What have we learned about the processes that bring about change in PE therapy? This research includes both general processes such as level of experiencing and emotional expression, as well as specific tasks such as Two Chair Work and Systematic Evocative Unfolding.
Watson & Greenberg (1996) identified a pathway from in-session process and task resolution, to post-session change and final outcome in a sample of depressed clients. Clients’ degree of problem resolution correlated significantly with depth of client experiencing, and sustained resolution over treatment resulted in better outcome. Clients’ task-specific post-session change scores correlated significantly with change in depression post-therapy and 6 months later, indicating that post-session change is related to reduction in symptoms. The two treatments also were compared on client process and outcome. The PE group generally showed significantly higher levels of experiencing, vocal quality and expressive stance, and greater problem resolution than the CC group.
Weerasekera, Linder, Greenberg, and Watson (2001) also examined the development of the working alliance in this sample. Analyses revealed that early alliance scores predicted outcome independently of early mood changes. Although no treatment group differences were found for bond and goal aspects of the alliance, the PE group displayed higher task alliance scores in the mid-phase of therapy.
As is true with other therapies (see reviews by Bohart & Wugalter, 1991; Hendricks, 2002), the degree to which clients or therapists are fully engaged in their experience has been found to predict the outcome of PE therapy.
In particular, Goldman (1998), identified segments in which clients were addressing core therapeutic themes, and found that increases across treatment in experiencing on these core themes predicted outcome on a range of measures. She found that increase in on-theme depth of experiencing, from early to late in therapy, was superior to working alliance in predicting outcome.
In a recent study of therapist experiencing, Greenberg and Adams (2000), building on Goldman’s study, found that the level of client experiencing to which therapist interventions referred predicted subsequent client level of psychotherapeutic experiencing and outcome. Therapist interventions oriented toward internal client experience were found to exert an immediate influence in shifting clients from external to internal experience. Significant correlations between proportion of therapist-initiated client shifts from external to internal process and residual gain scores on outcome measures were also found. Thus, within the context of experiential psychotherapy for depression, the level of client experience at which therapists aim their interventions can exert an immediate influence on client depth of experiencing and is related to reduced symptoms and increased self-esteem.
There is also empirical evidence that emotion expression and change leads to good outcome in PE therapy. Korman (1998) found that PE therapy of depression, when successful, led to significant changes in clients’ emotional states. This research used the Emotion Episode (EE) method (Greenberg & Korman, 1993; Korman, 1998) to identify in-session episodes in which clients talk about their emotions. Clients with better outcomes showed significantly more changes in their emotions from early to late sessions than did clients with poorer outcomes.
Pos (1999) found that increase in depth of experiencing on Emotion Episodes across therapy predicted outcome in the treatment of depression, while Warwar and Greenberg (2000) showed that, during Emotion Episodes, good outcome clients showed both higher emotional arousal and deeper levels on the Experiencing scale. This suggests that emotional arousal, plus making sense of this arousal to solve problems (indicated by high levels of client experiencing), distinguishes good from poor outcomes in PE therapy.
Recent research on Two Chair Dialogue for conflict splits (see Chapter 10) has continued to provide support for and elaboration of models of resolution, while also placing more focus on understanding self-critical processes. Mackay (1996) provided some empirical support for Greenberg ‘s (1983) three-stage model of successful Two Chair work, consisting of Opposition (conflict), Merging (softening and mutual understanding), and Integration (negotiation of mutually satisfying compromises). Moderate support was found for the model, but adding a Pre-opposition stage (for people who experienced a substantial interruption of contact) was also suggested. McKee (1995) found that clients engaged in Two Chair Dialogue tended to use significantly more focused (inwardly exploring) and emotional (distorted by overflow of emotion) vocal qualities than clients engaged in Empathic Exploration. Furthermore, during two chair work clients also used significantly less externalizing (lecturing) and limited (emotionally restricted) vocal qualities.
Turning to self-criticism processes, Sicoli and Halberg (1998) investigated novice client performance during two chair work. The presence of "wants and needs" was found to be significantly greater overall for sessions in which the critic softened, compared to sessions with no softening. Similarly, Whelton and Greenberg (2001) found that high contempt and low resilience in response to the critic related to depression proneness.
In her extensive process study on conflict splits, Stinckens (2001) found that PE therapists working with the two-chair technique frequently dealt with client self-criticism by using a strategy of integrating parts of self, and did so more frequently than other experiential therapists. She also found that PE therapists avoided distancing the critic.
In addition to the outcome research reviewed earlier in this chapter, there has been substantial recent process research on Empty Chair Work for unfinished relationship issues (see Chapter 11). Greenberg and Foerster (1996) validated a task resolution model for Empty Chair Work by comparing successful and unsuccessful resolution of unfinished business. Four performance components – intense expression of feeling, expression of need, shift in representation of other, and self-validation or understanding of the other – were found to discriminate between resolution and nonresolution performances. McMain (1995) related changes in self-other schemas to psychotherapy outcome in the treatment of unfinished business. The results indicated that successful outcome was predicted by change in the representation of the self. Specifically, an increase in self-autonomy, self-affiliation, and positive responses of self in relation to the significant other were each predictive of treatment outcome at posttherapy and four-month follow-up. Change in the representation of the other failed to predict treatment outcome. Using the same sample, Paivio and Bahr (1998) found that interpersonal problems at the beginning of treatment predicted alliance.
In a study of the process of resolving unfinished business, Greenberg and Malcolm (in press) found that clients who resolved their unfinished business with a significant other reported greater improvement on a variety of outcome measures. More importantly, the authors found that a significantly greater number of clients in the resolved group expressed intense emotions during Empty Chair Work. In addition, almost all clients in the resolution group experienced the mobilization of an interpersonal need and a shift in their view of the other, while no clients in the unresolved group experienced a shift in their view of the other. Finally, in a study of childhood maltreatment, Paivio et al. (2001) found that high and low engagers in imagined confrontations in Empty Chair Work, differed significantly in their outcomes. High engagers achieved significantly greater resolution of issues with abusive and neglectful others, and reduced discomfort on current abuse-related target complaints.
These studies, in combination, provide substantial evidence that degree of client engagement in expression of emotions and unmet needs during Empty Chair Work predicts successful resolution of unfinished issues with significant others.
Watson and Rennie (1994) used tape-assisted process recall to obtain clients’ reports of their subjective experiences during Systematic Evocative Unfolding of problematic reactions (see Chapter 9), and found that clients alternated between two primary activities: symbolic representation of their experience and reflexive self-examination. In addition, Watson (1996) found that resolution sessions, in contrast to nonresolution sessions, were characterized by high levels of concrete, sensory language, which occurred when clients described problematic situations and then immediately differentiated an emotional reaction; in these sessions, clients also reported a change in mood immediately following vivid descriptions of the problematic situation. These studies highlight both the role that vivid description can play in promoting clients’ emotional arousal during sessions and the role of self-reflection in the change process. These findings validate proposition that vividly re-evoking the situation, and clients’ subsequent differentiation of their subjective experience, are necessary but different aspects of productive therapy process, and in particular are important steps in resolving problematic reactions.
Clarke (1996) conducted a study to determine which client performance components distinguish successful from unsuccessful Creation of Meaning episodes (see Chapter 9). The test of the performance model revealed that it contained four steps that distinguished between successful and unsuccessful creation of meaning. These steps involved symbolization of the challenge to a cherished belief, the emotional reaction to that challenge, an hypothesis as to the origin of the belief, and an evaluation of the present tenability of the belief. The change processes involved in successful creation of meaning were demonstrated to include both cognitive and emotional elements.
The repeated theme in the process research we have briefly reviewed here is the importance of both emotional-expressive elements and reflective-meaning-making processes in PE therapy. This is of course highly consistent with the general dialectically constructive model of the change process that we describe in Chapter 6.
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Greenberg and Adams (2000) ch. 13
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©2003 Robert Elliott, Jeanne Watson, Rhonda Goldman, and Leslie Greenberg