis for formulating treatment guidelines. This is often portrayed
as an objective, neutral process of making straightforward inferences from
research evidence to the real world of practice. According to Bayesian statistics
(e.g., Lynch, 2010), however, this is an instance of the logical fallacy of the
“transposed conditional” (Siegfried, 2010): The famous “null hypothesis” against
which we test our results only evaluates the likelihood of hypothetical inference
from practice (thereal world”) to our research results, not in the opposite
direction, from our results to practice, which is the inference that we want to
make. Inference from evidence to practice only becomes possible when we factor
in our prior expectations, that is, our researcher and reviewer theoretical
860
allegiances. This means that it is critically important who reviews the research
evidence and what their prior expectations or allegiances are. And that means that
the guideline development committees that review research evidence will only
produce valid and fair guidelines if they contain a balanced representation of
researchers with varied theoretical allegiances. The implication for the HEPs is
that they need to put pressure on guideline development bodies for proper
representation.
Finally, we conclude as we did in our previous review (Elliott et al., 2004),
with training implications: The neglect of HEPs in training programs and
treatment guidelines is no longer warranted. Humanistic-experiential therapies
should generally be offered in postgraduate programs and internships, especially
as treatments for depression, relationship problems, and substance misuse, and
also to help people cope with chronic medical problems, and possibly to support
clients with psychotic processes, anxiety disorders, and eating difficulties. Like
CBT, HEPs are evidence-based for a wide range of client presenting problems. In
fact, we argue that the education of psychotherapists is incomplete and unscientific
without a greater emphasis on these approaches, to the ultimate detriment of
clients.
References
*References marked with an asterisk indicate studies newly added or updated in the meta-
analysis.
Adams, K. E., & Greenberg, L. S. (1996, June). Therapists’ influence on depressed clients’
thera- peutic experiencing and outcome. Paper presented at the 43rd Annual convention
of the Society for Psychotherapeutic Research, St. Amelia, Florida.
*Altenhoefer, A., Schwab, R., Schulz, W., & Eckert, J., (2007). Effectiveness of time limited
client-centered psychotherapy in the treatment of patients with adjustment disorders.
Psychotherapeut, 52, 24–34
Angus, L., & Greenberg, L. (2011). Working with narrative in emotion-focused therapy:
Changing stories, healing lives. Washington DC: American Psychological Association.
Angus, L. E., Lewin, J., Bouffard, B., & Rotondi-Trevisan, D. (2004). “What’s the story?”
working with narrative in experiential psychotherapy. In L. E. Angus & J. McLeod
(Eds.), The handbook of narrative and psychotherapy: Practice, theory and research.
Thousand Oaks, CA: Sage.
Angus, L., Levitt, H., & Hardtke, K. (1999). The narrative processes coding system: Research
applications and implications for psychotherapeutic practice. Journal of Clinical
Psychology, 55, 1255–1270.
Angus, L., & McLeod, J. (2004). The handbook of narrative and psychotherapy. London, United
Kingdom: Sage.
861
Auszra, L., Greenberg, L. S., & Herrmann, I. (2007, July). Emotional productivity in experiential
therapy for depression. Symposium in Lisbon, Portugal.
Barrett-Lennard, G. (1962). Dimensions of therapist response as causal factors in therapeutic
change. Psychological Monographs: General and Applied, 76(43), 1–36. doi:
10.1037/h0093918
Barrett-Lennard, G. (1997). The recovery of empathy: toward others and self. In Bohart A. C.,
Greenberg L. S. (Eds.), Empathy reconsidered: New directions in psychotherapy.
Washington, DC: American Psychological Association.
*Barrowclough, C., King, P., Colville, J., Russell, E., Burns, A., & Tarrier, N. (2001). A
randomized trial of the effectiveness of cognitive-behavioral therapy and supportive
counselling for anxiety symptoms in older adults. Journal of Consulting and Clinical
Psychology, 69, 756–762.
Baucom, D. H., Mueser, K. T., Shoham, V., & Daiuto, A. D. (1998). Empirically supported
couple and family interventions for marital distress and adult mental health problems.
Journal of Consulting and Clinical Psychology, 66, 53–88.
*Beck, A. T., Sokol, L., Clark, D. A., Berchick, R., & Wright, F. (1992). A crossover study of
focused cognitive therapy for panic disorder. American Journal of Psychiatry, 149, 778–
783.
Beutler, L. E., Engle, D., Mohr, D., Daldrup, R. J., Bergan, J., Meredith, K., & Merry, W.
(1991). Predictors of differential response to cognitive, experiential, and self-directed
psychotherapeutic procedures. Journal of Consulting and Clinical Psychology, 59, 333–
340.
*Blowers, C., Cobb, J., & Mathews, A. (1987). Generalised anxiety: A controlled treatment
study. Behaviour Research and Therapy, 25, 493–502.
Bohart, A. C., O’Hara, M. & Leitner, L. M. (1998). Empirically violated treatments:
Disenfranchisement of humanistic and other psychotherapies. Psychotherapy Research,
8, 141–157.
*Bond, A. J., Wingrove, J., Curran, H. V., & Lader, M. H. (2002). Treatment of generalized
anxiety disorder with a short course of psychological therapy, combined with buspirone
or placebo. Journal of Affective Disorders, 72, 267–271.
Bordeleau, L., Szalai, J. P., Ennis, M., Leszcz, M., Speca, M., Sela, R., . . . Goodwin, P. J.
(2003). Quality of life in a randomized trial of group psychosocial support in metastatic
breast cancer: Overall effects of the intervention and an exploration of missing data.
Journal of Clinical Oncology, 21, 1944–1951. doi: 10.1200/jco.2003.04.080
Boritz, T. Z., Angus, L., Monette, G., & Hollis-Walker, L. (2008). An empirical analysis of
autobiographical memory specificity subtypes in brief emotion-focused and client-
centered treatments of depression. Psychotherapy Research, 18, 584–593. doi:
10.1080/10503300802123245
Boritz, T. Z., Angus, L., Monette, G., Hollis-Walker, L., & Warwar, S. (2011). Narrative and
emotion integration in psychotherapy: Investigating the relationship between
autobiographical memory specificity and expressed emotional arousal in brief emotion-
862
focused and client-centred treatments of depression. Psychotherapy Research, 21, 16–26.
doi: 10.1080/10503307.2010.504240
Borkovec, R., & Costello, E. (1993). Efficacy of applied relaxation and cognitive-behavioral
therapy in the treatment of generalized anxiety disorder. Journal of Consulting and
Clinical Psychology, 61, 611–619.
Borkovec, T. D., & Mathews, A. (1988). Treatment of nonphobic anxiety disorders: A
comparison of nondirective, cognitive, and coping desensitization therapy. Journal of
Consulting and Clinical Psychology, 56, 877–884.
*Borkovec, T. D., Mathews, A. M., Chambers, A., Ebrahimi, S., Lytle, R., & Nelson, R. (1987).
The effects of relaxation training with cognitive or nondirective therapy and the role of
relaxation-induced anxiety in the treatment of generalized anxiety. Journal of Consulting
and Clinical Psychology, 55, 883–888.
Brinegar, M. G., Salvi, L. M., & Stiles, W. B. (2008). The case of Lisa and the assimilation
model: The interrelatedness of problematic voices. Psychotherapy Research, 18, 657–66.
Brodley, B. T. (1990). Client-centered and experiential: Two different therapies. In G. Lietaer, J.
Rombauts, & R. Van Balen (Eds.), Client-centered and experiential psychotherapy
towards the nineties (pp. 87–107). Leuven, Belgium: Leuven University Press.
Cain, D., & Seeman, J. (Eds.). (2002). Humanistic psychotherapies: Handbook of research and
practice. Washington, DC: APA.
Carryer, J. R., & Greenberg, L. S. (2010). Optimal levels of emotional arousal in experiential
therapy of depression. Journal of Consulting and Clinical Psychology, 78, 190–199. doi:
10.1037/a0018401
Chadwick, P. D. J. (2006). Person-based cognitive therapy for distressing psychosis. West
Sussex, United Kingdom: Wiley.
Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of
Consulting and Clinical Psychology, 66, 7–18.
*Classen, C., Butler, L., Koopman, C., Miller, E., DiMiceli, S., Giese-Davis, J.,... Spiegel, D.
(2001). Supportive-expressive group therapy and distress in patients with metastatic
breast cancer. Archives of General Psychiatry, 58, 494–501.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ:
Erlbaum.
*Coons, W. H., & Peacock, M. A. (1970). Interpersonal interaction and personality change in
group psychotherapy. Canadian Psychiatric Association Journal, 15, 347–355.
*Cooper, M. (2004). Counselling in schools project: Evaluation report. Glasgow, United
Kingdom: Counselling Unit, University of Strathclyde.
*Cooper, M. (2006). Counselling in schools project phase II: Evaluation report. Glasgow,
United Kingdom: Counselling Unit, University of Strathclyde.
Cooper, M., Watson, J. C., & Hölldampf, D. (Eds.). (2010). Person-centred and experiential
therapies work: A review of the research on counselling, psychotherapy and related
practices. Ross-on-Wye, United Kingdom: PCCS Books.
863
*Cooper, P. J., Murray, L., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and
long-term effect of psychological treatment of post-partum depression. British Journal of
Psychiatry, 182, 412–419.
*Cornelius-White, J. H. D. (2003). The effectiveness of a brief, nondirective person-centered
practice. Person-Centered Journal, 10, 31–38.
*Cottraux, J., Note, I., Albuisson, E., Yao, S. N., Note, B., Mollard, E.,... Coudert, A. J.
(2000). Cognitive behavior therapy versus supportive therapy in social phobia: A randomized
controlled trial. Psychotherapy and Psychosomatics, 69, 137-146.
*Cowen, E. L., & Combs, A. W. (1950). Follow-up study of 32 cases treated by nondirective
therapy. Journal of Abnormal Social Psychology, 45, 232–258.
*Craske, M. G., Maidenberg, E., & Bystritsky, A. (1995). Brief cognitive-behavioral versus
nondirective therapy for panic disorder. Journal of Behaviour Therapy & Experimental
Psychiatry, 26, 113–120.
Daldrup, R., Beutler, L., Engle, D., & Greenberg, L. (1988). Focused expressive therapy:
Freeing the overcontrolled patient. London, United Kingdom: Cassell.
Dale, P., Allen, J., & Measor, L. (1998). Counselling adults who were abused as children:
Clients’ perceptions of efficacy, client-counsellor communication, and dissatisfaction.
British Journal of Guidance and Counselling, 26, 141–157.
*Dekeyser, M., Prouty, G., & Elliott, R. (2008). Pre-therapy process and outcome: A review of
research instruments and findings. Person-Centered and Experiential Psychotherapies, 7,
37–55.
*Denton, W. H., Burleson, B. R., Clark, T. E., Rodriguez, C. P., & Hobbs, B. V. (2000). A
randomized trial of emotion-focused therapy for couples in a training clinic. Journal of
Marital and Family Therapy, 26, 65–78.
*Dessaules, A., Johnson, S. M., & Denton, W. (2003). Emotion-focused therapy for couples in
the treatment of depression: A pilot study. American Journal of Family Therapy, 31,
345–353.
*Diamond, G. S., Reis, B. F., Diamond, G. M., Siqueland, L., & Isaacs, L. (2002). Attachment-
based family therapy for depressed adolescents: A treatment development study. Journal
of the American Academy of Child & Adolescent Psychiatry, 41, 1190–1196.
Dierick, P., & Lietaer, G. (2008). Client perception of therapeutic factors in group psychotherapy
and growth groups: An empirically-based hierarchical model. International Journal of
Group Psychotherapy, 58, 203–230. doi: 10.1521/ijgp.2008.58.2.203
Dircks, P., Grimm, F., Tausch, A-M., & Wittern, J-O. (1982). Förderung der seelischen
Lebensqualität von Krebspatienten durch personenzentrierte Gruppengespräche.
Zeitschrift für Klinische Psychologie, 9, 241–251.
*Dobkin, P. L., Da Costa, D., Joseph, L., Fortin, P. R., Edworthy, S., Barr, S., . . . Clarke, A. E.
(2002). Counterbalancing patient demands with evidence: Results from a pan-Canadian
randomized clinical trial of brief supportive-expressive group psychotherapy for women
with systemic lupus erythematosus. Annals of Behavioral Medicine, 24, 88–99.
864
*Dodge, W. (2003). A comparison between a convergent and an integrated approach to the
treatment of oppositionally defiant adolescents with family therapy. Unpublished doctoral
dissertation. San Francisco, California, Saybrook Graduate School.
Eckert, J., & Wuchner, M. (1996). Long-term development of borderline personality disorder. In
R. Hutterer, G. Pawlowsky, P. E. Schmid, & R. Stipsits (Eds.), Client-centered and
experiential psychotherapy. A paradigm in motion (pp. 213–233). Frankfurt, Germany:
Peter Lang.
Edwards, A. G., Hulbert-Williams, N., & Neal, R. D. (2008). Psychological interventions for
women with metastatic breast cancer. Cochrane Database Systematic Reviews, (3),
CD004253. doi: 10.1002/14651858.CD004253.pub3
Elliott, R. (1985). Helpful and nonhelpful events in brief counseling interviews: An empirical
taxonomy. Journal of Counseling Psychology, 32, 307–322.
Elliott, R. (1986). Interpersonal process recall (IPR) as a psychotherapy process research method.
In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research
handbook (pp. 249–286). New York, NY: Guilford Press.
Elliott, R. (1996). Are client-centered/experiential therapies effective? A meta-analysis of
outcome research. In U. Esser, H. Pabst, G-W Speierer (Eds.), The power of the Person-
Centered-Approach: New challenges-perspectives-answers (pp. 125–138). Köln,
Germany: GwG Verlag.
Elliott, R. (1998). Editor’s introduction: A guide to the empirically-supported treatments
controversy. Psychotherapy Research, 8, 115–125.
Elliott, R. (2002). Research on the effectiveness of humanistic therapies: A meta-analysis. In D.
Cain & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and
practice (pp. 57–81). Washington, DC: APA.
Elliott, R. (2002a). Hermeneutic single case efficacy design. Psychotherapy Research, 12, 1–20.
Elliott, R. (2002b). Render unto Ceasar: Quantitative and qualitative knowing in research on
humanistic therapies. Person-Centered and Experiential Psychotherapies, 1, 102–117.
Elliott, R. (2010). Psychotherapy change process research: Realizing the promise. Psychotherapy
Research, 20, 123–135.
Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011). Empathy. In J. Norcross
(Ed.), Psychotherapy relationships that work (2nd ed., pp. 132–152). New York, NY:
Oxford University Press.
Elliott, R., Clark, C., Kemeny, V., Wexler, M. M., Mack, C., & Brinkerhoff, L. J. (1990). The
impact of experiential therapy on depression: The first ten cases. In G. Lietaer, J.
Rombauts, & R. Van Balen (Eds.), Client-centered and experiential psychotherapy in the
nineties (pp. 549–578). Leuven, Belgium: Katholieke Universiteit Leuven.
Elliott, R., Fischer, C. T., & Rennie, D. L. (1999). Evolving guidelines for publication of
qualitative research studies in psychology and related fields. British Journal of Clinical
Psychology, 38, 215–229.
865
Elliott, R., Greenberg, L. S., & Lietaer, G. (2004). Research on experiential psychotherapies. In
M. J. Lambert (Ed.), Bergin & Garfield’s handbook of psychotherapy and behaviour
change (5th ed., pp. 493–540). New York, NY: Wiley.
Elliott, R., Partyka, R., Wagner, J., Alperin, R., Dobrenski. R., Messer, S. B., . . . Castonguay, L.
G. (2009). An adjudicated hermeneutic single-case efficacy design of experiential therapy
for panic/phobia. Psychotherapy Research, 19, 543–557.
Elliott, R., & Rodgers, B. (2010, March). Person-centred/experiential approaches to social
anxiety: Initial outcome results. Paper presented at conference of the UK Chapter of the
Society for Psychotherapy Research, Ravenscar, United Kingdom.
Elliott, R., Slatick, E., & Urman, M. (2001). Qualitative change process research on
psychotherapy: Alternative strategies. In J. Frommer & D. L. Rennie (Eds.), Qualitative
psychotherapy research: Methods and methodology (pp. 69–111). Lengerich, Germany:
Pabst Science.
Elliott, R., Stiles, W. B., & Shapiro, D. A. (1993). Are some psychotherapies more equivalent
than others? In T. R. Giles (Ed.), Handbook of effective psychotherapy (pp. 455–479).
New York, NY: Plenum Press.
*Esplen, M. J., Hunter, J., Leszcz, M., Warner, E., Narod, S., Metcalfe, K., . . . Wong, J. (2004).
A multicenter study of supportive-expressive group therapy for women with
BRCA1/BRCA2 mutations. Cancer, 101, 2327–2340.
Farber, B. A., & Doolin, E. M. (2011). Positive regard and affirmation. In J. Norcross (Ed.),
Psychotherapy relationships that work (2nd ed., pp. 168–186). New York, NY: Oxford
University Press.
Fosha, D. (2000). The transforming power of affect: A model of accelerated change. New York,
NY: Basic Books.
*Foulds, M. L., & Hannigan, P. S.(1976). Effects of Gestalt marathon workshops on measured
self-actualization: A replication and follow-up study. Journal of Counseling Psychology,
23, 60–65.
*Foulds, M. L., & Hannigan, P. S. (1977). Gestalt workshops and measured changes in self-
actualization: Replication and refinement study. Journal of College Student Personnel,
18, 200–205.
*Friedli, K., King, M. B., Lloyd, M., & Horder, J. (1997). Randomized controlled assessment of
non-directive psychotherapy versus routine general-practitioner care. Lancet, 350, 1662–
1665.
*Freire, E. S., Hough, M., & Cooper, M. (2008). Person-centred counselling in schools: An
evaluation. Internal report, Counselling Unit, University of Strathclyde, Glasgow, UK.
Furukawa, T.A. (1999). From effect size into number needed to treat. Lancet, 353, 1680.
Geller, S. M., & Greenberg, L. S. (2002). Therapeutic presence: Therapists’ experience of
presence in the psychotherapy encounter. Person-Centered and Experiential
Psychotherapies, 1, 71–86.
866
Gendlin, E. T. (1970). A theory of personality change. In J. T. Hart & T. M. Tomlinson (Eds.),
New directions in client-centered therapy (pp. 129–173). Boston, MA: Houghton Mifflin.
Gendlin, E. T. (1981). Focusing. New York, NY: Bantam Books.
Gendlin, E. T. (1996). Focusing-oriented psychotherapy: A manual of the experiential method.
New York, NY: Guilford Press.
*Gibbard, I., & Hanley, T. (2008). A five-year evaluation of the effectiveness of person-centred
counselling in routine clinical practice in primary care. Counselling & Psychotherapy
Research, 8, 215–222
*Giese-Davis, J., Koopman, C., Butler, L. D., Classen, C., Cordova, M., Fobair, P.,... Spiegel, D.
(2002). Change in emotion-regulation strategy for women with metastatic breast cancer
following supportive-expressive group therapy. Journal of Consulting and Clinical
Psychology, 70, 916–925.
Gilbert, P. (2009). The compassionate mind. London, United Kingdom: Constable & Robinson.
Giyaur, K., Sharf, J., & Hilsenroth, M. J. (2005). The capacity for dynamic process scale (CDPS)
and patient engagement in opiate addiction treatment. Journal of Nervous and Mental
Disease, 193(12), 833–838. doi: 10.1097/01.nmd.0000188978.50765.39
Godfrey, E., Chalder, T., Risdale, L., Seed, P., & Ogden, J. (2007). Investigating the active
ingredients of cognitive behavioural therapy and counselling for patients with chronic
fatigue in primary care: Developing a new process measure to assess treatment fidelity
and predict outcome. British Journal of Clinical Psychology, 46, 253–272.
*Goldman, R. N., Greenberg, L. S., & Angus, L. (2006). The effects of adding emotion-focused
interventions to the client-centered relationship conditions in the treatment of depression.
Psychotherapy Research, 16, 537–549.
Goldman, R. N., Greenberg, L. S., & Pos, A. E. (2005). Depth of emotional experience and
outcome. Psychotherapy Research, 15, 248–260.
Gonçalves, M., Mendes, I., Ribeiro, A., Angus., L., & Greenberg, L. (2010 ). Innovative
moments and change in emotion-focused therapy: The case of Lisa. Journal of
Constructivist Psychology, 23, 267–294.
*Goodwin, P. J., Leszcz, M., Ennis, M., Koopmans, J., Vincent, L., Guther, H., . . . Hunter, J.
(2001). The effect of group psychosocial support on survival in metastatic breast cancer.
New England Journal of Medicine, 345, 1719–1726.
Gordon, K. M., & Toukmanian, S. G. (2002). Is how it is said important? the association
between quality of therapist interventions and client processing. Counselling &
Psychotherapy Research, 2, 88–98. doi: 10.1080/14733140212331384867
Grafanaki, S., & McLeod, J. (1999). Narrative processes in the construction of helpful and
hindering events in experiential psychotherapy. Psychotherapy Research, 9, 289–303.
Grafanaki, S., & McLeod, J. (2002). Experiential congruence: Qualitative analysis of client and
counselor narrative accounts of significant events in time-limited person-centred therapy.
Counselling and Psychotherapy Research, 2, 20–32.
867
*Grawe, K., (1976). Differentielle Psychotherapie I: Indikation und spezifische Wirkung von
Verhaltenstherapie und Gesprächspsychotherapie: Eine Untersuchung an phobischen
Patienten. Bern, Switzerland: Hans Huber.
*Grawe, K., Caspar, F., & Ambühl, H. (1990). Differentielle Psychotherapieforschung: Vier
Therapieformen im Vergleich. Zeitschrift für Klinische Psychologie, 19, 287–376.
Greenberg, L. S. (1979). Resolving splits: The two-chair technique. Psychotherapy: Theory,
Research and Practice, 16, 310–318.
Greenberg, L. S. (1983). Toward a task analysis of conflict resolution in gestalt therapy.
Psychotherapy: Theory, Research and Practice, 20, 190–201.
Greenberg, L. S. (2010). Emotion-focused therapy. Washington, DC: American Psychological
Association.
Greenberg, L. S., Auszra, L., & Herrmann, I. R. (2007). The relationship among emotional
productivity, emotional arousal and outcome in experiential therapy of depression.
Psychotherapy Research, 17, 482–482–493. doi: 10.1080/10503300600977800
Greenberg, L. S., Elliott, R., & Lietaer, G. (1994). Research on humanistic and experiential
psychotherapies. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy
and behaviour change (4th ed., pp. 509–539). New York, NY: Wiley.
Greenberg, L. S., & Foerster, F. (1996). Resolving unfinished business: The process of change.
Journal of Consulting and Clinical Psychology, 64, 439–446.
Greenberg, L. S. & Johnson, S. M (1988). Emotionally focused therapy for couples. New York,
NY: Guilford Press.
Greenberg, L. S., & Korman, L. M. (1993). Assimilating emotion into psychotherapy integration.
Journal of Psychotherapy Integration, 3, 249–265.
Greenberg, L. S., & Malcolm, W. (2002). Resolving unfinished business: Relating process to
outcome. Journal of Consulting and Clinical Psychology, 70, 406–416.
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional change: The moment-
by-moment process. New York, NY: Guilford Press.
Greenberg, L. S., & Van Balen, R. (1998). The theory of experience-centered therapies. In L. S.
Greenberg, J. C. Watson, & G. Lietaer (Eds.), Handbook of experiential psychotherapy
(pp. 28–57). New York, NY: Guilford Press.
*Greenberg, L. J., Warwar, S. H., & Malcolm, W. M. (2008). Differential effects of emotion-
focused therapy and psychoeducation in facilitating forgiveness and letting go of
emotional injuries. Journal of Counseling Psychology, 55, 185–185–196. doi:
10.1037/0022–0167.55.2.185
*Greenberg, L., Warwar, S., & Malcolm, W. (2010). Emotion-focused couples therapy and the
facilitation of forgiveness. Journal of Marital and Family Therapy, 36(1), 28–42.
doi:10.1111/j.1752–0606.2009.00185.x
Greenberg, L. S., & Watson, J. (1998). Experiential therapy of depression: Differential effects of
client-centered relationship conditions and process experiential interventions.
Psychotherapy Research, 8, 210–224.
868
Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression. Washington,
DC: American Psychological Association. doi: 10.1037/11286–000
Greenberg, L. S., & Webster, M. (1982). Resolving decisional conflict by means of two-chair
dialogue: Relating process to outcome. Journal of Counseling Psychology, 29, 468–477.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An
experiential approach to behavior change. New York, NY: Guilford Press.
*Hener, T., Weisenberg, M., & Har-Even D. (1996). Supportive versus cognitive-behavioral
intervention programs in achieving adjustment to home peritoneal kidney dialysis.
Journal of Consulting and Clinical Psychology, 64, 731–741.
Hendricks, M. (2002). Focusing-oriented/experiential psychotherapy. In D. Cain & J. Seeman
(Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 221–251).
Washington, DC: American Psychological Association.
Higgins, J. P. T., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring
inconsistency in meta-analyses, British Journal of Medicine, 327, 557–560.
Holden, J. M., Sagovsky, R., & Cox, J. L. (1989). Counselling in a general practice setting:
Controlled study of health visitor intervention in treatment of postnatal depression.
British Medical Journal, 298, 223–226.
Holstein, B. E. (1990, August). The use of focusing in combination with a cognitive-behavioral
weight loss program. Paper presented at American Psychological Association meeting,
Boston, Massachusetts.
Honos-Webb, L., Stiles, W. B., Greenberg, L. S., & Goldman, R. N. (1998) Assimilation
analysis of process-experiential psychotherapy: A comparison of two cases.
Psychotherapy Research, 8, 264–286.
Honos-Webb, L. Surko, M., Stiles, W. B. & Greenberg, L. S. (1999). Assimilation of voices in
psychotherapy: The case of Jan. Journal of Counseling Psychology, 46, 448–460.
Horvath, A., Del Re, A.C., Flückiger, C., & Symonds, D. (2011). Alliance in individual
psychotherapy. In J. Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp.
25–91). New York, NY: Oxford University Press.
Hunter, J. E., & Schmidt, F. L. (1990). Methods of meta-analysis. Newbury Park, CA: Sage.
*Jacobs, S., & Bangert, M. (2005). Effekte und Prozessmerkmale der klientenzentrierten
Gespråchspsychotherapie bei Alkoholismus. Gespråchspsychotherapie und
Personzentrierte Beratung, 2, 97–107.
Johnson, B. T. (1989). D/STAT: Software for the meta-analytic review of research literatures.
Hillsdale, NJ: Erlbaum.
Johnson, W. R. (1977). The use of a snake phobia paradigm and nonverbal behavior change in
assessing treatment outcome: “The empty chair” versus systematic desensitization
(Doctoral dissertation, Georgia State University, 1976). Dissertation Abstracts
International, 37, 4146B. (University Microfilms No. 77–2933)
*Kaplan, S., & Kozin, F. (1981). A controlled study of group counseling in rheumatoid arthritis.
Journal of Rheumatology, 8, 91–99.
869
Katonah, D. G. (1991). Focusing and cancer: A psychological tool as an adjunct treatment for
adaptive recovery. Unpublished dissertation, Illinois School of Professional Psychology,
Chicago, IL. Available online at
www.focusing.org/adjunct_treatment.html
*Kenardy, J., Mensch, M., Bowen, K., Green, B., & Walton, J. (2002). Group therapy for binge
eating in type 2 diabetes: A randomized trial. Diabetic Medicine, 19, 234–239.
Kennedy-Moore, E., & Watson, J. C. (1999). Expressing emotion: Myths, realities and
therapeutic strategies. New York, NY: Guilford Press.
Kepner, J. (1993). Body process: Working with the body in psychotherapy. San Francisco, CA:
Jossey-Bass.
*Kissane, D. W., Grabsch, B., Clarke, D. M., Smith, G. C., Love, A. W., Bloch, S., . . . Yuelin,
L. (2007). Supportive-expressive group therapy for women with metastatic breast cancer:
Survival and psychosocial outcome from a randomized controlled trial. Psycho-
Oncology, 16, 277–286.
Klein, M. H., Mathieu-Coughlan, P. L., Kiesler, D. J., & Gendlin, E. T. (1969/1983). The
experiencing scale: A research and training manual. Madison: University of Wisconsin.
Klein, M. H., Mathieu-Coughlan, P. L., & Kiesler, D. J.(1986). The experiencing scales. In L. S.
Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook
(pp. 21–71). New York, NY: Guilford Press.
*Klein, M. J., & Elliott, R. (2006). Client accounts of personal change in process-experiential
psychotherapy: A methodologically pluralistic approach. Psychotherapy Research, 16,
91–105.
*Klontz, B. T., Wolf, E. M., & Bivens, A. (2000). The effectiveness of a multimodal brief group
experiential psychotherapy approach. International Journal of Action Methods:
Psychodrama, Skill-Training, and Role Playing, 53, 119–135.
Knox, R. (2008) Clients’ experiences of relational depth in person-centred counselling.
Counselling & Psychotherapy Research, 8, 182–188.
Kolden, G. G., Klein, M. H., Wang, C-C., & Austin, S. B. (2011). Congruence/genuineness. In J.
Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 187–202). New
York, NY: Oxford University Press.
Lambert, M. J. (2005). Early response in psychotherapy: Further evidence for the importance of
common factors rather than “placebo effects.” Journal of Clinical Psychology, 61(7),
855–869.
Lambert, M. J., & Barley, D. E. (2002). Research summary on the therapeutic relationship and
psychotherapy outcome. In J. Norcross (Ed.), Psychotherapy relationships that work (pp.
17–36). New York, NY: Oxford University Press.
Leahy, R. L. (2002). A model of emotional schemas. Cognitive and Behavioral Practice, 9, 177–
190. doi: 10.1016/S1077–7229(02)80048–7
870
Lewin, J. K. (2001). Both sides of the coin: Comparative analyses of narrative process patterns
in poor and good outcome dyads engaged in brief experiential psychotherapy for
depression. Unpublished master’s thesis, York University Toronto, Ontario, Canada.
Lietaer, G. (1992). Helping and hindering processes in client-centered/experiential
psychotherapy: A content analysis of client and therapist postsession perceptions. In S. G.
Toukmanian & D. L. Rennie (Eds.), Psychotherapy process research: Paradigmatic and
narrative approaches (pp. 134–162). Newbury Park, CA: Sage.
Lillie, N. (2002). Women, alcohol, self-concept and self-esteem: A qualitative study of the
experience of person-centred counselling. Counselling & Psychotherapy Research, 2, 99–
107.
Lipkin, S. (1954). Clients’ feelings and attitudes in relation to the outcome of client-centered
therapy. Psychological Monographs, 68, 1–30.
Lipsey, M. W., & Wilson, D. B. (1993). The efficacy of psychological, educational, and
behavioral treatment: Confirmation from meta-analysis. American Psychologist, 48,
1181–1209.
Lipsey, M. W., & Wilson, D. B. (2001). Practical meta-analysis. Thousand Oaks, CA: Sage .
Luborsky, L., Diguer, L., Seligman, D. A., Rosenthal, R., Krause, E. D., Johnson, S., . . .
Schweizer, E. (1999). The researcher’s own therapy allegiances: A “wild card” in
comparisons of treatment efficacy. Clinical Psychology: Science and Practice, 6, 95–106.
Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis
of motivational interviewing: Twenty-five years of empirical studies. Research on Social
Work Practice, 20, 137–160.
Lynch, S. (2010). Introduction to applied bayesian statistics and estimation for social scientists.
New York, NY: Springer.
Macaulay, H. L., Toukmanian, S. G., & Gordon, K. M. (2007). Attunement as the core of
therapist-expressed empathy. Canadian Journal of Counselling, 41, 244–244–254.
Retrieved from
http://search.proquest.com/docview/621941204?accountid=1477
1
*Machado, L. A. C., Azevedo, D. C., Capanema, M. B., Neto, T. N., & Cerceau, D. M. (2007).
Client-centered therapy vs exercise therapy for chronic low back pain: A pilot
randomized controlled trial in Brazil. Pain Medicine, 8, 251–258.
*Maisiak, R., Austin, J. S., West, S. G., & Heck, L. (1996). The effect of person-centered
counselling on the psychological status of persons with systemic lupus erythematosus or
rheumatoid arthritis: A randomized, controlled trial. Arthritis Care and Research, 9, 60–
66.
*Makinen, J. A., & Johnson, S. M. (2006). Resolving attachment injuries in couples using
emotionally focused therapy: Steps toward forgiveness and reconciliation. Journal of
Consulting and Clinical Psychology, 74, 1055–1064.
*Manne, S. L., Rubin, S., Edelson, M., Rosenblum, N., Bergman, C., Hernandez, E., . . . Winkel,
G. (2007). Coping and communication-enhancing intervention versus supportive
871
counseling for women diagnosed with gynecological cancers. Journal of consulting and
Clinical Psychology, 75, 615–628.
*Martinez, M. (2002). Effectiveness of operationalized gestalt therapy role-playing in the
treatment of phobic behaviors. Gestalt Review, 6,148–167.
*Maunder, R. G., & Esplen, M. J. (2001). Supportive-expressive group psychotherapy for
persons with inflammatory bowel disease. Canandian Journal of Psychiatry, 46, 622–
626.
*Maynard, C. K. (1993). Comparison of effectiveness of group interventions for depression in
women. Archives of Psychiatric Nursing, 7, 277–283.
McLean, L. M., Jones, J. M., Rydall, A. C., Walsh, A., Esplen, M. J., Zimmermann, C., & Rodin,
G. M. (2008). A couples intervention for patients facing advanced cancer and their
spouse caregivers: Outcomes of a pilot study. Psycho-Oncology, 17, 1152–1156. doi:
10.1002/pon.1319
McMullen, E., & Watson, J. C. (2005). An examination of therapist and client behaviour in high
and low alliance sessions in cognitive-behavioural therapy and process experiential
therapy. Psychotherapy: Theory, Research, Practice, and Training, 42, 297–310.
*McNamara, K., & Horan, J. J. (1986). Experimental construct validity in the evaluation of
cognitive and behavioral treatments for depression. Journal of Counseling Psychology,
33, 23–30.
Meneses, C. W., & Greenberg, L. S. (2011), The construction of a model of the process of
couples’ forgiveness in emotion-focused therapy for couples. Journal of Marital and
Family Therapy, 37, 491–502. doi: 10.1111/j.1752–0606.2011.00234.x
Meyer, A. E., Richter, R., Grawe, K., von Schulenburg, J.-M., & Schulte, B. (1991).
Forschungsgutachten zu Fragen eines Psychotherapeutengesetzes. Hamburg, Germany:
Universitaetskrankenhaus Eppendorf.
Meyers, S. (2000). Empathic listening: Reports on the experience of being heard. Journal of
Humanistic Psychology, 40, 148–173.
Miller, J. R. (1999). A social learning perspective toward the prevention of dating violence: An
evaluation of a group counseling model (violence prevention). Dissertation Abstracts
International, 60, 3018B.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change
(2nd ed.). New York, NY: Guilford Press.
Missirlian, T. M., Toukmanian, S. G., Warwar, S. H., & Greenberg, L. S. (2005). Emotional
arousal, client perceptual processing, and the working alliance in experiential
psychotherapy for depression. Journal of Consulting and Clinical Psychology, 73, 801–
871.
Moerman, M., & McLeod, J. (2006). Person-centered counseling for alcohol-related problems:
The client’s experience of self in the therapeutic relationship. Person-Centered and
Experiential Psychotherapies, 5, 21–35.
872
*Mohr, D. C., Boudewyn, A. C., Goodkin, D. E., Bostrom, A., & Epstein, L. (2001).
Comparative outcomes for individual cognitive-behavior therapy, supportive-expressive
group psychotherapy, and sertraline for the treatment of depression in multiple sclerosis.
Journal of Consulting and Clinical Psychology, 69, 942–949.
*Mohr, D. C., Classen, C., & Barrera, M. J. (2004). The relationship between social support,
depression and treatment for depression in people with multiple sclerosis. Psychological
Medicine, 34, 533–541.
*Mohr, D. C., Hart, S. L., Julian, L., Catledge, C., Honos-Webb, L., Vella, L., & Tasch, E. T.
(2005). Telephone-administered psychotherapy for depression. Archives of General
Psychiatry, 62, 1007–1014.
*Moorey, S., Greer, S., Bliss, J., & Law, M. (1998). A comparison of adjuvant psychological
therapy and supportive counselling in patients with cancer. Psycho-Oncology, 7, 218–
228.
*Moran, M., Watson, C. G., Brown, J., White, C., & Jacobs, L. (1978). Systems releasing action
therapy with alcoholics: An experimental evaluation. Journal of Clinical Psychology, 34,
769–774.
Moreno, J. L., & Moreno, Z.T. (1959). Foundations of psychotherapy. Beacon, NY: Beacon
House.
*Morrell, C. J., Slade, P., Warner, R., Paley, G., Dixon, S., Walters, S. J., . . . Nicholl, J. (2009).
Clinical effectiveness of health visitor training in psychologically informed approaches
for depression in postnatal women: Pragmatic cluster randomised trial in primary care.
British Medical Journal, 338, a3045.
*Müller-Hofer, B., Geiser, C., Juchli, E., & Laireiter, A-R. (2003). Kleintenzentrierte
Körperpsychotherapie (GFK-Methode) – Ergebnisse einer Praxisevaluation [Client-
centered body therapy: An effectiveness study]. Psychotherapie Forum, 11, 1–13,
National Collaborating Centre for Mental Health. (2009). Depression: The treatment and
management of depression in adults (update) (NICE clinical guideline 90). London,
United Kingdom: National Institute for Clinical Excellence. Available from
www.nice.org.uk/CG90
National Collaborating Centre for Mental Health [NICE]. (2010). Schizophrenia core
interventions in the treatment and management of schizophrenia in adults in primary and
secondary care (updated edition). Leicester and London, United Kingdom: British
Psychological Society & Royal College of Psychiatrists.
Newman, M. G., Castonguay, L. G., Borkovec, T. D., Fisher, A. J., Boswell, J. F., Szkodny, L.
E., & Nordberg, S. S. (2011). A randomized controlled trial of cognitive-behavioral
therapy for generalized anxiety disorder with integrated techniques from emotion-focused
and interpersonal therapies. Journal of Consulting and Clinical Psychology, 79, 171–181.
doi: 10.1037/a0022489
Nicolo, G., Dimaggio, G., Procacci, M., Semerari, A., Carcione, A., & Pedone, R. (2008). How
states of mind change in psychotherapy: An intensive case analysis of Lisa’s case using
the grid of problematic states. Psychotherapy Research, 18, 645–656.
873
Norcross, J. (Ed.). (2011). Psychotherapy relationships that work. New York, NY: Oxford
University Press.
Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research
conclusions and clinical practices. In J. Norcross (Ed.), Psychotherapy relationships that
work (2nd ed., pp. 423–430). New York, NY: Oxford University Press.
*O’Brien, M., Harris, J., King, R., & O’Brien, T. (2008). Supportive-expressive group therapy
for women with metastatic breast cancer: Improving access for Australian women
through use of teleconference. Counselling and Psychotherapy Research, 8, 28–35.
Osatuke, K., Glick, M. J., Stiles, W. B., Shapiro, D. A., & Barkham, M. (2005). Temporal
patterns of improvement in client-centred therapy and cognitive-behaviour therapy.
Counselling Psychology Quarterly, 18, 95–108.
Paivio, S. C., & Greenberg, L. S. (1995). Resolving “unfinished business”: Efficacy of
experiential therapy using empty chair dialogue. Journal of Consulting and Clinical
Psychology, 63, 419–425.
Paivio, S. C., Hall, I. E., Holowaty, K. A. M., Jellis, J. B., & Tran, N. (2001). Imaginal
confrontation for resolving child abuse issues. Psychotherapy Research, 11, 433–453.
Paivio, S. C., Holowaty, K. A. M., & Hall, I. E. (2004). The influence of therapist adherence and
competence on client reprocessing of child abuse memories. Psychotherapy: Theory,
Research, Practice, Training, 41, 56–58.
Paivio, S. C., Jarry, J. L., Chagigiorgis, H., Hall, I., & Ralston, M. (2010). Efficacy of two
versions of emotion-focused therapy for resolving child abuse trauma. Psychotherapy
Research, 353–366.
Paivio, S. C., & Pascual-Leone, A. (2010). Emotion-focused therapy for complex trauma: An
integrative approach. Washington, DC: American Psychological Association.
*Papadopoulos, L., Walker, C., & Anthis, L. (2004). Living with vitiligo: A controlled
investigation into the effects of group cognitive-behavioural and person-centred
therapies. Dermatology and Psychosomatics, 5, 172–177.
Pascual-Leone, A. (2009). Dynamic emotional processing in experiential therapy: Two steps
forward, one step back. Journal of Consulting and Clinical Psychology, 77(1), 113–126.
doi:10.1037/a0014488
Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional processing in experiential therapy:
Why “the only way out is through.” Journal of Consulting and Clinical Psychology,
75(6), 875–887.
Perls, F. S., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy. New York, NY: Julian
Press.
*Pintér, G. (1993). A szemelykozpontu pszichoterapia hatekonysaganak vizsgalata I. Psychiatria
Hungarica, 8(2), 139–152.
*Pintér, G. (1993). A szemelykozpontu pszichoterapia hatekonysaganak vizsgalata II.
Psychiatria Hungarica, 8(4), 279–292.
874
Pos, A. E., Greenberg, L. S., Goldman, R. N., & Korman, L. M. (2003). Emotional processing
during experiential treatment of depression. Journal of Consulting and Clinical
Psychology, 71, 1007–1016.
Pos, A. E., Greenberg, L. S., & Warwar, S. (2010). Testing a model of change for experiential
treatment of depression. Journal of Consulting and Cliinical Psychology, 77, 1055–1066.
Purton, C. (2004). Person-centred therapy. The focusing-oriented approach. Basingstoke, United
Kingdom: Palgrave Macmillan.
Ragsdale, K. G., Cox, R. D., Finn, P., & Eisler, R. M. (1996). Effectiveness of short-term
specialized inpatient treatment for war-related posttraumatic stress disorder: A role for
adventure-based counseling and psychodrama. Journal of Traumatic Stress, 9, 269–283.
Rennie, D. L. (1990). Toward a representation of the client’s experience of the psychotherapy
hour. In G. Lietaer, J. Rombauts, & R. Van Balen (Eds.), Client-centered and
experiential therapy in the nineties (pp. 155–172). Leuven, Belgium: Leuven University
Press.
Rennie, D. L. (1992). Qualitative analysis of the client’s experience of psychotherapy: The
unfolding of reflexivity. In S. Toukmanian & D. Rennie (Eds.), Psychotherapy process
research: Paradigmatic and narrative approaches (pp. 211–233). Newbury Park, CA:
Sage.
Rennie, D. (1994a). Client’s deference in psychotherapy. Journal of Counseling Psychology, 41,
427–437.
Rennie, D. (1994b). Clients’ accounts of resistance in counselling: A qualitative analysis.
Canadian Journal of Counselling, 28(1), 1994, 43–57.
Rennie, D. L., Phillips, J. R., & Quartaro, G. K. (1988). Grounded theory: A promising approach
to conceptualization in psychology? Canadian Psychology, 29, 139–150.
Rhodes, R. H., Hill, C. E., Thompson, B. J., & Elliott, R. (1994). Client retrospective recall of
resolved and unresolved misunderstanding events. Journal of Counseling Psychology, 41,
473–483.
Rice, L. N., & Greenberg, L.S. (1984). Patterns of change. Intensive analysis of psychotherapy
process. New York, NY: Guilford Press.
Rodgers, B. (2002). Investigation into the client at the heart of therapy. Counselling and
Psychotherapy research, 2, 185–193.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change.
Journal of Consulting Psychology, 21, 95–103.
Rogers, C. R. (1959). A theory of therapy, personality and interpersonal relationships as
developed in the client-centered framework. In S. Koch (Ed.), Psychology: A study of
science. Vol. III, Formulations of the person and the social context (pp. 184–256). New
York, NY: McGraw Hill.
Rogers, C. R. (1961) On becoming a person: A therapist’s view of psychotherapy. London,
United Kingdom: Constable.
875
*Rogers, C. R., & Dymond, R. F. (1954). (Eds.). Psychotherapy and personality change.
Chicago, IL: University of Chicago Press.
Rogers, C. R., Walker, A., & Rablen, R. (1960). Development of a scale to measure process
changes in psychotherapy. Journal of Clinical Psychology, 16, 79–85.
Rogers, J. L., Howard, K. I., & Vessey, J. T. (1993). Using significance tests to evaluate
equivalence between two experimental groups. Psychological Bulletin, 113, 553–565.
Sachse, R. (1990). Concrete interventions are crucial: The influence of the therapist’s processing
proposals on the client’s interpersonal exploration in client-centered therapy. In G.
Lietaer, J. Rombauts, & R. Van Balen (Eds.), Client-centered and experiential
psychotherapy in the Nineties (pp. 295–308). Leuven, Belgium: Leuven University Press.
Sachse, R. (1992a). Zielorientierte Gesprächspsychotherapie. Göttingen, Germany: Hogrefe.
Sachse, R. (1992b). Differential effects of processing proposals and content references on the
explication process of clients with different starting conditions. Psychotherapy Research,
2, 235–251.
Sachse, R., & Elliott, R. (2002). Process-outcome research on humanistic therapy variables. In
D. J. Cain & J. Seeman (Eds.), Humanistic psychotherapies. Handbook of research and
practice (pp. 83–116). Washington, DC: APA Books.
Sachse, R., & Maus, C. (1991). Zielorientiertes Handeln in der Gesprächspsychotherapie.
Stuttgart, Germany: Kohlhammer.
Sachse, R., & Takens, R.J. (2004). Klärungsprozesse in der Psychotherapie. Göttingen,
Germany: Hogrefe.
Schneider, K. J. (1998). Toward a science of the heart: Romanticism and the revival of
psychology. American Psychologist, 53, 277–289.
Schnellbacher, J., & Leijssen, M. (2009). The significance of therapist genuineness from the
client’s perspective. Journal of Humanistic Psychology, 49, 207–228.
Schutzmann, K., Schutzmann, M., & Eckert, J. (2010). Wirksamkeit von ambulanter
Gesprachspsychotherapie bei Bulimia nervosa: Ergebnisse einer randomisiert-
kontrollierten Studie [The efficacy of outpatient client-centered psychotherapy for
bulimia nervosa: results of a randomised controlled trial]. Psychotherapie,
Psychosomatik, medizinische Psychologie, 60, 52–63. doi: 10.1055/s-0029–1234134
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001). Mindfulness-based cognitive therapy
for depression: A new approach to preventing relapse. New York, NY: Guilford Press.
*Sellman, J. D., Sullivan, P. F., Dore, G. M., Adamson, S. J., & MacEwan, I. (2001). A
randomized controlled trial of motivational enhancement therapy (MET) for mild to
moderate alcohol dependence. Journal of Studies on Alcohol, 62, 389–396.
*Serok, S., & Levi, N. (1993). Application of gestalt therapy with long-term prison inmates in
Israel. Gestalt Journal, 16, 105–127.
Serok, S., & Zemet, R. M. (1983). An experiment of gestalt group therapy with hospitalized
schizophrenics. Psychotherapy: Theory, Research & Practice, 20, 417–424.
876
*Shaffer, C. S., Shapiro, J., Sank, L. I., & Coghlan, D. J. (1981). Positive changes in depression,
anxiety, and assertion following individual and group cognitive behavior therapy
intervention. Cognitive Therapy and Research, 5(2), 149–157.
Shahar, B., Carlin, E. R., Engle, D. E., Hegde, J., Szepsenwol, O., & Arkowitz, H. (2011), A
pilot investigation of emotion-focused two-chair dialogue intervention for self-criticism.
Clinical Psychology & Psychotherapy. doi: 10.1002/cpp.762
*Shear, K. M., Houck, P., Grenno, C., & Masters, S. (2001). Emotion-focused psychotherapy for
patients with panic disorder. American Journal of Psychiatry, 158, 1993–1998.
Shear, K. M., Pilkonis, P. A., Cloitre, M., & Leon, A. C. (1994). Cognitive behavioral treatment
compared with nonprescriptive treatment of panic disorder. Archives of General
Psychiatry, 51, 395–401.
Sicoli, L. A., & Hallberg, E. T. (1998). An analysis of client performance in the two-chair
method. Canadian Journal of Counselling, 32, 151–162.
Siegfried, T. (2010, March 27). Odds are, it’s wrong: Science fails to face the shortcomings of
statistics. Science News, 26–29.
Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore,
MD: Johns Hopkins University Press.
*Souliere, M. (1995). The differential effects of the empty chair dialogue and cognitive
restructuring on the resolution of lingering angry feelings. (Doctoral dissertation,
University of Ottawa, 1994). Dissertation Abstracts International, 56, 2342B. (University
Microfilms No. AAT NN95979)
Spiegel, D., Bloom, J. R., & Yalom, I. (1981). Group support for patients with metastatic cancer.
Archives of General Psychiatry, 38, 527–533.
Spiegel, D., Butler, L. D., Giese-Davis, J., Koopman, C., Miller, E., DiMiceli, S., . . . Kraemer,
H. C. (2007). Effects of supportive-expressive group therapy on survival of patients with
metastatic breast cancer: A randomized prospective trial. Cancer, 110, 1130–1138. doi:
10.1002/cncr.22890
*Spiegel, D., Morrow, G. R., Classen, C., Raubertas, R., Stott, P. B., Mudaliar, N., . . . Riggs, G.
(1999). Group psychotherapy for recently diagnosed breast cancer patients: A multicenter
feasibility study. Psycho-Oncology, 8, 482–493.
*Stanley, M. A., Beck, J. G., & Glassco, J. D. (1996). Treatment of generalized anxiety in older
adults: A preliminary comparison of cognitive-behavioral and supportive approaches.
Behavior Therapy, 27, 565–581.
Steckley, P. L. (2006). An examination of the relationship between clients’ attachment
experiences, their internal working models of self and others, and therapists’ empathy in
the outcome of process-experiential and cognitive-behavioural therapies. Dissertation
Abstracts International, 67, 2055B.
Steckley, P., & Watson, J. C. (2000, June). Client attachment styles and psychotherapy outcome
in cognitive behavioural and process-experiential psychotherapy. Paper presented to the
31st Annual Meeting of the Society for Psychotherapy Research Conference, Chicago,
Illinois.
877
Stephen, S., Elliott, R. & Macleod, R. (2011). Person-centred therapy with a client experiencing
social anxiety difficulties: A hermeneutic single case efficacy design. Counselling &
Psychotherapy Research, 11, 55–66.
*Stice, E., Burton, E., Bearman, S. K., & Rohde, P. (2006). Randomized trial of brief depression
prevention program: An elusive search for a psychosocial placebo control condition.
Behaviour Research and Therapy, 45, 863–876.
Stice, E., Rohde, P., Gau, J. M., & Wade, E. (2010). Efficacy trial of a brief cognitive-behavioral
depression prevention program for high-risk adolescents: Effects at 1- and 2-year follow-
up. Journal of Consulting and Clinical Psychology, 78, 856–867.
Stiles, W. B. (2002). Assimilation of problematic experiences. In J. C. Norcross (Ed.),
Psychotherapy relationships that work: Therapist contributions and responsiveness to
patients (pp. 357–365). New York, NY: Oxford University Press.
*Stiles, W. B., Barkham, M., Mellor-Clark, J., & Connell, J. (2008). Effectiveness of cognitive-
Behavioural, person-centred, and psychodynamic therapies as practiced in UK primary
care routine practice: replication in a larger sample. Psychological Medicine, 38, 677–
688.
*Stiles, W. B., Barkham, M., Twigg, E., Mellor-Clark, J. & Cooper, M. (2006). Effectiveness of
cognitive-behavioural, person-centred and psychodynamic therapies as practiced in UK
national health service settings. Psychological Medicine, 36, 555–566.
Stinckens, N., Lietaer, G., & Leijssen, M. (2002). The inner critic on the move: Analysis of the
change process in a case of short-term client-centred/experiential therapy. Counselling &
Psychotherapy Research, 2, 40–54.
*Svartberg, M., Seltzer, M. H., Choi, K., & Stiles, T. C. (2001). Cognitive change before, during,
and after short-term dynamic and nondirective psychotherapies: A preliminary growth
modeling study. Psychotherapy Research, 11, 201–219.
*Svartberg, M., Seltzer, M. H., & Stiles, T. C. (1998). The effects of common and specific
factors in short-term anxiety-provoking psychotherapy: A pilot process-outcome study.
The Journal of Nervous and Mental Disease, 186, 691–696.
*Szapocznik, J., Feaster, D. J., Mitrani, V. B., Prado, G., Smith, L., Robinson-Batista, C., . . .
Robbins, M. S. (2004). Structural ecosystems therapy for HIV-Seropositive African
American women: Effects on psychological distress, family hassles, and family support.
Journal of Consulting and Clinical Psychology, 72, 288–303.
*Szekely, B., Botwin, D., Eidelman, B. H. Becker, M., Elman, N., & Schemm, R. (1985).
Nonpharmacological treatment of menstrual headache: Relaxation-biofeedback behavior
therapy and person-centered insight therapy. Headache, 26, 86–92.
Takens, R. J. (2008). Diepgang in het exploratieproces: analyse van de therapeutische interactie.
In G. Lietaer, G. Vanaerschot, H. Snijders, & R. J. Takens (Eds.), Handboek
gesprekstherapie. De persoonsgerichte experiëntiële benadering (pp. 181–203). Utrecht,
The Netherlands: De Tijdstroom.
Tarrier, N., Kinney, C., McCarthy, E., Humphreys, L., Wittkowski, A., & Morris, J. (2000).
Two-year follow-up of cognitive-behavioral therapy and supportive counseling in the
878
treatment of persistent symptoms in chronic schizophrenia. Journal of Consulting and
Clinical Psychology, 68, 917–922.
Tarrier, N., Yusupoff, L., Kinney, C., McCarthy, E., Gledhill, A., & Morris, J. (1998). A
randomised controlled trial of intensive cognitive behaviour therapy for chronic
schizophrenia. British Medical Journal, 317, 303–307.
Task Force on Promotion and Dissemination of Psychological Procedures. (1995). Training in
and dissemination of empirically-validated psychological treatments: Report and
recommendations. Clinical Psychologist, 48, 3–23.
Teusch, L. (1990). Positive effects and limitations of client-centered therapy with schizophrenic
patients. In G. Lietaer, J. Rombauts, & R. Van Balen (Eds.), Client-centered and
experiential psychotherapy in the nineties (pp. 637–644). Leuven, Belgium: Leuven
University Press.
*Teusch, L., Böhme, H., Finke, J., Gastpar, M., & Skerra, B. (2003). Antidepressant medication
and the assimilation of problematic experiences in psychotherapy. Psychotherapy
Research, 13, 307–322.
Teusch, L., Böhme, H., & Gastpar, M. (1997). The benefit of an insight-oriented and experiential
approach on panic and agoraphobia symptoms. Psychotherapy & Psychosomatics, 66,
293–301.
Timulak, L. (2007). Identifying core categories of client-identified impact of helpful events in
psychotherapy: A qualitative meta-analysis. Psychotherapy Research, 17, 310–320.
Timulak, L. (2009). Qualitative meta-analysis: A tool for reviewing qualitative research findings
in psychotherapy. Psychotherapy Research, 19, 591–600.
Timulak, L. (2010). Significant events in psychotherapy: An update of research findings.
Psychology and Psychotherapy, 83, 421–447.
Timulak, L., Belicova, A., & Miler, M. (2010). Client identified significant events in a successful
therapy case: The link between the significant events and outcome. Counselling
Psychology Quarterly, 23, 371–386.
Timulak, L., & Creaner, M. (2010). Qualitative meta-analysis of outcomes of person-
centred/experiential therapies. In M. Cooper, J. C. Watson, & D. Holledampf (Eds.),
Person-centred and experiential psychotherapies work. Ross-on-Wye, United Kingdom:
PCCS Books.
Timulak, L., & Elliott, R. (2003). Empowerment events in process-experiential psychotherapy of
depression: A qualitative analysis. Psychotherapy Research, 13, 443–460.
Timulak, L., & Lietaer, G. (2001). Moments of empowerment: A qualitative analysis of
positively experienced episodes in brief person-centred counseling. Counselling &
Psychotherapy Research, 1, 62–73.
Toukmanian, S. G. (1986). A measure of client perceptual processing. In L. Greenberg & W.
Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 107–130). New
York, NY: Guilford Press.
879
Toukmanian, S. G. (1992). Studying the client’s perceptual process and their outcomes in
psychotherapy. In S. G. Toukmanian & D. L. Rennie, (Eds.), Psychotherapy process
research: paradigmatic and narrative approaches (pp. 77–107). Newbury Park, CA:
Sage.
Toukmanian., S. G., & Gordon, K. M. (2004). The levels of client perceptual processing
(LCPP): A training manual. Department of Psychology, York University, Toronto.
Toukmanian, S. G., Jadaa, D., & Armstrong, M. S. (2010). Change processes in clients’ self-
perceptions in experiential psychotherapy. Person-Centered and Experiential
Psychotherapies, 9, 37–51. doi: 10.1080/14779757.2010.9688503
Traynor, W., Elliott, R., & Cooper, M. (2011). Helpful factors and outcomes in person-centered
therapy with clients who experience psychotic processes: Therapists’ perspectives.
Person-Centered and Experiential Psychotherapies, 10, 89–104.
Truax, C. B. (1962). A tentative scale for the measurement of depth of intrapersonal exploration.
Wisconsin Psychiatric Institute, University of Wisconsin.
Truax, C. B., & Carkhuff, R. R. (1967). Towards effective counseling and psychotherapy:
Training and practice. Chicago, IL: Aldine.
*Turner, R. M. (2000). Naturalistic evaluation of dialectical behavior therapy-oriented treatment
for borderline personality disorder. Cognitive and Behavioral Practice, 7, 413–419.
*Tyson, G. M., & Range, L. M. (1987). Gestalt dialogues as a treatment for mild depression:
Time works just as well. Journal of Clinical Psychology, 43, 227–231.
Vanaerschot, G., & Lietaer, G. (2007). Therapeutic ingredients in helping session episodes with
observer-rated low and high empathic attunements: A content analysis of client and
therapist postsession perceptions in three cases. Psychotherapy Research, 17, 338–338–
352. doi: 10.1080/10503300600650910
Vanaerschot, G., & Lietaer, G. (2010). Client and therapist postsession perceptions of therapeutic
ingredients in helping episodes. A study based on three cases. Person-Centered &
Experiential Psychotherapies, 9, 205–219. doi: 10.1080/14779757.2010.9689067
van der Pompe, G., Duivenvoorden, H. J., Antoni, M. H., Visser, A., & Heijnen, C. J. (1997).
Effectiveness of a short-term group psychotherapy program on endocrine and immune
function in breast cancer patients: An exploratory study. Journal of Psychosomatic
Research, 42, 453–466.
*Walker, J. G., Johnson, S., Manion, I., & Cloutier, P. (1996). Emotionally focused marital
intervention for couples with chronically ill children. Journal of Consulting and Clinical
Psychology, 64, 1029–1036.
Warwar, S. H. (2003). Relating emotional processes to outcome in experiential psychotherapy of
depression. Unpublished doctoral dissertation, York University, Toronto, Canada.
Warwar, S. H., & Greenberg, L. S. (2000, June). Catharsis is not enough: Changes in emotional
processing related to psychotherapy outcome. Paper presented at the International
Society for Psychotherapy Research Annual Meeting. Chicago, Illinois.
880
Warwar, S. H., Greenberg, L. S., & Perepeluk, D. (2003). Reported in-session emotional
experience in therapy. Paper presented at the annual meeting of the International Society
for Psychotherapy Research. Weimar, Germany.
*Washington, O. (1999). Effects of cognitive and experiential group therapy on self-efficacy and
perceptions of employability of chemically dependent women. Issues in Mental Health
Nursing, 20, 181–198.
*Washington, O. G. M. (2001). Using brief therapeutic interventions to create change in self-
efficacy and personal control of chemically dependent women. Archives of Psychiatric
Nursing, 15, 32–40.
Watson, J. C., & Bedard, D. L. (2006). Clients’ emotional processing in psychotherapy: A
comparison between cognitive-behavioral and process-experiential therapies. Journal of
Consulting and Clinical Psychology, 74, 152–152–159. doi: 10.1037/0022–
006X.74.1.152
Watson, J. C., & Geller, S. (2005). An examination of the relations among empathy,
unconditional acceptance, positive regard and congruence in both cognitive-behavioral
and process-experiential psychotherapy. Psychotherapy Research, 15, 25–33.
Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2007). Case-studies in the experiential
treatment of depression: A comparison of good and bad outcome. Washington, DC: APA
Books.
*Watson, J. C., Gordon, L. B., Stermac, L., Kalogerakos, F., & Steckley, P. (2003). Comparing
the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the
treatment of depression. Journal of Consulting and Clinical Psychology, 71, 773–781.
Watson, J. C., Greenberg, L. S., & Lietaer, G. (2010). Relating process to outcome in person-
centered and experiential psychotherapies: The role of the relationship conditions and
clients’ experiencing. In M. Cooper, J. C. Watson & D. Hölldampf (Eds.), Person-
centred and experiential therapies work: A review of the research on counseling,
psychotherapy and related practices (pp. 132–163). Ross-on-Wye, United Kingdom:
PCCS Books.
Watson, J. C., McMullen, E. J., Prosser, M. C., & Bedard, D. L. (2011). An examination of the
relationships among clients’ affect regulation, in-session emotional processing, the
working alliance, and outcome. Psychotherapy Research, 21, 86–86–96. doi:
10.1080/10503307.2010.518637
Watson, J. C., & Prosser, M. (2007, July). The relationship of affect regulation to outcome in the
treatment of depression. Paper presented to the 22nd Annual Conference of the Society
for the Exploration of Psychotherapy Integration, Lisbon, Portugal.
Watson, J., & Rennie, D. (1994). Qualitative analysis of clients’ subjective experience of
significant moments during the exploration of problematic reactions. Journal of
Counseling Psychology, 41, 500–509.
Watson, J. C., Schein, J., & McMullen, E. (2009). An examination of clients’ in-session changes
and their relationship to the working alliance and outcome. Psychotherapy Research, 4,
1–10. doi: 10.1080/10503300903311285
881
*Weston, T. (2005). The clinical effectiveness of the person-centred psychotherapies: A
preliminary inquiry including literature review, CORE-OM questionnaires, client session
recordings and client feedback. Unpublished Masters dissertation. University of East
Anglia.
*Weston, T. (2008). The clinical effectiveness of person-centred psychotherapies: The impact of
the therapeutic relationship. Unpublished draft doctoral dissertation, University of East
Anglia.
Westra, H. A., & Dozois, D. J. A. (2006). Preparing clients for cognitive behavioral therapy: A
randomized pilot study of motivational interviewing for anxiety. Cognitive Therapy and
Research, 30, 481–498.
*Wetzel, H., Szegedi, A., Scheurich, A., Lörch, B., Singer, P., Schläfke, D., . . . Hautzinger, M.
(2004). Combination treatment with nefazodone and cognitive-behavioral therapy for
relapse prevention in alcohol-dependent men: A randomized controlled study. Journal of
Clinical Psychiatry, 65, 1406–1413.
Whelton, W. J., & Greenberg, L. S. (2000). The self as a singular multiplicity: A process
experiential perspective. In J. Muran (Ed.), The self in psychotherapy. Washington, DC:
American Psychological Association.
*Wickberg, B., & Hwang, C. P. (1996). Counselling of postnatal depression: A controlled study
on a population based Swedish sample. Journal of Affective Disorders, 39, 209–216.
*Wilhelm, S., Deckersbach, T., Coffey, B. J., Bohne, A., Peterson, A. L., & Baer, L. (2003).
Habit reversal versus supportive psychotherapy for Tourette’s disorder: A randomized
controlled trial. American Journal of Psychiatry, 160, 1175–1177.
Wilson, D. B., & Lipsey, M. W. (2001). Practical meta-analysis. Thousand Oaks, CA: Sage.
*Wilson, G. L. (1990). Psychotherapy with depressed incarcerated felons: A comparative
evaluation of treatments. Psychological Reports, 67, 1027–1041.
Wnuk, S. (2009). Treatment development and evaluation of emotion-focused group therapy for
women with symptoms of bulimia nervosa. Unpublished Doctoral Dissertation, York
University, Toronto, Canada.
Woldarsky, C. (2011). Forgiveness in emotion-focused couples therapy: Relating process to
outcome. Unpublished PhD dissertation, York University, Toronto, Canada.
Wolfe, B., & Sigl, P. (1998). Experiential psychotherapy of the anxieety disorders. In L. S.
Greenberg, J. C. Watson, & G. Lietaer (Eds.), Handbook of experiential psychotherapy
(pp. 272–294). New York, NY: Guilford Press.
Yalom, I. D. (1980). Existential psychotherapy. New York, NY: Basic Books.
... The contribution of clients' ability to process their emotions to alleviation of psychopathological symptoms has been widely recognized in psychotherapy research (Baker et al., 2012;Elliott et al., 2013;Foa et al., 2006;Greenberg, 2015;Pinheiro et al., 2020;Whelton, 2004). Difficulties with emotional processing have been associated with the emergence and maintenance of psychopathology (Elliott et al., 2013;Foa et al., 2006;Greenberg, 2015;Whelton, 2004). ...
... The contribution of clients' ability to process their emotions to alleviation of psychopathological symptoms has been widely recognized in psychotherapy research (Baker et al., 2012;Elliott et al., 2013;Foa et al., 2006;Greenberg, 2015;Pinheiro et al., 2020;Whelton, 2004). Difficulties with emotional processing have been associated with the emergence and maintenance of psychopathology (Elliott et al., 2013;Foa et al., 2006;Greenberg, 2015;Whelton, 2004). Improved emotional processing capacity during therapy has been found to relate to better outcomes (Baker et al., 2012;Pascual-Leone, 2018;Pascual-Leone & Yeryomenko, 2017;Pinheiro et al., 2020). ...
... Humanistic-experiential therapies view clinical problems resulting from impaired ability to process painful emotions (Elliott et al., 2013;Greenberg, 2015;Greenberg & Watson, 2006;Pos et al., 2003). These therapies therefore facilitate such ability. ...
Article
Objective: Prior research, mainly conducted on depression, observed that clients' improved capability to process their emotions predicted better therapeutic outcomes. The current comparative study aimed to investigate whether emotional processing was related to therapeutic change in complicated grief. Method: We analyzed two contrasting cases (good or poor outcome) treated with grief constructivist therapy. In both cases we investigated the association of emotional processing (Experiencing Scale) to (1) therapeutic outcome (Inventory of Complicated Grief), and (2) change in the type of grief-related emotions (Emotions Episodes). Results: The session-by-session growth of clients' emotional processing and the change of grief-related emotions were qualitatively explored throughout both cases. Compared with the poor outcome case, the good outcome case achieved more improvement in the ability to process emotions. Such improvement occurred alongside a deeper change in the type of grief-related emotions aroused, from maladaptive to more adaptive responses. Conclusion: Our findings suggest that a higher emotional processing capability may be associated with the transformation of grief-related maladaptive emotions and with the improvement of complicated grief condition.
... Several studies (Elliott, 2002;Drouin, 2008;Zech, 2008;Elliott et al., 2013;Angus et al., 2015) confirm the effectiveness of humanistic and existential approaches. Meta-analysis by Elliott et al. (2013) and Angus et al. (2015) concluded that, in comparative studies with random groups, clients in humanistic psychotherapy experience change at levels that are as elevated as those of clients undergoing other forms of therapy. ...
... Several studies (Elliott, 2002;Drouin, 2008;Zech, 2008;Elliott et al., 2013;Angus et al., 2015) confirm the effectiveness of humanistic and existential approaches. Meta-analysis by Elliott et al. (2013) and Angus et al. (2015) concluded that, in comparative studies with random groups, clients in humanistic psychotherapy experience change at levels that are as elevated as those of clients undergoing other forms of therapy. So, as other approaches, humanistic therapy in its various forms is an effective means of helping those in distress, and this includes a wide range of mental disorders: depression, anxiety, adjustment, and interpersonal issues (Elliott, 2002;Drouin, 2008). ...
Article
Full-text available
This article explores the theme of presence of the psychotherapist, a concept that has been of particular interest in humanistic and existential approaches. Presence was first associated with the humanistic attitudes of the practitioner and the way he or she embodies these attitudes in the here and now of the encounter. Since the publication in 2002 of Geller and Greenberg’s model of therapeutic presence, several quantitative studies have explored the relationship between the therapist’s perception of presence and other dimensions of the therapeutic process. However, qualitative explorations still seem necessary to account for the complexity of the therapist’s presence and its role in the therapeutic process. Centered on the therapist’s perspective, we use an idiographic methodology and refer to lived clinical experience to highlight the dimension of sensory contact that, through the body, actualize a connection to a virtual space of the therapeutic relationship. We so describe how a therapist can achieve an embodied processing to clinical material from what we describe as “traces of presence” of the other. From this point of view, the patient’s presence incorporates itself into the therapist’s experience and the therapist can perceive aspects of this presence in a tangible, concrete, and useful way. The therapist’s presence thus takes on a meaning that is not reduced to what the patient will perceive and interpret of his or her attitude. It becomes the main material from which the therapist orients his or her clinical interventions. To view the online publication, please click here: https://www.frontiersin.org/articles/10.3389/fpsyg.2022.783417/full
... A medida que avanzaban los encuentros, comenzamos a notar claros efectos de transformación en los pacientes, lo que nos llevó a investigar el impacto que este proceso estaba teniendo en ellos. Consideramos que la mejor manera de demostrar esto, más allá de nuestra opinión, fue investigando sus propias percepciones y particularmente su propio registro de los factores o eventos significativos que influyeron en sus procesos de cambio (Elliott et al., 2013). Por tanto, la pregunta era: ¿Cuáles son los eventos útiles y obstaculizadores percibidos por los participantes de un grupo de psicodrama virtual con fines terapéuticos? ...
... La complejidad de este campo ha llevado a los investigadores a interesarse por estudiar episodios o eventos relevantes en las sesiones de psicoterapia (Krause et al., 2006), analizando tanto aquellos que son productivos como aquellos que pueden resultar problemáticos u obstructivos para el proceso (Timulak, 2010). El estudio de episodios relevantes se origina en el contexto de las psicoterapias experienciales (dentro de las cuales se encuentra el psicodrama), aunque rápidamente trascendió y comenzó a ser utilizado en diferentes investigaciones empíricas (Elliott et al., 2013). Tiene una larga tradición en investigación que ha acumulado numerosos estudios bajo la noción general de "evento significativo". ...
Article
Full-text available
Virtual psychodrama is a novel device that has gained great relevance throughout the world since the Covid19 pandemic. However, we still find almost no research that accounts for the processes and results of this new way of doing psychodrama. The present work sought to identify and describe the significant events that led to processes of change enunciated by the participants of virtual psychodrama groups with therapeutic purposes. The results indicate that the significant events that were identified as favorable in the responses of the participants indicate two central aspects of the psychodramatic method (dramatization and sharing) and a specific technique (mirror). In relation to the factors of therapeutic change, “universality” and “interpersonal learning” were the most mentioned. Finally, in relation to the events perceived as not useful or hindering, two categories were identified that were foreseen (sharing and dramatization) and two emerging categories (virtuality and group finalization). El psicodrama virtual es un dispositivo novedoso que ha tomado gran relevancia en el mundo entero a partir de la pandemia Covid19. Sin embargo, nos encontramos aún casi sin investigaciones que den cuenta de los procesos y resultados de este nuevo modo de hacer psicodrama. El presente trabajo se buscó identificar y describir los eventos significativos que llevaron a procesos de cambio enunciados por los participantes de grupos de psicodrama virtual con finalidad terapéutica. Los resultados indican que los eventos significativos que fueron identificados como favorecedores en las respuestas de los participantes señalan dos aspectos centrales del método psicodramático (dramatización y compartir) y una técnica específica (espejo). En relación con los factores de cambio terapéutico, la “universalidad” y el “aprendizaje interpersonal” fueron los más mencionados. Finalmente, en el que se refiere a los eventos percibidos como no útiles u obstaculizantes, se identificaron dos categorías que estaban previstas (compartir y dramatización) y dos categorías emergentes (virtualidad y finalización del grupo).
... Tato studie se však soustředila pouze na studie věnující se párové formě EFT. Dřívější metaanalýza (Elliott et al., 2013) sice zahrnovala individuální formu EFT, nicméně hodnotila účinnost humanistických psychoterapeutických přístupů jako celek a při detailní analýze sloučila individuální a párovou formu do jednoho klastru. ...
Article
Full-text available
Objective: The methodology of a systematic review of studies verifying the efficacy of intervention in the treatment of mental disorders helps to reduce bias by using explicit and rigorous methods for literature search and critical evaluation of previous studies. Up to now, no systematic review has been conducted on the efficacy of individual emotion focused therapy (EFT), despite the growing number of research findings examining the efficacy of EFT. The aim of this systematic review is therefore to evaluate the efficacy of an individual form of EFT in the treatment of mental problems and disorders. Method: In this study, the authors followed the PRISMA methodological manual. A systematic literature search was performed in the EBSCO, PubMed and Web of Science databases. The analysis was focused on assessing the magnitude of the effect of pre-post therapeutic changes, the sustainability of change within follow-up, or comparing the effect of change with another psychotherapeutic approach by evaluating the statistical and material significance of changes (effect size). Results: The authors identified seven studies that used a (quasi) experimental method to investigate the efficacy of EFT. The results support the efficacy of EFT as well as the sustainability of change in the treatment of depression. There is preliminary support for the efficacy of EFT in the treatment of social anxiety, trauma and eating disorders. So far, in the case of the above-mentioned disorders and difficulties, it is possible to consider EFT as probably effective. Limitations: Only studies written in English were selected in this systematic review. Case studies were not included. Key words: Emotion Focused Therapy, psychotherapy, systematic review, efficacy, effectiveness
... The effect sizes are similar to those found for other types of humanistic and relational therapies (Angus et al., 2014;Elliott et al., 2013). Evaluation of counselling clinics in the UK, which included community clinics (Barkham et al., 2001) and university counselling (Connell et al., 2008), also suggested similar effectiveness of such therapies in routine practice. ...