8a Mathematics Expert Only

EBSCO Publishing Citation Format: APA (American Psychological Assoc.):

NOTE: Review the instructions at http://support.ebsco.com.library.capella.edu/help/?int=ehost&lang=&

feature_id=APA and make any necessary corrections before using. Pay special attention to personal names,

capitalization, and dates. Always consult your library resources for the exact formatting and punctuation guidelines.

References

Pinheiro, P., Mendes, I., Silva, S., Gonçalves, M. M., & Salgado, J. (2018). Emotional processing and

therapeutic change in depression: A case study. Psychotherapy, 55(3), 263–274. https://doi-

org.library.capella.edu/10.1037/pst0000190

<!--Additional Information:

Persistent link to this record (Permalink): http://library.capella.edu/login?url=http://search.ebscohost.com

/login.aspx?direct=true&db=pdh&AN=2018-43053-006&site=ehost-live&scope=site

End of citation-->

Emotional Processing and Therapeutic Change in Depression: A Case Study / EVIDENCE-

BASED CASE STUDY

By: Patrícia Pinheiro

School of Psychology, University of Minho, Braga, Portugal

Inês Mendes

Department of Psychology, Royal Holloway, University of London

Sara Silva

Department of Social Science and Behavior, Maia University Institute–ISMAI

Miguel M. Gonçalves

School of Psychology, University of Minho

João Salgado

Department of Social Science and Behavior, Maia University Institute–ISMAI;

Acknowledgement: This study was partially conducted at the Psychology Research Centre

(UID/PSI/01662/2013), University of Minho, and supported by the Portuguese Foundation for

Science and Technology and the Portuguese Ministry of Science, Technology and Higher Education

through national funds and co-financed by FEDER through COMPETE2020 under the PT2020

Partnership Agreement (POCI-01-0145-FEDER-007653). This research was also partially supported

by a grant (PTDC/PSI-PCL/103432/2008) and a PhD Studentship grant (SFRH/BD/93696/2013) from

the Portuguese Foundation for Science and Technology.

The way clients process their emotional experiences and how this processing contributes to

therapeutic change has received renewed interest in psychotherapy research (Baker et al., 2012;

Elliott, Greenberg, Watson, Timulak, & Freire, 2013; Foa, Huppert, & Cahill, 2006; Greenberg, 2010;

Whelton, 2004). In different therapeutic approaches, the achievement of a high capacity for

emotional processing during therapy has been associated to good outcome (Baker et al., 2012;

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

1 of 22 3/1/2019, 5:27 PM

Greenberg & Watson, 2006; Whelton, 2004).

Although previous studies found a relationship between higher levels of emotional processing and

greater symptomatic improvement from pre- to posttherapy, it is not yet clear whether those higher

levels of emotional processing are associated with the session-by-session improvement. Such a

longitudinal analysis would be relevant to clarify and provide a more comprehensive understanding of

the role of emotional processing as a variable associated with gradual improvement during therapy.

In the current article, we will explore in a good-outcome case of depression whether these variables

are, as theoretically expected, associated throughout therapy. Consistent with the model of theory-

building case studies (Stiles, 2015), the degree of congruency between our observations and the

theoretical expectations may increase confidence in or suggest modifications to current assumptions

about the contribution of emotional processing to therapeutic change in depression.

Emotional Processing

The concept of emotional processing was first introduced in the context of behavioral approaches,

mainly to explain the effect of exposure in anxiety disorders (Foa, Rothbaum, & Furr, 2003; Goldfried,

2003; Whelton, 2004). For these approaches, successful emotional processing involved the

activation of the dysfunctional emotion and the gradual reduction of its intensity during the exposure

to the trigger stimulus (Rauch & Foa, 2006).

Later, humanistic–experiential approaches conceptualized emotional processing differently, giving it a

prominent role in psychotherapy. For these approaches, the impairment in the processing of

emotions is associated to psychopathological conditions, such as depression (Greenberg, 2010;

Greenberg & Watson, 2006). According to Greenberg and Watson (2006), in depression, the

experiential self is organized as unlovable or worthless and helpless or incompetent because of the

activation of early schematic memories of being humiliated, abused, criticized, trapped, and/or

abandoned. Once activated, depressive emotional schemes automatically produce maladaptive

emotional responses to situations, impairing the person’s ability to process painful emotions

(Greenberg & Watson, 2006). The therapeutic change involves promoting the client’s capability to

process their emotions, that is, to be aware, to experience and make meaning of such emotions, and

to transform the underlying emotional scheme into a more adaptive one (Elliott et al., 2013;

Greenberg, 2010; Pos, Greenberg, Goldman, & Korman, 2003). In this sense, emotions are a source

of information that needs to be explored to create new meaning and change the maladaptive

emotional experiences (Greenberg, 2010; Greenberg & Watson, 2006).

To humanistic–experiential approaches, emotional processing is a continuum of stages that goes

beyond the arousal (and eventual decrease) of the emotional experience that typically occurs in

traditional exposure methods. In these approaches, the creation of new meaning based on the

information derived from aroused emotions is a key process associated with the achievement of

higher levels of emotional processing and with the transformation of the depressive emotional

scheme (Pos et al., 2003). To make sense of emotions, the client needs to cognitively explore the

emotional information, integrating affect and cognition (Greenberg, 2010; Greenberg & Pascual-

Leone, 2006; Whelton, 2004). In sum, for humanistic–experiential approaches, emotional processing

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

2 of 22 3/1/2019, 5:27 PM

broadly involves the following: (a) being aware of emotions, (b) arousing emotions and tolerating live

contact with them, (c) exploring to make meaning of the emotional experience, and, finally, (d)

transforming the emotional scheme, that is, the maladaptive emotions that underlie and influence

how the client feels, thinks, and behaves (Elliott et al., 2013; Greenberg, 2010; Greenberg & Watson,

2006).

The humanistic–experiential concept of emotional processing has been measured through different

scales. In the current study, we used the concept as it is operationalized by the application of the

Experiencing Scale (EXP; Klein, Mathieu-Coughlan, & Kiesler, 1986) to emotionally loaded segments

of psychotherapy-emotion episodes (EEs; Greenberg & Korman, 1993; Korman, 1991). In previous

studies, the rating of the EXP during EEs was an appropriate measure of the emotional processing

continuum within emotional clinical relevant segments of therapy (Pos et al., 2003; Pos, Greenberg,

& Warwar, 2009). The EXP is an observational scale that provides a cognitive–affective continuum of

a client’s engagement and exploration of inward experiences to make sense of those experiences,

transform maladaptive emotions, and solve personal problems in a meaningful way (Klein et al.,

1986). From lower to higher levels of the EXP, clients increase their ability to access feelings, to be in

contact with them, to explore them, to create meaning from them, and to achieve new ones. Although

its focus is on the emotional component, the EXP also considers the cognitive component involved

both in the exploration of inner experiences to create new meaning and to transform emotions, and in

the coherent integration of those experiences into the self.

Emotional Processing and Symptomatic Improvement

The facilitation of in-session emotional processing, as assessed by the EXP, has been recognized as

a promoter of therapeutic change (Elliott et al., 2013; Greenberg, 2010; Greenberg, Auszra, &

Herrmann, 2007). Several studies on emotion-focused therapy (EFT) and client-centered therapy

found that the achievement of higher levels on EXP during psychotherapy predicts better outcomes

in depression (Goldman, Greenberg, & Pos, 2005; Pos et al., 2003, 2009; Pos, Paolone, Smith, &

Warwar, 2017). These results are not limited to humanistic–experiential therapies. In cognitive–

behavioral therapy (CBT), higher levels on EXP were predictive of a greater decrease in symptoms

from pre- to posttherapy (Watson, Mcmullen, Prosser, & Bedard, 2011), and in both CBT and

psychodynamic–interpersonal therapy for depression, good-outcome cases presented higher levels

of emotional processing than poor-outcome cases (Rudkin, Llewelyn, Hardy, Stiles, & Barkham,

2007). More importantly, a meta-analysis of 10 studies and 406 clients using different

psychotherapeutic approaches found that the level of EXP achieved was a significant outcome

predictor at the end of treatment, with a small-to-medium effect size (r = −.19; Pascual-Leone &

Yeryomenko, 2017).

Although there is evidence of the association between emotional processing and therapeutic

outcome, previous studies have not clarified whether there is a session-by-session association

between the increase in the level of emotional processing and the decrease in symptom intensity

throughout therapy. As those studies were focused on the contribution of emotional processing to

pre- to posttherapy change in symptoms, their design did not include a longitudinal assessment of

variables, namely, (a) they did not consider session-by-session measurements of clinical symptoms,

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

3 of 22 3/1/2019, 5:27 PM

and (b) emotional processing was assessed in a reduced number of sessions sampled from the

entire treatment (usually, two to three sessions per case). Leading process-outcome researchers

(Crits-Christoph, Gibbons, & Mukherjee, 2013) point out that ignoring the session-to-session

variability and analyzing only a few sessions of the therapeutic process may result in the

generalization of unrepresentative results. Thus, they recommended that longitudinal studies be

carried out to avoid this potential source of bias.

To the best of our knowledge, no studies have been carried out to explore the relationship between

emotional processing and symptoms change on a session-by-session basis. Only a recent study in

psychodynamic therapy (Fisher, Atzil-Slonim, Bar-Kalifa, Rafaeli, & Peri, 2016) has explored the

longitudinal association between the clients’ level of emotional engagement in therapy (a process

related to, but distinct from, emotional processing) and their functioning, observing a bidirectional

relation between variables. Although emotional engagement is a less comprehensive process (EXP

considers emotional engagement and a cognitive component) and has been assessed using a

retrospective self-report measure (EXP is an observational measure), those results suggest a more

complex (nonunidirectional) relation between variables than suggested in previous studies. As such,

further clarification of the session-by-session patterns of association between emotional processing

and symptoms may provide a more comprehensive and accurate understanding of the role of

emotional processing on the gradual improvement in depression.

Emotional Processing and Change From Maladaptive to Adaptive Emotions

For humanistic–experiential approaches, the transformation of the emotional scheme is the ultimate

stage on the continuum of emotional processing. The increase in the clients’ capability to process

their emotions contributes to transforming the depressive emotional scheme, resulting in the

emergence of new and more adaptive emotional responses to daily situations (Greenberg, 2010;

Greenberg & Watson, 2006).

On the basis of the clinical distinction of types of emotions, Greenberg (2010) described a three-step

sequence involved in the change of the maladaptive emotional experiences: Secondary maladaptive

emotions evolve to primary maladaptive emotions, and then to primary adaptive emotions.

Secondary maladaptive emotions, such as worthlessness, are secondary reactive responses to

primary emotions (e.g., sadness) that are perceived as threatening or overwhelming, and they need

to be transformed to make it possible to access primary emotions, the first fundamental responses to

situations (Greenberg, 2010; Greenberg & Watson, 2006). Primary adaptive emotions refer to

immediate responses to situations that mobilize the person for adaptive actions, whereas primary

maladaptive emotions trigger dysfunctional action tendencies and cognitive processes that interfere

with a person’s adaptive functioning (Greenberg, 2010). For instance, primary maladaptive shame

can be replaced by primary sadness, assertive anger, self-forgiveness, and self-worth (Greenberg &

Watson, 2006). Primary adaptive emotions need to be accessed to symbolize their information,

which is essential for the enhancement of the level of emotional processing and to change the

depressive emotional scheme (Greenberg, 2010; Greenberg et al., 2007; Greenberg & Watson,

2006; Pascual-Leone & Greenberg, 2007). In this sense, accessing adaptive emotions such as anger

to replace unfairness or sadness for what was lost is important to ensure the self-capacity to be loved

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

4 of 22 3/1/2019, 5:27 PM

and to achieve self-worth (Greenberg & Watson, 2006).

Supporting this theoretical background, Herrmann, Greenberg, and Auszra (2014) found that a high

frequency of primary emotions during the therapeutic working phase and a high frequency of change

from maladaptive to adaptive emotions are predictors of good outcome. However, to sustain the

theoretical claim that the increase in the clients’ capability to process their emotions is associated to

the change from maladaptive to more adaptive emotional responses, we still need to explore this

relationship further.

Aims

This research consists of an intensive case study analysis of a good-outcome case of depression

treated with EFT (Elliott, Watson, Goldman, & Greenberg, 2004; Greenberg, 2010; Greenberg &

Watson, 2006) and aims to explore if emotional processing is longitudinally associated with the

gradual therapeutic change in depression. The first specific aim was to explore the session-by-

session associations between the levels of emotional processing and the intensity of symptoms. The

second aim was to explore the relationship between the increase in the levels of emotional

processing and the change in the type of emotional responses (adaptive or maladaptive) aroused

throughout therapy.

Method

Participants

Client

Elizabeth (fictional name) was a Portuguese woman in her early 40s with low levels of both education

and socioeconomic status. She was divorced and lived with her three children. Elizabeth participated

in the ISMAI Depression Study (Salgado, 2014), a clinical trial that compared the efficacy of EFT and

CBT in the treatment of major depression (outcome study). The inclusion criteria for the clinical trial

were a diagnosis of major depressive disorder, no medication, and a Global Assessment of

Functioning above 50. The exclusion criteria were as follows: (a) currently using medication; (b) a

current or previous diagnosis with one of the following Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition Axis I disorders: panic, substance abuse, psychosis, bipolar, or eating

disorder; (c) diagnosis of one of the following Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition Axis II disorders: borderline, antisocial, narcissistic, or schizotypal; or (d) a high risk of

suicide. At baseline assessment, Elizabeth received the diagnosis of mild major depression, and she

was randomly assigned to EFT. She received her treatment in the psychotherapeutic lab at ISMAI

during 16 therapeutic sessions. Elizabeth consented to have her sessions videotaped, which were

obtained after she had been informed about the aims and procedures of the clinical trial and about

the further use of the collected data in process-outcome studies (such as the current study that

demanded qualitative analyses of the level of emotional processing and the type of emotions

aroused throughout sessions). The ethical principles of both the American Psychological Association

and the Order of Portuguese Psychologists were followed.

Elizabeth’s case was randomly chosen from EFT good-outcome cases (N = 18) according to the

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

5 of 22 3/1/2019, 5:27 PM

Beck Depression Inventory-II (BDI-II; translated and validated to the Portuguese population from

Beck, Steer, & Brown, 1996, by Coelho, Martins, & Barros, 2002). It was considered a recovered and

reliably changed case because (a) in the last session the total score was below the cutoff point of 13

(BDI-II pre-treatment score = 31, post-treatment = 0) and (b) the change from pre- to posttest was

higher than the reliable change index (Christensen & Mendoza, 1986; Jacobson & Truax, 1991) of

7.75 (Δ BDI-II scores = 31).

Elizabeth’s core issues were related to experiencing feelings of worthlessness and of being an

unlovable person. First, she felt that she failed as a mother because she got divorced and could not

provide her children with the traditional family she had idealized. Because of her early experience as

a victim of her father’s intimate violence, she had the main goal of providing a nonviolent and

supportive family for her children. Although she got divorced to avoid a violent family environment for

her children, she believed that not providing her children with the presence of a father meant that

they would be ultimately unhappy. Second, she felt unlovable and rejected by others, mostly by her

critical and dismissive father and her ex-husband, making her question her self-worth and her ability

to be loved.

Therapist

Elizabeth’s therapist was a female doctorate in clinical psychology who was in her early 30s. She had

9 years of experience as a psychotherapist and had been trained in EFT during the previous 4 years.

The therapist received weekly supervision.

Therapy

EFT is an integrative humanistic–experiential therapy that incorporates techniques from person-

centered and gestalt approaches (Greenberg, 2010; Greenberg & Watson, 2006). According to EFT,

emotions play a unique role in the human experience, contributing both to adaptive and maladaptive

functioning (Elliott et al., 2004; Greenberg, 2010; Greenberg & Watson, 2006). In depression, clinical

problems are associated with maladaptive emotional processing, and therapy aims to solve those

difficulties through specific emotion-evocative therapeutic tasks (Watson & Bedard, 2006). The goal

of those experiential strategies is to promote access to the depressive emotional scheme and to

enhance the level of emotional processing, facilitating the change in the maladaptive scheme, and

the consequent experiencing of new and more adaptive emotions (Greenberg & Pascual-Leone,

2006). According to this approach, different and opposing self-aspects or voices compose the self,

and poor or disturbing communication between them causes emotional pain, impairing access to

adaptive emotions and the resolution of personal problems (Elliott et al., 2004). Thus, therapeutic

tasks facilitate contact between the opposing voices or parts of the self. Throughout Elizabeth’s

treatment, the prevailing experiential tasks used were the two-chair dialogue with her critical and

blaming internal voice and the empty-chair dialogue with her father and ex-husband regarding

unfinished business.

Measures

Process measures

Emotion Episodes

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

6 of 22 3/1/2019, 5:27 PM

An EE (Greenberg & Korman, 1993; Korman, 1991) is an emotionally loaded segment of

psychotherapy in which the client expresses an emotion (e.g., sadness) or an associated action

tendency (e.g., crying) in response to a situation or context (e.g., relationship breakup). According to

the emotional response (emotion or action tendency) presented in the EEs, these are categorized

into six basic emotions: EE of Love, EE of Joy, EE of Fear, EE of Anger, EE of Sadness, and EE of

Guilt/Shame (EE Manual; Korman, 1991). As the client’s emotional scheme underlies the activation

of specific emotional responses to situations (Greenberg & Korman, 1993), changes in the aroused

emotions regarding the same situation may indicate some transformation of the scheme.

Following the EE Manual (Korman, 1991), the coding of EEs involved (a) identification in the client’s

speech of an emotional response toward a situation, context, or event; (b) delimitation of the EE by

tracking the client’s speech back to where the situation or context relevant to the emotional reaction

emerged and forward to where either the theme of the discourse or the emotion changed; and,

finally, (c) categorization of the basic emotion of the EE according to the expressed emotional

response (whenever an EE contained different basic emotions, the rule was to categorize it

according to the dominant one, based on clinical judgment). In previous studies, the interrater

agreement on the identification of EEs was strong (99%; Pos et al., 2003). Clinicians were able to

discriminate between EEs and non-EEs in psychotherapy segments, suggesting an appropriate

validity (Greenberg & Korman, 1993).

Experiencing Scale

The EXP (Klein et al., 1986) assesses the level at which the client is cognitively and emotionally

involved in the processing of inward experiences through a 7-point ordinal rating scale. Namely, it

assesses to what level a client focuses on, experiences, explores, and reflects on information to

create new meaning, transform emotional experiences, and solve personal problems in a meaningful

way. Higher levels indicate higher emotional processing. At EXP Level 1, clients describe their

experience from an external perspective. At EXP Level 2, clients are only behaviorally or

intellectually involved with the described situation. At EXP Level 3, clients describe external events,

presenting feelings and personal reactions circumscribed to these events. At EXP Level 4, clients

shift to an inward focus, describing feelings, inner experiences, and personal assumptions and

perceptions. At this stage, clients speak “from” instead of talk “about” their personal experience. At

EXP Level 5, clients present and explore hypotheses about their feelings, inner experiences, and

personal problems. At EXP Level 6, they present a synthesis of vivid and accessible feelings to

describe the achievement of personal problem resolution and/or the transformation of meanings and

emotional experiences. Finally, at EXP Level 7, the new inner experiences and feelings are applied

to a wider range of situations, resulting in clients’ new and expansive understanding of themselves.

The rating of the EXP involved the identification of the EXP peak level, that is, the highest level

achieved during each EE (EXP Manual; Klein et al., 1986). In previous research, the interrater

reliability coefficients (intraclass correlation coefficient-ICC) ranged from .76 to .91 and the rating–

rerating correlation coefficient was approximately .80 (Klein et al., 1986). The EXP presented a

moderate concurrent validity with the Observer-Rated Measure of Affect Regulation (Pearson’s r =

.44; Watson et al., 2011).

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

7 of 22 3/1/2019, 5:27 PM

Symptoms measure

The Outcome Questionnaire 10.2 (OQ-10.2; Lambert, Finch, Okiishi, & Burlingame, 2005) is a self-

report inventory that assesses a client’s general clinical symptoms. The 10 items (e.g., “I am satisfied

with my life” and “I feel blue”) are scored on a scale ranging from 0 to 4. The total score ranges from

0 to 40, with higher scores indicating more intense symptomatic distress. The Portuguese version

presented an adequate internal consistency (Cronbach’s α = .77) and test–retest reliability over a

1-week interval (Pearson’s r = .74) in the ISMAI Depression Study’s sample (Salgado, 2014; N = 64).

The instrument presented a moderate concurrent validity with the BDI-II (Pearson’s r = .51).

Procedures

Process measurement

Emotion episodes

Judges’ training

The judges were two female, doctoral-level students of clinical psychology (first and third authors),

both with previous training in EFT. One of the judges was an expert in the coding of EEs and

provided the second judge with training based on the EE Manual (Korman, 1991). The training

procedures encompassed weekly meetings (2 hr) over approximately 3 months, which included the

following steps: (a) reading and discussion of the coding manual, (b) coding of all excerpts from the

manual, and, finally, (c) coding of videotaped sessions from the ISMAI Depression Study’s cases (not

from Elizabeth’s case). The last step was concluded when a good level of reliability was achieved

between judges (Cohen’s κ ≥ .65).

Reliability

The judges were unaware of the evolution of the clinical symptoms (OQ-10.2 scores) of Elizabeth’s

case and performed an independent coding of the sessions (following their chronological order).

Reliability was determined by comparing the judges’ independent codification of the (a)

presence/absence of EEs and (b) the emotion in each EE. The interjudge agreement for the

presence/absence of the EEs was a Cohen’s κ of .80 and for the emotions of EEs was a Cohen’s κ

of .81. Disagreements were discussed afterward to reach a consensus.

Data analysis

For the final codification, we computed the total frequency of EEs and the frequency of the EEs

categorized in each of the basic emotions. Frequencies were computed both for the entire case and

for each session.

Adaptive or maladaptive EEs

Judges

The judges were the same ones who previously coded the EEs. They were clinicians trained in EFT

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

8 of 22 3/1/2019, 5:27 PM

and familiarized with Greenberg’s (2010) distinction between adaptive and maladaptive emotions.

Reliability

On the basis of theoretical knowledge and clinical judgment, the judges performed an independent

categorization of each EE (following their chronological order) as presenting adaptive or maladaptive

emotions. The interjudge agreement was excellent (Cohen’s κ = .95). Disagreements were discussed

to reach a consensus.

Data analysis

For the final codification, we computed the frequency of the adaptive and maladaptive EEs of Love,

Joy, Fear, Anger, Sadness, and Guilt/Shame. Frequencies were computed both for the entire case

and for each session.

Experiencing Scale

Judges’ training

A clinical psychologist with a doctoral degree, expert in the EXP and in EFT, trained two judges,

namely, a female doctoral-level student (first author) and a master’s degree student in clinical

psychology. The training was based on the EXP Manual (Klein et al., 1986) and encompassed

weekly meetings (2 hr) over approximately 4 months. It included three steps: (a) reading and

discussion of the rating manual, (b) rating of excerpts from the manual, and, finally, (c) rating on

previously delimitated EEs in ISMAI Depression Study’s videotaped sessions (not from Elizabeth’s

case). This last step was completed when a good reliable index was achieved between the trainees’

and the expert judge’s ratings, ICC(2, 1) ≥ .65.

Reliability

Both judges were unaware of the evolution of the clinical symptoms (OQ-10.2 scores) of Elizabeth’s

case and performed an independent rating of the EXP of each previously identified EE (following the

chronological order of the sessions). The interrater agreement was based on their ratings of each EE

and presented a good reliability index, ICC(2, 2) = .85. Disagreements were discussed to reach a

consensus.

Data analysis

The final EXP ratings were averaged for each session. The average was computed based on a

varied number of EEs.

Symptoms measurement

The OQ-10.2 was filled in by the client at the beginning of all 16 therapeutic sessions, at the

assessment, and at the 1-month follow-up session. Because it is an appropriate measure of changes

in general clinical symptoms over short time periods, it will be used in the current study as a session-

by-session measure of symptoms.

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

9 of 22 3/1/2019, 5:27 PM

Statistical analysis

The longitudinal association between the client’s emotional processing and the clinical symptoms

was computed based on bootstrapping methods using the simulation modeling analysis software

(SMA; Borckardt & Nash, 2014). SMA was designed to statistically account for autocorrelated time-

series data streams of single-case designs (i.e., several observations of the same variable

throughout the sessions). Pearson rho tests based on SMA cross-correlation models were computed

to explore multiple temporal associations between variables. Because it is an exploratory study, we

compared the strength of the association between the level of emotional processing in one session

and the intensity of clinical symptoms in the same session (lag 0), the subsequent session (lag + 1),

and the preceding session (lag − 1). We used the Bonferroni-adjusted α level of .016 (.05/3).

Results

The entire case presented 132 EEs, with an average of eight EEs per session (range from five to 12).

Elizabeth presented a growing tendency of her ability to process her emotions across therapy, as the

EXP average level in Session 1 ranged from 3 to 4 (EXP average level = 3.5) and in the last session

ranged from 5 to 6 (EXP average = 5.5).

Emotional Processing and Clinical Symptoms

The evolution of the client’s level of emotional processing (EXP average levels per session) and the

intensity of clinical symptoms (OQ-10.2 scores) throughout therapy are presented in Figure 1.

Whereas the EXP level tended to increase, the intensity of the clinical symptoms decreased,

achieving lower scores. Regarding symptoms, some setbacks occurred (Sessions 4, 7, and 15), but

these peaks were progressively lower throughout therapy. Pearson’s correlation coefficient indicated

a strong, significant negative association between the EXP Level and the OQ-10.2 scores in the

same session (lag 0), r = −.71, p < .001. We found nonsignificant negative associations between

EXP Levels and OQ-10.2 scores in the subsequent session (lag + 1), r = −.29, p = .180, and the

preceding session (lag − 1), r = −.37, p = .101.

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

10 of 22 3/1/2019, 5:27 PM

Figure 1. Average EXP level and OQ-10.2 scores throughout therapy. EXP = Experiencing Scale;

OQ-10.2 = Outcome Questionnaire 10.2.

Emotional Processing and Types of Emotions Aroused (Adaptive or Maladaptive)

During the entire case, the most frequent EEs were of Joy (N = 54), Anger (N = 37), Guilt/Shame (N

= 20), and Sadness (N = 12). The EEs of Fear (N = 9) presented a lower frequency, and no EEs of

Love were identified (Figure 2a). All EEs of Guilt/Shame were categorized as maladaptive, whereas

all the EEs of Joy and Sadness were categorized as adaptive. The EEs of Anger were categorized

as both adaptive (n = 19) and maladaptive (n = 17; Figure 2b). Most of the EEs of maladaptive Anger

(n = 14) were identified within the first five sessions. After Session 5, EEs of adaptive Anger (n = 15)

were identified more often. Regarding the EEs of Fear, only one was categorized as maladaptive

(Session 6). We decided not to further explore the EEs of Fear because these presented a residual

frequency and in its majority were adaptive responses to a restricted situation not related to the

client’s main issues-the illness of her young child (Session 7). Overall, as the EXP Levels increased

throughout treatment, the most frequent EEs also changed, that is, the initial EEs of maladaptive

Guilt/Shame (Sessions 1–4) were replaced by EEs of maladaptive Anger and adaptive Sadness

(Session 5), and finally by EEs of adaptive Anger and Joy (Sessions 6–16).

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

11 of 22 3/1/2019, 5:27 PM

Figure 2. (a) Frequency of EEs of Guilt/Shame, Anger, Sadness, Fear, and Joy throughout therapy.

(b) Frequency of EEs of Anger categorized as adaptive and maladaptive throughout therapy. EEs =

emotion episodes.

Sessions 1 to 4

The EEs of maladaptive Guilt/Shame were prevalent in the initial sessions, being associated with

Elizabeth’s perception of failing as a mother. The client predominantly presented EXP Levels 3 and 4

in those sessions.

At EXP Level 3, Elizabeth mainly described the situation in which she identified the negative impact

her decision to get divorced had on her children. Although she enriched those descriptions with brief

references to the inward impact of such situations (spontaneously or at the request of the therapist),

her focus was on the events themselves. In the following excerpt, rated as EXP Level 3 (EEs of

Guilt/Shame; Session 1), the client described a situation with her son and made a brief reference to

her feelings of guilt. ElizabethMy son told me “my father will make lots of money and will come back

home” and I said to him “he can’t come here, son” [. . .]. Perhaps my son will blame me because his

father is trying to reconnect (cries). It makes me feel so guilty.

The therapist’s interventions, namely, the request for further inner elaboration (e.g., “How’s that

feeling of guilt?”) and the empathic conjectures (e.g., “It saddens you”), seem to have promoted the

redirection of the client’s focus to her inner experiences associated with feelings of Guilt/Shame.

Instead of describing the external events, at EXP Level 4, the client focused on her experience of

failure, clarifying how this was felt for her. The following excerpt (EEs of Guilt/Shame; Session 1)

illustrates a detailed description of the client’s inner experience and feelings following the therapeutic

intervention. ElizabethI failed, I deprived my children of an important person [father] in their

growth.TherapistIt’s so painful.ElizabethIt’s hurting me so much. I feel so guilty. It’s a terrible feeling,

gives me a great desire to do nothing, to not fight for anything. I just wanted to sleep today and wake

up tomorrow again with 20 years and have the chance to change everything [. . .]

From Session 1 to Session 4, the average EXP Level presented a trend of constant growth.

Elizabeth reached EXP Level 5 more frequently, that is, she defined and explored internally her

problem of failing as a mother. In the following excerpt (EE of Guilt/Shame; Session 4), the client

initially reached EXP Level 4 when she accessed the internal conflict between two different parts of

herself: the need to protect her children from a disturbed family and an inner pressure to ensure her

children’s happiness by maintaining their connection to their father. To expand the client’s awareness

about her feelings of guilt, the therapist promoted the exploration of the emotional impact of this issue

and its association with her childhood experiences. Elizabeth achieved EXP Level 5 when she

hypothesized that her feelings of guilt resulted from the nonachievement of her cherished goal of

providing her children a happy childhood. Through this meaning-making, she caught her first glimpse

of the idea that the presence of her children’s father might not guarantee that they would be happier,

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

12 of 22 3/1/2019, 5:27 PM

as she had experienced the negative impact of having a dismissive father.

ElizabethFor me, it is very hard to raise my children alone, but if I was still with their father this would

be harder because he was destroying everything I did. But sometimes that lady there (critical part of

herself) tells me: “How can you be so sure that he was not going to change?” This is terrible! (cries)

I’ve given so many opportunities to him and he never changed, why would he change now? But I

believe I’m stealing a happy childhood from them. (Therapist: It’s so painful.) This drives me crazy,

it’s an unbearable guilt and powerlessness. It’s a feeling of worthlessness and failure.

TherapistYou’ve dreamed of a family so many years. How was the family you dreamed of?

ElizabethI dreamed of a family with a husband who would like to be with our kids.

TherapistYou dreamed about a father who cares.

ElizabethExactly, because I already had had a dismissive father and it was horrible!

TherapistIt is painful for you to realize that you cannot give your children something that you’ve also

wanted for you but didn’t have.

ElizabethOf course. It is a feeling of guilt due to a failed promise I made to myself “to give my

children a better father than I had.” Somehow, I got it, but to give them a different father from my

own, I had to get my children away from their own father. [. . .]

TherapistThe inner child who dreamed of this family, what would she tell you?

ElizabethShe would tell me: “you have destroyed all my dreams.” I couldn’t do it! (cries) I feel so

guilty. I destroyed everything I wanted for my children. They deserved . . .

Therapist“Your children are not happy!” (voice of the critical part of the client)

ElizabethThey are happy, but of course they miss a part.

TherapistThe same that you would’ve felt if you had not had the presence of your father.

ElizabethIf I had not had my father I would be a much confident and happier person. I wish I hadn’t

had a father. Maybe my kids will prefer the life they have to the life they could take.

Session 5

After Session 4, the high frequency of EEs of maladaptive Guilt/Shame decreased and became

absent after Session 8. In Session 5, the EEs of Anger were the most frequent. Although the EEs of

maladaptive Anger already emerged in the previous sessions, in Session 5, they emerged together

with EEs of adaptive Sadness.

The EEs of maladaptive Anger were mainly associated with Elizabeth’s father’s and ex-husband’s

criticism to her value as a mother and as a person. During the expression of this rejecting Anger,

Elizabeth reached the first EXP Level 6, presenting both a new and enriched self-experience and the

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

13 of 22 3/1/2019, 5:27 PM

inner work that fostered the development of this change. In the following excerpt (EE of maladaptive

Anger), extracted from the beginning of Session 5, the client described how her feelings of

worthlessness were transformed into rejecting anger regarding her father and her ex-husband. She

realized that what prevented the accomplishment of her inner child’s dream of having a happy family

was not her fault, changing her feelings of guilt. ElizabethIn the last session we have stirred up the

destruction of the dreams of my inner girl who has never forgiven me. I didn’t want to see her

because I know it would hurt me.TherapistBecause it is very painful to think that you did not

accomplished her dream.ElizabethYes, but now I’m sure I have no reason to continue to blame

myself. Perhaps what has changed from the last session is that I used to feel rejected, humiliated

and dismissed, and it was transformed into contempt, detachment, revolt and anger. I feel a lot of

anger for them [father and ex-husband] because they helped destroy my inner girl’s dream. I want

them to suffer for all the pain they’ve caused me.TherapistYou’ve always felt that they devalued,

rejected, and despised you, feeding that part of you that criticizes and blames yourself for having

failed.ElizabethNow, I’m feeling that differently. I’m relieved, I do not blame myself. This doesn’t

mean that I didn’t have any responsibility, but that heavy guilt that it had on me is gone. I realized that

they were the main culprits for destroying my inner child’s dreams.

In Session 5, after some of the EEs of maladaptive Anger, Elizabeth described EEs of adaptive

Sadness regarding the same issue. Specifically, the client aroused emotions of Sadness for what she

had lost in her childhood and for the failed relationship with her father and ex-husband. In the

following excerpt, in response to the therapist’s efforts to internally focus the client, she differentiated

her feelings of Sadness. Elizabeth reached EXP Level 5 when she hypothesized that her feelings

had resulted from (a) not having a father who valued her and (b) having a changeless relationship

with him. ElizabethIt is discouraging. My father doesn’t realize that someday it will be too

late!TherapistRealizing that he and your relationship with him is not going to change is

painful.ElizabethYes. It doesn’t make me guilty or angry, but sorry. It saddens me the words I have to

say to a person who should be one of the most important persons in my life.TherapistIt’s like you still

have some hope that he could be the father you needed.ElizabethMaybe that’s what makes me sad.

The hope that he would change was always there for me, but now it is very, very, very tiny. I know our

relationship is not going to change. It saddens me not to have a loving and supporting father.

Sessions 6 to 16

As Elizabeth moved toward the end of therapy, the EXP average level increased between 5 and 6.

She more frequently achieved EXP Level 6 in the EEs of Anger and Joy.

At this stage of the therapy, the EEs of Anger were the most frequent only in Session 15, being

associated with a quarrel between the client and her eldest daughter on the eve of the session. In the

remaining sessions, these EEs were the second most frequent (second to Joy).

After Session 5, the frequency of EEs of maladaptive Anger declined, being replaced by EEs of more

adaptive Anger. In these EEs of adaptive Anger, the client draws a clearer identification and assertion

of her own rights. In the following excerpt rated with EXP Level 6 (Session 6), Elizabeth felt frustrated

with her father’s behavior while deciding not to get involved in his problem. Encouraged by the

therapist’s internally focused interventions, she identified the emotional impact of her new behavior

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

14 of 22 3/1/2019, 5:27 PM

and described the inner work underlying this change. The client realized how her involvement with

other people’s problems caused her feelings of worthlessness. She assumed that she is someone

who likes to take care of others but must do it in a different way to protect herself. The statement of

the client’s personal value and rights resulted in feelings of self-confidence and empowerment.

ElizabethInstead of bringing people closer to him [her father], he pushes them further away. I’m

frustrated about that, but I know it’s not my business, so I turned away.TherapistAnd do you feel

guilty?ElizabethNo. I do not feel guilty anymore. I spent a lot of time thinking about others, feeling

sorry for others and forgetting and ignoring myself. I have a life and I deserve to enjoy

it.TherapistYou deserve time for yourself, to take care of yourself.ElizabethYes, and I’m not being

selfish. I deserve it, I’ve always deserved it! I used to think I had the responsibility to change the

world and the people, which made me feel worthless.TherapistYou felt the weight of the world on

your shoulders.ElizabethYes, it was a burden. I’m a person who likes to help others, but I’m not going

to put them first. It is enough! I must accept it or walk away to protect myself (pause). Protect myself

makes me feel confident and stronger. I deserve it!

From Session 6 to the last one, the EEs of adaptive Joy were the most frequent. The client usually

achieved higher EXP Levels (EXP Levels 4–6) in these EEs. These EEs were related to Elizabeth’s

accomplishment of her self-worth (a) as a mother, because she realized that she did in fact provide a

happy childhood to her children, and (b) as a person, because she recognized herself as a more

able, stronger, and lovable person. The next clinical excerpt (Session 12) rated as EXP Level 6

referred to the client’s current relationship with her inner child, who dreamed of raising a different,

happy family from the one she had. The client’s awareness that she was actually providing a happy

childhood to her children allowed her to both be at peace with her inner child and recover happy

memories of her own childhood. She explored and elaborated on the change in the experience of her

inner child, accessing to the meaning and emotional impact of such transformation. Elizabeth’s

awareness of herself as responsible for the achievement of her cherished goal resulted in feelings of

self-pride and empowerment, changing her previous self-experience of worthlessness.

ElizabethWhen I saw my inner girl for the first time she was in a confused and dark scenario. Now

she is happy and quiet at my grandparents’ house, where I had the best moments of my

childhood.TherapistWhat do you think that helped your inner girl to go over there?ElizabethNow, I

know I provided the best family to my kids, where they feel safe and happy. Perhaps my peace today

is reflected in her peace. Maybe that’s it.TherapistNow she can be peaceful and content. Does her

peacefulness help you too?ElizabethSeeing her like that gives me peace. That means that I haven’t

missed everything in my childhood. For me, if I didn’t have a happy childhood, I wouldn’t have

anything in my life. But I was happy with my grandparents, only that was obscured by what went

wrong.TherapistDo you think your peace let her go there and she also gave you more

peace?ElizabethIt gives me the sense that I gave her enough to stop crying. So, instead of feeling

guilty for not accomplishing what she wanted, I’m glad she’s happy.Therapist“I helped her to find

happiness.” How does that feel?ElizabethIt’s comforting, it’s almost a trophy, “I got this!” I was afraid

because I thought that I’d never get her out of that state because she suffered so many

disappointments, but I did! I’m at peace with my inner girl. It’s a feeling of accomplishment! I’m not a

loser!

Discussion

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

15 of 22 3/1/2019, 5:27 PM

The intensive study of Elizabeth’s case was carried out to explore the humanistic–experiential

assumption that the increase in the clients’ capability of emotional processing is associated with

successful therapeutic change in depression. More specifically, we aimed to explore the session-by-

session association between the level of emotional processing achieved and the client’s gradual

improvement. According to Stiles’s (2015) theory-building case studies perspective, the comparison

of our observations in Elizabeth’s case with the theoretical assumptions may increase confidence or

suggest modifications to the theory. Thus, this case study may improve and extend the current

knowledge on the role of emotional processing on therapeutic change in depression.

Emotional Processing

During the therapeutic process, Elizabeth enhanced her ability to process emotions. In the initial

sessions, the client wavered between brief references to the inward and emotional impact of specific

daily situations (EXP Level 3), and a deeper focus on what it was like to be herself and how events

were inwardly experienced by her (EXP Level 4). As expected, this good-outcome case began with

moderate levels of emotional processing (Watson & Bedard, 2006), that is, she did not initiate

therapy by refusing to get involved (EXP Level 1) or presenting only a behavioral or intellectual

involvement with her inner experiences (EXP Level 2).

In the final sessions, Elizabeth achieved a consistent trend of higher emotional processing. She

explored her inner experiences (EXP Level 5), developed new feelings, meanings and experiential

insights, diluting her personal feelings of worthlessness (EXP Level 6). This observation of a gradual

increase in the level of emotional processing is consistent with the previous results in good-outcome

cases (Goldman et al., 2005; Pascual-Leone & Yeryomenko, 2017; Pos et al., 2003, 2009, 2017;

Watson & Bedard, 2006).

Emotional Processing and Clinical Symptoms

During Elizabeth’s therapy, while the levels of emotional processing presented a trend of growth, the

intensity of clinical symptoms decreased. The time-series analysis indicated that these variables

were strongly and negatively associated in the same session (lag 0), r = −.71, p < .001. The

associations between emotional processing and symptoms in the subsequent (lag + 1), r = −.29, p =

.180, and preceding session (lag − 1), r = −.37, p = .101, were found to be nonsignificant.

In the same session, the decrease of clinical symptoms was strongly associated with an increase in

the level of emotional processing. This means that when Elizabeth initiated a session with a lower

intensity of clinical symptoms, she achieved higher levels of emotional processing. On the other

hand, when she started the session with more intense symptoms, she presented a lesser ability to

process her emotional experiences. Therefore, the intensity of clinical symptoms may influence the

clients’ capability to process their emotions during the same session. This association throughout

therapy suggests that in good-outcome cases of depression, the reduction of symptoms may be

related to an increase in the clients’ ability to be aware, arouse, explore, make meaning, and

transform their maladaptive emotions.

Although the variables were synchronically associated in Elizabeth’s case, neither the negative

association between the level of emotional processing and the next-session intensity in symptoms

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

16 of 22 3/1/2019, 5:27 PM

nor the negative association between the intensity of symptoms and the next-session level of

emotional processing was statistically significant. These results were not expected based on

previous research that found in different samples of clients that the achievement of a higher level of

emotional processing predicted a decrease in symptoms from pre- to posttherapy (Elliott et al., 2013;

Goldman et al., 2005; Pascual-Leone & Yeryomenko, 2017; Pos et al., 2003, 2009; Watson &

Bedard, 2006).

For Elizabeth, achieving higher levels of emotional processing in one session did not ensure a better

clinical condition in the next session, whereas the intensity of symptoms assessed at the beginning of

the session was strongly associated with the emotional processing during the same session. First,

these results suggest that the session-by-session relationship between the level of emotional

processing and the intensity of clinical symptoms may not be linear in Elizabeth’s case. In a detailed

analysis, we observed steeper variations throughout therapy in the intensity of symptoms than in the

average level of emotional processing. Specifically, the decrease in the intensity of clinical symptoms

showed clear setbacks throughout therapy, whereas the levels of emotional processing had a more

steady and constant development. Thus, at an idiographic level, the theoretically expected benefits of

achieving higher levels of emotional processing may not emerge necessarily in the following session.

In addition, achieving higher levels of emotional processing may not be translated in symptoms

gains, as subsequent unexpected negative life events occurred. There were unpredictable negative

events between sessions (e.g., the illness of her child and a quarrel with her daughter at Sessions 7

and 15, respectively), which apparently disturbed the client and may account for the sudden increase

in the intensity of clinical symptoms. Therefore, Elizabeth’s increased ability to process her emotions

did not prevent her from feeling worse about negative life events in the next session. Instead, we

hypothesized that it may have had a delayed effect on symptoms, that is, that her increased

capability to process her painful emotions may have reduced the symptomatic impact of next

negative life events. Therefore, it could take longer than one session interval to have translation at

the symptoms level. Finally, these nonsignificant results may be due to the low number of

observations (N = 16), thus reducing the statistical power to detect effects.

Summarizing, this study suggests that in good-outcome cases of depression, the level of emotional

processing may be strongly dependent on the level of suffering reported by the client at the onset of

the same session, and it may not have a direct effect on symptoms in the next session.

Emotional Processing and Type of Emotions Aroused (Adaptive or Maladaptive)

As the levels of emotional processing increased throughout Elizabeth’s case, we observed a

transformation from maladaptive Guilt/Shame (Sessions 1–4) to maladaptive Anger, adaptive

Sadness (Session 5), and finally to adaptive Anger and Joy (Sessions 6–16). This change from

maladaptive to more adaptive emotions seems to be largely consistent with the theoretical sequence

of the emotional change proposed by Greenberg (2010).

During initial sessions (Sessions 1–4), the level of Elizabeth’s emotional processing increased from

the brief contact with the emotional experience (EXP Level 3) to the inward exploration of personal

issues activating emotions of Guilt/Shame (EXP Level 5). We hypothesized that such an increase in

the level of emotional processing resulted in the subsequent decline of the EEs of maladaptive

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

17 of 22 3/1/2019, 5:27 PM

Guilt/Shame and in the emergence of EEs of Anger (Session 5). Indeed, the client described the

transformation of her feelings of failure into rejecting Anger regarding her father and ex-husband

(EXP Level 6) after she had explored more deeply her feeling of Guilt/Shame.

These responses of maladaptive Anger, focused on the attack and rejection of her father and ex-

husband, are expected to be the first step to change the client’s negative self-evaluation (Pascual-

Leone & Greenberg, 2007). Elizabeth’s higher emotional processing of these feelings of Anger (EXP

Level 6) seemed to have been connected to the emergence of EEs of Sadness regarding the same

issue (Session 5). These emotional responses of Sadness were associated with what the client lost

and will not achieve, mobilizing her to accept and let go of those unfulfilled needs (Greenberg &

Watson, 2006). The client’s awareness, arousing, exploring, and reflecting on the meaning of that

feelings of Sadness (EXP Level 5) may have contributed to transform the maladaptive Anger into a

more adaptive emotional response. In the late EEs of Anger (Sessions 6–16), instead of being

focused on her father and ex-husband, she accepted that they would not change and made a clear

statement of her rights to be happy and protect herself from others’ criticism (Greenberg, 2010).

Until the end of therapy, Elizabeth deeply explored those adaptive emotions of Anger. She described

her new assertive behaviors, the inner work, and the experiential impact of her process of change,

namely, the experiencing of feelings of self-pride and empowerment (EXP Level 6). Alongside this

assertive statement (EEs of adaptive Anger), the EEs of adaptive Joy became the most frequent

(Sessions 6–16), mobilizing her to be congruent with her rights and needs (Greenberg, 2010). This

transformation is theoretically expected. According to Greenberg and Watson (2006), accessing

adaptive emotions such as anger to replace unfairness and sadness for the unfulfilled needs ensures

the self-capacity to achieve self-worth and to feel loved.

The emotional scheme underlies the activation of specific emotions; therefore, changes in the

aroused emotions regarding the same issue may suggest a transformation of the scheme

(Greenberg, 2010; Greenberg & Korman, 1993; Greenberg & Watson, 2006). Specifically, the

observed change in Elizabeth’s in-session aroused emotions suggests that her shame-based

worthlessness scheme associated with her early experiences with her father was transformed and

became more adaptive during therapy (Greenberg & Watson, 2006). Because this changing to more

adaptive emotions occurred during the increase in the level of emotional processing, it seems to

provide further support for the claim of humanistic–experiential approaches that emotional

processing contributes to transforming the underlying emotional scheme, resulting in new and more

adaptive emotions (Greenberg, 2010; Greenberg & Watson, 2006).

Contrary to our expectation, we observed a low frequency of EEs of Sadness (Greenberg & Watson,

2006). First, the absence of maladaptive EEs of Sadness (e.g., hopelessness) in the initial sessions

may have been masked by the high frequency of EEs Guilt/Shame. Sporadic emotional responses of

Sadness may have been expressed along with emotional responses of Guilt/Shame, thus considered

nondominant during the EE. Second, instead of adaptive Sadness, accessing adaptive Anger for

unfairness was more frequent in Elizabeth’s case. This high frequency of EE of Anger may be

associated with Elizabeth’s specific issues. As she was victim of a critical and dismissive father and

ex-husband, Anger was an adaptive emotional response that mobilized her to a proactive affirmation

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

18 of 22 3/1/2019, 5:27 PM

and healthy entitlement, ensuring her self-capacity and self-worth (Greenberg & Watson, 2006;

Pascual-Leone, 2009). Hence, accessing adaptive Sadness, even with a low frequency, may have

been productive for her acceptance and letting go of her unfulfilled needs of being loved by her father

(Greenberg & Watson, 2006). Although this result may be due to this client’s specific problems and

idiosyncrasies, it suggests that in some cases of successful change of depression, the arousing of

sadness can have a low frequency.

Conclusion, Limitations, and Further Investigation

Considering that this research is an exploratory case study, the results may be due to the client’s

idiosyncrasies, which prevents any generalization. However, the congruencies and discrepancies

between our observations and the theory can be informative (Stiles, 2015).

First, the change from maladaptive to more adaptive emotions during the increase in the level of

emotional processing was theoretically expected, strengthening the hypothesis that it may contribute

to changes in clients’ emotional responses and the underlying emotional scheme (Greenberg, 2010;

Greenberg & Watson, 2006). Thus, a client’s ongoing ability to process his or her emotions may hint

at the gradual transformation of the client’s depressive schema.

Second, instead of the level of emotional processing contributing to the subsequent intensity of

symptoms (Elliott et al., 2013; Pascual-Leone & Yeryomenko, 2017; Pos et al., 2003, 2009), we

observed that it was the intensity of the symptoms that may have influenced the level of emotional

processing achieved during the same session. Thus, symptoms in a given session may provide

information about the client’s capability to emotionally process their experiences, thus allowing

therapists to adjust their interventions. Specifically, favoring the use of strategies focused on

promoting higher levels of emotional processing in sessions with less intense symptoms. Future

studies should address the relationship between emotional processing and symptoms in the following

sessions, as the pattern observed may have resulted from (a) idiosyncrasies of the case, (b)

procedures of data analysis (i.e., the impact on symptoms may have been nonlinear or delayed), or

(c) additional variables influencing the results.

Footnotes

The clinical vignettes were translated from Portuguese.

References

Baker, R., Owens, M., Thomas, S., Whittlesea, A., Abbey, G., Gower, P., . . .Thomas, P. W. (2012).

Does CBT facilitate emotional processing?Behavioural and Cognitive Psychotherapy, 40, 19–37.

10.1017/S1352465810000895

Beck, A. T., Steer, R. A., & Brown, G. (1996). BDI-II: Beck Depression Inventory-II Manual. New York,

NY: Psychological Corporation.

Borckardt, J. J., & Nash, M. R. (2014). Simulation modelling analysis for small sets of single-subject

data collected over time. Neuropsychological Rehabilitation, 24, 492–506.

10.1080/09602011.2014.895390

1

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

19 of 22 3/1/2019, 5:27 PM

Christensen, L., & Mendoza, J. (1986). A method of assessing change in a single subject: An

alteration of the RC index. Behavior Therapy, 17, 305–308. 10.1016/S0005-7894(86)80060-0

Coelho, R., Martins, A., & Barros, H. (2002). Clinical profiles relating gender and depressive

symptoms among adolescents ascertained by the Beck Depression Inventory II. European

Psychiatry, 17, 222–226. 10.1016/S0924-9338(02)00663-6

Crits-Christoph, P., Gibbons, M. B. C., & Mukherjee, D. (2013). Psychotherapy process-outcome

research. In M. J.Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior

change (6th ed., pp. 298–340). Hoboken, NJ: Wiley.

Elliott, R., Greenberg, L. S., Watson, J. C., Timulak, L., & Freire, E. (2013). Research on humanistic-

experiential psychotherapies. In M. J.Lambert (Ed.), Bergin and Garfield’s handbook of

psychotherapy and behavior change (6th ed., pp. 495–538). New York, NY: Wiley.

Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused

therapy: The process-experiential approach to change (1st ed.). Washington, DC: American

Psychological Association. 10.1037/10725-000

Fisher, H., Atzil-Slonim, D., Bar-Kalifa, E., Rafaeli, E., & Peri, T. (2016). Emotional experience and

alliance contribute to therapeutic change in psychodynamic therapy. Psychotherapy, 53, 105–116.

10.1037/pst0000041

Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory: An update. In B.

O.Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 3–24).

New York, NY: Guilford Press.

Foa, E. B., Rothbaum, B. O., & Furr, J. M. (2003). Augmenting exposure therapy with other CBT

procedures. Psychiatric Annals, 33, 47–53. 10.3928/0048-5713-20030101-08

Goldfried, M. R. (2003). Cognitive–behavior therapy: Reflections on the evolution of a therapeutic

orientation. Cognitive Therapy and Research, 27, 53–69. 10.1023/A:1022586629843

Goldman, R. N., Greenberg, L. S., & Pos, A. E. (2005). Depth of emotional experience and outcome.

Psychotherapy Research, 15, 248–260. 10.1080/10503300512331385188

Greenberg, L. S. (2010). Emotion-focused therapy. Theory, research and practice. 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, 482–493. 10.1080/10503300600977800

Greenberg, L. S., & Korman, L. (1993). Assimilating emotion into psychotherapy integration. Journal

of Psychotherapy Integration, 3, 249–265. 10.1037/h0101172

Greenberg, L. S., & Pascual-Leone, A. (2006). Emotion in psychotherapy: A practice-friendly

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

20 of 22 3/1/2019, 5:27 PM

research review. Journal of Clinical Psychology, 62, 611–630. 10.1002/jclp.20252

Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression (1st ed.).

Washington, DC: American Psychological Association. 10.1037/11286-000

Herrmann, I. R., Greenberg, L. S., & Auszra, L. (2014). Emotion categories and patterns of change in

experiential therapy for depression. Psychotherapy Research, 26, 178–195.

10.1080/10503307.2014.958597

Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining

meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59,

12–19. 10.1037/0022-006X.59.1.12

Klein, M. H., Mathieu-Coughlan, P., & 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.

Korman, L. (1991). Emotion episodes (Unpublished master’s thesis). York University, Toronto,

Ontario, Canada.

Lambert, M., Finch, A. M., Okiishi, J., & Burlingame, G. M. (2005). Administration and scoring manual

for the OQ-45.2. Orem, UT: American Professional Credentialing Services, LLC.

Pascual-Leone, A. (2009). Dynamic emotional processing in experiential therapy: Two steps forward,

one step back. Journal of Consulting and Clinical Psychology, 77, 113–126. 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, 875–887.

10.1037/0022-006X.75.6.875

Pascual-Leone, A., & Yeryomenko, N. (2017). The client “experiencing” scale as a predictor of

treatment outcomes: A meta-analysis on psychotherapy process. Psychotherapy Research, 27,

653–665. 10.1080/10503307.2016.1152409

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.

10.1037/0022-006X.71.6.1007

Pos, A. E., Greenberg, L. S., & Warwar, S. H. (2009). Testing a model of change in the experiential

treatment of depression. Journal of Consulting and Clinical Psychology, 77, 1055–1066.

10.1037/a0017059

Pos, A., Paolone, D. A., Smith, C. E., & Warwar, S. H. (2017). How does client expressed emotional

arousal relate to outcome in experiential therapy for depression?Person-Centered and Experiential

Psychotherapies, 16, 173–190. 10.1080/14779757.2017.1323666

Rauch, S. A., & Foa, E. B. (2006). Emotional processing theory (EPT) and exposure therapy for

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

21 of 22 3/1/2019, 5:27 PM

PTSD. Journal of Contemporary Psychotherapy, 36, 61–65. 10.1007/s10879-006-9008-y

Rudkin, A., Llewelyn, S., Hardy, G., Stiles, W. B., & Barkham, M. (2007). Therapist and client

processes affecting assimilation and outcome in brief psychotherapy. Psychotherapy Research, 17,

613–621. 10.1080/10503300701216298

Salgado, J. (2014, June). ISMAI Depression Project: Results of a comparative clinical trial of EFT

and CBT. Paper presented at 45th International Annual Meeting of Society for Psychotherapy

Research, Copenhagen, Denmark.

Stiles, W. B. (2015). Theory-building, enriching, and fact-gathering: Alternative purposes of

psychotherapy research. In O.Gelo, A.Pritz, & B.Rieken (Eds.), Psychotherapy research: General

issues, process, and outcome (pp. 159–179). New York, NY: Springer-Verlag.

10.1007/978-3-7091-1382-0_8

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, 152–159. 10.1037/0022-006X.74.1.152

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, 86–96. 10.1080/10503307.2010.518637

Whelton, W. J. (2004). Emotional processes in psychotherapy: Evidence across therapeutic

modalities. Clinical Psychology and Psychotherapy, 11, 58–71. 10.1002/cpp.392

Submitted: November 21, 2017 Revised: June 26, 2018 Accepted: June 28, 2018

This publication is protected by US and international copyright laws and its content may not be

copied without the copyright holders express written permission except for the print or download

capabilities of the retrieval software used for access. This content is intended solely for the use of the

individual user.

Source: Psychotherapy. Vol. 55. (3), Sep, 2018 pp. 263-274)

Accession Number: 2018-43053-006

Digital Object Identifier: 10.1037/pst0000190

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=ecace4...

22 of 22 3/1/2019, 5:27 PM