EFT Emotion-Focused Therapy Clinic.

EFT Emotion-Focused Therapy Clinic.

Dr. Les Greenberg, primary originator and developer of Emotion-focused Therapy (EFT) has opened the new EFT Clinic in affiliation with the York University Psychology Clinic (YUPC), a state-of-the-art community mental health and training center associated with the Department of Psychology in the Faculty of Health at York University.


Maintenance of Gains Following Experiential Therapies for Depression

Jennifer A. Ellison, Leslie S. Greenberg, Rhonda N. Goldman, and Lynne Angus

York University


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

Keywords: Depression; Emotion; Experiential therapy; Follow-up; Relapse prevention

Maintenance of Gains Following Experiential Therapies for Depression

Numerous researchers have investigated the effects of brief psychotherapies for the treatment of unipolar depression, and a number of treatments have been found to be generally effective in the treatment of Major Depressive Disorder (MDD; e.g., Dimidjian et al., 2006; Elkin et al., 1989; Hollon, DeRubeis, & Evans, 1996; Hollon et al., 2005; Jacobson et al., 1996; Shapiro, Barkham, Rees, Hardy, Reynolds, & Startup, 1994; Watson, Gordon, Stermac, Kalogerakos, & Steckley, 2003). While beneficial effects have been identified within various comparative outcome studies, earlier trials regarding enduring effects in the prevention of depressive relapse following the administration of evidence-based, short-term psychotherapeutic treatment packages have been variable and less promising (Agosti, 1999; Brown, Schulberg, Madonia, Shear, & Houck, 1996; Gortner, Gollan, Dobson, & Jacobson, 1998; Kupfer et al., 1992; McLean & Hakstian, 1990; Prien et al., 1984; Shapiro et al., 1994; Shapiro, Rees, Barkham, Hardy, Reynolds, & Startup, 1995; Shea et al., 1992; Thase & Simons, 1992). There has been more promising recent evidence of the long-term effects of cognitive-behavioral therapies (CBT; Dobson, Hollon, Dimidjian, Schmaling, Kohlenberg, & Gallop, 2008; Hollon et al., 2005; Hollon, Stewart, & Strunk, 2006). However, there has been relatively little or no investigation of the long-term effects of experiential therapies.

Both client-centered therapy (CC; Greenberg & Watson, 1998; King et al., 2000) and emotion-focused therapy (EFT; Goldman, Greenberg, and Angus, 2006; Watson et al., 2003) have been showed to be efficacious in the treatment of MDD. These experiential approaches place the therapeutic focus on the empathic relationship, deepening exploration, and the facilitation of the moment-by-moment emotional experience of the client. In a randomized controlled trial (RCT) comparing 36 CC and 36 EFT clients, Goldman et al. (2006) found large pre-post effect sizes for clients who received either CC or EFT, on the Beck Depression Inventory (BDI), Global Severity Index (GSI) of the SCL-90-R (Symptom-Check-list-Revised), Rosenberg Self-Esteem Measure (RSE), and Inventory of Interpersonal Problems (IIP). In addition, EFT was found to have significantly larger effects on all of these indices, although there were no significant differences in proportion of treatment responders in each group at posttreatment.

Watson et al. (2003) compared short-term treatment effects of EFT and CBT for depression in a RCT and found that EFT and CBT were equally effective in decreasing depressive symptomatology, and EFT clients, on average, showed significantly greater decrease in self-reported problems in interpersonal functioning. In this study, 19 clients (58%) in EFT and 17 clients (52%) in CBT met the reliable change index (RCI; Jacobson & Truax, 1991; Ogles, Lambert, & Sawyer, 1995) for the BDI, and there was not a significant difference between the treatment groups on this index. Experiential treatments of depression therefore have been shown to be effective. However, to date, there is no evidence of maintenance of gains following these short-term experiential treatments that focus on emotion as the primary site of change.

In the present study, we compared the maintenance of gains in depression over 18 months following short-term CC and EFT treatments. In CC therapy for depression, the main therapeutic action is the therapeutic relationship in which core conditions of therapist empathy, acceptance and genuineness (Rogers, 1951, 1975) are paramount. Within such a relational environment, clients become more open to the exploration of emotional experiences and learn to appreciate and value the informative nature of their emotional experience. These processes are proposed to lead to a strengthening of the client’s resilience and a change in their self-concept. The CC therapist’s general stance is one of empathically following what is most poignant in the client’s experience. In EFT for depression, emotion-focused, marker-guided interventions designed to help clients resolve depressogenic affective-cognitive problems, such as self-critical splits and unfinished business (Greenberg, Rice, & Elliot, 1993; Greenberg & Watson, 2006), are added to the client-centered relational conditions. The primary EFT interventions for depression are (a) focusing on an unclear bodily felt sense, (b) two-chair dialogue with one’s critical internal voice, (c) empty-chair dialogue with a significant other in an unfinished business situation, and (d) systematic evocative unfolding in response to problematic reactions. The EFT therapist guides clients, within the context of the core client-centered relational conditions, to be aware of, regulate, transform, and reflect upon emotions that underlie and influence how they feel, think, and (inter)act (Greenberg, 2002; Greenberg & Watson, 2006; Samoilov & Goldfried, 2000). The EFT therapist’s general stance is one of balancing following and leading the client’s experiential processes within the context of marker-guided interventions.

The primary purpose of the present study was to determine the comparative rates of relapse in CC and EFT across an 18-month follow-up period. Based on previous findings of enhanced experiential process during EFT (Watson & Greenberg, 1996; Pos, Greenberg, Goldman, & Korman, 2003), in addition to EFT’s significantly greater efficacy at posttreatment when compared to CC (Goldman et al., 2006), our expectation was that EFT clients who responded to the acute phase of treatment would maintain gains more than CC clients.

We hypothesized that clients who responded to the EFT treatment, when compared with those who responded to CC treatment, would : (a) experience significantly less depressive relapse during each follow-up period; (b) on average, experience a significantly greater number of “well weeks” (successive addition of weeks where clients reported minimal or no depressive symptoms) (c) would “survive,” or not experience first relapse of depression, for a significantly longer cumulative period of time; and that (d) regardless of whether or not clients were treatment responders, those in EFT, when compared to those in CC therapy, would report significantly more change on self-report measures (BDI, SCL-90-R, RSE, and IIP) at follow-up evaluation compared to CC clients.



Original outcome study. Information regarding the original outcome study is summarized below. More detailed information regarding the original acute phase treatment sample from which the present pool of clients was derived (including therapist selection, manualized training, and treatment adherence) can be found in the original outcome study paper (Goldman et al., 2006).

Potential clients were initially screened by phone on inclusion and exclusion criteria following recruitment through local referral and by means of radio and written media to the

residents of a large metropolitan area.. They were provided with information about the treatment and gave their informed consent to participate in the assessment phase (treatment consent was obtained following determination of eligibility). The protocol was approved by the relevant institutional ethics review committees. Clients considered for randomization included those who met for met criteria for MDD based on the Structured Clinical Interview (Spitzer, Williams, Gibbon, & First, 1992)for the Diagnostic and Statistical Manual of Mental Disorders- third edition-revised (DSM-III-R; American Psychiatric Association, 1987). Exclusion criteria included current treatment (psychotherapy and/or medication) for depression, and/or a current diagnosis of any of the following: bipolar I; panic disorder; substance dependence; eating disorders; psychotic disorder; two or more schizotypical features; and paranoid, borderline, or antisocial personality disorders. Clients were also excluded if they were regarded as in need of treatment focusing on others problems (e.g., recent suicide attempts or active suicidal state) or in need of immediate crisis intervention, had the loss of a significant other in the last year, had recently been or currently was a victim of incest or sexual abuse, or were currently involved in a physically abusive relationship. Research assistants independent of the primary investigators assigned code numbers to suitable clients, and clientswere randomly assigned to receive either CC or EFT for depression at a psychotherapy research clinic at an urban university.

Recruitment to follow-up occurred from 1993 to 2002. The total sample of clients reported in Goldman et al. (2006) consisted of 36 CC and 36 EFT clients (see Figure 1). None of these clients reported having been diagnosed with more than 3 previous depressive episodes, and none had a Global Assessment of Functioning (GAF) score less than 50. Clients, on average, fell within the moderate to severe range of depressive symptomatology on the BDI (Beck, Rush, Shaw, & Emery, 1979). Therapists provided treatment in both conditions and had at least 1 year of experience with both EFT and CC treatment approaches.


Two brief (16-20 sessions) experiential therapies were implemented: CC and EFT. Both

treatments aim to increase and deepen the client’s capacity for emotional processing within the context of a supportive therapeutic relationship.

Client-centered treatment (CC). This approach was conducted according to a manual developed by Greenberg, Rice, and Watson (1994), in addition to supplemental readings by Rogers (1951, 1975). The three therapeutic relationship conditions that are most central in this orientation are empathy, acceptance, and genuineness. The mainstay of CC is empathic responding to promote deeper client experiencing (emotional and meaning-making processes) within a supportive, nonjudgemental therapeutic environment. The therapist attends to what is most alive and poignant in the client’s experience and empathically understands the client’s internal frame of reference. Depression is hypothesized to result, in part, from incomplete processing of emotional experience (Greenberg & Paivio, 1997), and the facilitation of deeper experiencing is understood as the primary goal and vehicle of change in this treatment. This is seen as leading to change in the client’s self-concept in a way that is more congruent with the client’s growth-oriented organismic tendencies (Rogers, 1975).

Emotion-focused treatment (EFT). This approach was conducted according to a manual developed by Greenberg et al. (1993) and further explicated by Greenberg & Watson (2006).

EFT involves the essential elements of CC with specific supplementation of process-directive, marker-guided interventions derived from experiential and gestalt therapies applied at in-session intrapsychic and/or interpersonal targets. These targets are thought to play prominent roles in the development and exacerbation of depressive experience. The major emotion-focused interventions of EFT are: Gendlin’s (1996) focusing intervention at a marker of an unclear bodily felt sense; gestalt empty-chair dialogues at markers of unfinished business where clients imagine a significant other in an empty chair and communicate unresolved feelings to them; gestalt two-chair dialogues at conflict split markers where clients engage in a dialogue with their critical inner, often introjected, voice; and systematic evocative unfolding at points of problematic reactions where clients are imaginally guided back to the problematic situation so that they may re-experience and make sense of their reactions (Greenberg et al., 1993; Rice, 1974). These specific interventions are hypothesized to facilitate the creation of new meaning from bodily felt referents, letting go of anger and hurt in relation to another person, increasing acceptance and compassion for oneself, and developing a new view and understanding of oneself (Greenberg, 2002; Watson & Greenberg, 1996).

The first three sessions of the treatment focus on establishing a therapeutic alliance and providing a facilitative therapeutic relationship. During this phase, only the three CC relationship conditions are implemented. Thereafter, the EFT active interventions are implemented, within the context of the facilitative conditions, when depressogenic affective-cognitive problem markers arise. The primary aims are: facilitating the client’s symbolization of particular aspects of subjective emotional experience, facilitating new emotional responses to old situations, and making new meaning of one’s experience based on new information that becomes available through the reprocessing of emotional material (Greenberg & Watson 2006).

Outcome Measures

The Longitudinal Interval Follow-up Evaluation (LIFE-II; Keller et al., 1987) for depression was administered at the beginning of each 6-, 12-, and 18-month interview to obtain retroactive evaluations of the 6-month period prior to each follow-up evaluation (6-, 12-, and 18-month periods). Four self-report questionnaires were administered at 6- and 18-month follow-up periods: BDI, SCL-90-R, RSE, and IIP.

Longitudinal Interval Follow-up Evaluation (LIFE-II). The LIFE-II (Keller et al., 1987) is a semi-structured interview and integrated rating system developed to assess the longitudinal course of psychiatric disorders along various dimensions, such as depression, anxiety, and psychosis according to the Diagnostic and Statistical Manual of Mental Disorders- third edition-revised (DSM-III-R; American Psychiatric Association, 1987) over the previous 6 months. The interview provides retroactive information regarding psychosocial and psychopathologic status and any return to treatment. The weekly psychopathology measures, or psychiatric status ratings (PSR), are ordinal symptom-based scales with categories consistent with levels of symptoms used in the DSM-III-R for each particular disorder being assessed. Retroactive weekly PSR ratings for depression during the previous 6 months were collected ranging from meeting criteria for the index episode (rating of 5 or 6) to no residual symptoms (rating of 1).

A total of 5 advanced PhD student clinical evaluators, each whom had been trained by a senior clinician with expertise in LIFE-II administration and who were blind to treatment condition during the administration of the LIFE-II, conducted an equivalent number of interviews. Queries regarding the client’s experience of the treatment to which they had been assigned occurred after LIFE-II administration, and no evaluator interviewed the same client on more than one occasion during the outcome and follow-up periods. Audiotape interrater reliability of the LIFE-II was conducted. Clinical evaluators were not informed which interviews would be used for reliability purposes. A senior clinician with previous experience in administering the LIFE-II and who was blind to treatment condition provided reliability ratings. One-third of the interviews of treatment responders (N = 43) were randomly selected from the 18- month follow-up period and were rated by the senior clinician to obtain agreement on whether depressive episodes had occurred. The average kappa coefficient (Cohen, 1960) for these assessments was .87.

Beck Depression Inventory-Long Form (BDI). The BDI (Beck et al., 1979) is a 21-item self-report measure that measures severity of depression. Responses are scored on a four-point likert scale, with higher scores indicating greater severity of depression (scores may range from 0-63). Internal consistency for the BDI ranges from .73 to .92 with a mean of .86 and the measure correlates highly with other self-report measures of depression (Beck, Steer, & Garbin, 1988),.

Symptom Check-List-Revised (SCL-90-R). The SCL-90-R (Derogatis, 1983) is a self-report measure used to assess general symptom distress. On a five-point likert scale, clients indicate to what extent they experienced each of 90 distress symptoms in the past week. The measure provides a Global Severity Index (GSI) that indicates overall current symptomatology distress level. Internal consistency for the SCL-90-R ranges from .77 to .90 and test-retest reliability between .80 and .90 over a one-week period (Derogatis, Rickels, & Rock, 1976).

Rosenberg Self-Esteem Measure (RSE). The RSE (Rosenberg, 1965)was used to assess client level of self-esteem. This is a 10-item measure which yields a total score with a higher score indicating higher self-esteem. High internal reliability (.89 to .94) and test-retest reliability (.80 to .90) have been reported (Bachman & O’Malley, 1977).

Inventory of Interpersonal Problems (IIP). The IIP (Horowitz, Rosenberg, Baer, Ureño, & Villaseñor, 1988)is a 127-item self-report measure of current difficulties in interpersonal functioning. A total score is obtained to determine overall level of interpersonal difficulties. High internal consistency, validity, and reliability have been reported, and this measure is reported to be sensitive to clinical change (Horowitz, Rosenberg, Baer, Ureño, & Villaseñor, 1988).



Follow-up interviews were conducted at 6, 12, and 18 months posttreatment. Each interview began with administration of the LIFE-II followed by open-ended questioning regarding the 6 months prior to the interview and progressively focused on more specific areas of interest within the following domains: (a) the client’s experience of therapy; (b) changes in relation to feelings, behaviors, view of self, and/or interactions with others that have occurred as a result of therapy; (c) life events or challenges that they have encountered; (d) the role of social support in their lives; and (e) whether they took part in continued treatment for depression. In addition to the interview component, clients completed self-report outcome measures at 6- and 18-month follow-up evaluation.

Operational Criteria for Treatment Response and Relapse

Treatment responders were identified as client who had a minimum of 8 consecutive weeks with minimal or no depressive symptoms (PSR of 1 or 2 on the LIFE-II) directly following the end of the treatment phase. Treatment responders were considered to have relapsed if they met criteria for a Major Depressive Episode on the LIFE-II (PSR of 5 or 6) for a minimum of two consecutive weeks during the follow-up period. Relapse was also defined as having occurred at the time of returning to treatment for depression (psychotherapy for depression and/or antidepressant medication) during the follow-up phase, regardless of reported depressive symptoms on the LIFE-II.

Data Analysis

The data analyses on relapse were conducted on all treatment responders. The statistical tests in the follow-up sample of treatment responders must be interpreted with caution given the follow-up sample no longer benefited from randomization as in the original sample. Post-hoc power estimates were observed to be medium to large, depending on the analysis being conducted. An alpha level of .05 was used for all statistical tests except the repeated measures comparative analyses in which Bonferroni adjustment for multiple comparisons was used. Chi-square tests were used to compare treatment conditions for proportions of clients in the original sample who responded to treatment and did not relapse across the follow-up period. Analyses of variance were used to compare treatments in cumulative number of well weeks among treatment responders across follow-up. Survival analysis was conducted to compare the time to first relapse among treatment responders by condition. Lastly, we conducted repeated measures comparative analyses, with treatment group (CC and EFT) as the between-subjects factor and time (pretreatment, 6-month follow-up, and 18-month follow-up) as the within-subjects factor, at each follow-up period on self-report outcome measures (BDI, SCL-90-R, RSE, and IIP). Clients in the treated groups for whom complete self-report follow-up data had been obtained, regardless of whether or not they were responders during the acute treatment phase, were included in these analyses. An exception to this was the exclusion of treatment responders who has returned to treatment for depression during the follow-up phase given that their responses on self-report measures were expected to have been effected by intervention during follow-up and would not have been reflective of experimental treatment effects.


Sample Characteristics and Participant Flow

Figure 1 provides detail of participant flow. Fifty-two (25/36 CC and 27/36 EFT) clients responded to the acute phase treatment and were considered for follow-up analyses. Two treatment responders (1 CC and 1 EFT) declined taking part in the follow-up stage of the trial. Four EFT and 3 CC treatment responders were lost due to attrition during the follow-up phase. Three treatment responders (2 CC and 1 EFT) returned to treatment for depression during the follow-up period. As noted, self-report data collected at 6- and 18-month follow-up evaluation for these clients were excluded from the follow-up comparative analyses of outcomes measures as these symptom reports would likely have been impacted by the return to treatment and would not have been reflective of experimental treatment effects.

Only those clients for whom complete data had been collected were included in the relapse analyses. Complete relapse data across the 18-month follow-up period were obtained for 43 (83%; 21 CC and 22 EFT) of 52 treatment responders, and these clients were compared on relapse rates, number of asymptomatic or minimally symptomatic weeks, and survival times across the 18-month follow-up period. Demographic and clinical characteristics for the acute phase treatment responders upon whom the relapse results are based are presented in Table 1. There were no significant differences in demographic and clinical characteristics between the CC and EFT responder groups who were compared across follow-up (all ps > .05). There were also no significant differences in demographic and clinical characteristics between clients who started the acute treatment phase and those who entered the follow-up phase, regardless of treatment response (ps > .05). For comparative analyses on outcome indices after removing those lost due to attrition and those who returned to treatment for depression, 56 treatment responders (29 CC and 27 EFT) who had completed all self-report follow-up data were compared on 6- and 18-month self-report measures.

Attrition Analyses

Analyses were conducted to investigate potentially significant differential rates of attrition between treatments across the entire follow-up period. Clients declining participation or lost due to attrition during the 18-month follow-up period were all treatment responders (5 EFT and 4 CC). Chi-square comparisons of differential attrition rates within the two treatment groups during the 18-month follow-up period revealed no significant difference in the number of clients lost due to attrition during the follow-up period, χ 2 (1, N = 9) = 0.50, p = .48. In addition, there were no significant differences between clients who were lost due to attrition and clients who were retained across follow-up on demographic characteristics, including sex, age, ethnicity, education, and marital status (all ps > .05).

Combined sample pre- and posttest comparison on all self-report outcome measures showed that there were no significant differences (all ps> .05)between those lost due to attrition and those retrained across the entire follow-up period. In addition, within-group comparisons on pre- and posttest comparisons showed that there were no significant differences (all ps> .05)between those lost due to attrition and those retained across the entire follow-up period.

Treatment Response and Relapse Rates

Table 2 summarizes the rates of clients (a) entering treatment, (b) completing treatment, and (c) responding to treatment according the LIFE-II criteria. Table 3 presents the percentage of treatment responders in each condition who relapsed across the 6- and 18-month follow-up periods. There was no significant difference in relapse between the two treatment groups across 6-month follow-up. During the 18-month follow-up period, there was a significant difference between groups in the proportion of treatment responders who relapsed, χ 2(1, 43) = 4.04, p = .044. A significantly greater proportion of the EFT treatment group did not relapse during the entire follow-up period in comparison with the CC treatment group. By the end of the 18-month follow-up period, approximately 52% (11/21) of CC clients and 23% (5/22) of EFT clients had experienced depressive relapse.

Well Weeks

Table 4 shows the mean cumulative number of well weeks (successive addition of weeks where clients experienced no or minimal depressive symptoms) during each follow-up period by treatment condition. Clients included in these analyses were treatment responders for whom complete LIFE-II follow-up data had been attained.

There was no significant difference between the two treatment conditions in well weeks on the LIFE-II across the 6-month follow-up period, F(1, 43) = 3.147 p = .083, although there was a trend indicating that EFT clients, on average, experienced a longer period free from depression in comparison with CC clients. In fact, no EFT clients reported any or more than minimal depressive symptoms across the 6-month posttreatment period. There was a significant difference between the two treatment conditions in well weeks on the LIFE-II across the entire 18-month follow-up period, F(1, 43) = 5.183 p = .024 with EFT clients, on average, experiencing a longer period of time with minimal or no depressive symptoms in comparison with CC clients.

Survival Time to First Relapse

Survival analyses, a method of regression analysis used for analyzing longitudinal data and the timing of events, were conducted to compare the mean survival time in terms of weeks before first depressive relapse on the LIFE-II for the two treatment conditions. Clients included in this analysis were those for whom complete follow-up data on the LIFE-II were obtained. Clients lost due to attrition were excluded from this analysis due to violation of the independence assumption and because when they were included in the analysis, the result was extreme right-censoring where these clients erroneously pulled the survival functions to the right, leading to overestimates of the benefits of each treatment condition cumulative function.

Figure 2 shows the survival functions of time to first depressive relapse for treatment responders in each treatment condition. Median survival times for the CC and EFT treatment groups were 66 and 72 weeks, respectively. Mean survival times for the CC and EFT treatment groups were 53 and 68 weeks, respectively. A Log-Rank test using the Kaplan-Meier product-limit method comparing the survival distributions between the two treatment conditions was significant, 2 (1, N = 43) = 4.18, p = .041, indicating that the probability of surviving, or not experiencing depressive relapse during the 18-month follow-up period, was significantly greater for clients in EFT than for those in the CC treatment.

Comparative Analyses on Outcome Indices

Longitudinal analyses were conducted for each self-report outcome measure. All clients in the treated groups for whom complete self-report follow-up data had been obtained, regardless of whether or not they responders during the acute treatment phase, were included in these analyses (with the exception of those who had returned to treatment for depression).

In the repeated measures analyses of variance (ANOVA), there was a significant main effect of time on all self-report measures (all p < .001). For the BDI, the main effect of time was qualified by a significant time by group interaction, , F(2, 108) = 4.84, p = .015. For the SCL, the main effect of time was qualified by a significant time by group interaction, SCL-90-R, F(2, 108) = 4.16, p = .018. For the RSE, the main effect of time was qualified by a significant time by group interaction, F(2, 108) = 4.96, p = .009. For the IIP, the main effect of time was qualified by a significant time by group interaction, F(2, 108) = 3.80, p = .025.

As each of the time by group interactions was statistically significant, a series of planned comparisons were conducted with Bonferroni adjustments on post-hoc planned contrasts. Table 5 displays the means and standard deviations by treatment group at each time point for each self-report measure. Repeated measure plots by instrument can be found in Figures 3, 4, 5, and 6. For the BDI, planned comparisons revealed no significant difference between the groups at 6-month follow-up, F(1, 54) < 1, and a significant difference in favour of EFT at 18-month follow-up, F(1, 54) = 6.76, p = .010. For the SCL-90-R, planned comparisons revealed no significant difference between the groups at 6-month follow-up, F(1, 54) < 1, and there was a trend in favour of EFT at 18-month follow-up, F(1, 54) = 4.80, p = .027. For the RSE, there was again no significant difference between the groups at 6-month follow-up, F(1, 54) = 1.56, p < .05, and there was a significant difference in favour of EFT at 18-month follow-up, F(1, 54) =5.89, p = .012. Lastly, for the IIP, there was no significant difference between the groups at 6-month follow-up, F(1, 54) < 1, and there was a trend in favour of EFT at 18-month follow-up, F(1, 54) = 4.39, p = .035.


This study provides the first evidence of differential long-term effects in CC and EFT treatments. Overall, there was support for the hypothesis that the addition of emotion-focused interventions of EFT to the relational conditions of CC during the acute treatment phase would lead to increased maintenance of gains across follow-up. While the two treatment groups were not significantly differentiated during 6-month follow-up in terms of depressive relapse, EFT were significantly more likely to not experience depressive relapse in comparison with clients in the CC treatment when the entire follow-up period was taken into account. In addition, while the treatment groups did not differ significantly across 6-month follow-up on average number of weeks with minimal or no depressive symptoms, EFT clients maintained treatment gains of minimal or no depressive symptoms for a significantly longer period of time across the entire follow-up period compared to CC clients.

On self-reported symptomatology, CC and EFT clients did not differ significantly at 6-month follow-up evaluation where both treatment groups appeared to maintain gains to a similar degree. By the 18-month follow-up evaluation, clients in the EFT treatment showed, on average, more improvement on self-report measures of depressive symptomatology and self-esteem. Trends were found in favour of EFT over CC at 18-month follow-up in general symptom distress and interpersonal problems.

The overall pattern of convergence of the treatment conditions on many criteria at 6-month follow-up and the divergence at 18-month follow-up may be due to a number of factors. Before 6-month follow-up, CC clients may have been benefiting from the prior relational support and from an ability to self-mobilize as a benefit of a less directive form of therapy that aims to mobilize the client’s growth-oriented or actualizing tendency. Self-mobilization is conceptualized by CC theorists as taking place during treatment and operating and potentially developing after treatment (Rogers, 1961). However, the mobilization of the client’s growth tendency, while beneficial in terms of sustained improvement to 6 months posttreatment, may not have endured nor served CC clients as well as the deeper emotional processing and emotional transformation acquired by EFT clients (Watson & Greenberg 1996).

From clients’ self-reports EFT appears to have led to more active and effective ways of dealing with emotional distress in the follow-up period. In follow-up interviews, EFT clients talked about exercising emotional processing skills that they had learned in therapy to help deal with distressing life events. These emotion processing skills may have increased awareness of and the ability to deal with potential depressogenic emotional events that emerged during the follow-up period. Clients may have become better able to recognize vulnerable periods, approach emotions, and self-initiate tools that acted as protective factors against the emergence of a new depressive episode. This study suggests that the addition of EFT interventions at appropriate markers to the core relational conditions in CC and promotes greater depressive relapse prevention for periods greater than 6 months posttreatment.

A limitation of the present study was the absence of a control group. Although the absence of change in untreated depressed clients has been reported (for example, see Nietzel, Russel, Hemmings, & Greeter, 1987), a control group would have provided a useful comparison. In addition, as with many outcome and follow-up studies, the generalizability of the findings is limited by the overrepresentation in the sample of European clients. A common problem in follow-up studies of differential sieve among treatment conditions and across follow-up (Klein, 1996) is also noteworthy. Also, clients were extensively screened, and the present sample may not be representative of the population seeking treatment for depression given the stringent exclusion criteria used, thereby limiting the generalizability of the present findings to potentially “more troubled and difficult-to-treat patients” (Westen & Morrison, 2001, p. 880). Lastly, specific factors (e.g., number of previous MDD episodes) beyond treatment control that could have accounted for sustained remission and/or relapse rates across follow-up were not identified and/or controlled.

While the present study provides evidence of the generally superior effects of EFT in comparison with CC in terms of long-term maintenance of gains, it does not allow for identification of the nature of change processes that occurred within each treatment that led to this effect. Intensive process analyses of both acute treatment and follow-up periods are needed to identify change processes that contribute to maintenance of gains and relapse following treatment. In addition, comparing treatment groups on the frequency of discrete depressive episodes (beyond first recurrence) across follow-up, and the duration of relapse episodes, are important directions for future study.

Lastly, replication of this study by other researchers is important given that, as with most outcome and long-term efficacy studies, the current study involved only one site where investigators and therapists, although claiming allegiance to both approaches, may be argued to have shown greater allegiance to EFT over CC. Accordingly, further investigation at various sites with investigators from differing theoretical orientations promises to be revealing.


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Author Note

Jennifer A. Ellison, Leslie S. Greenberg, Rhonda N. Goldman, and Lynne Angus, Department of Psychology, York University, Ontario, Canada.

Rhonda N. Goldman is now at Department of Psychology, Illinois School of Professional Psychology at Argosy University, Schaumburg, Illinois.

This research was supported in part by grants from the National Institute of Mental Health and from the Ontario Mental Health Foundation, both granted to the second author.

Correspondence concerning this article should be addressed to Jennifer A. Ellison, Department of Psychology, York University, Toronto, Ontario, Canada. E-mail: jennifer@alumni.yorku.ca

Table 1

Demographic and Clinical Characteristics For Treatment Responders

Treatment Condition



(n= 21)


(n = 22)


(N = 43)

Female, n (%)

13 (61.9)

12 (54.5)

25 (58.1)

European, n (%)

17 (81.0)

16 (72.7)

33 (76.7)


M (and SD)

Range (n)

38.76 (11.62)


37.64 (7.27)


38.19 (9.54)

Marital Status, n (and %)








9 (42.9)

5 (23.8)

7 (33.3)

7 (31.8)

9 (40.9)

6 (27.3)

16 (37.2)

14 (32.6)

13 (30.2)


Axis II Diagnosisa, n (and %)



7 (33.3)

6 (27.3)

13 (30.2)

BDI Pretreatment, M (and SD)



25.10 (7.34)

27.32 (6.64)

26.23 (7.00)

BDI Postreatment, M (and SD)

6.19 (3.79)

5.23 (4.85)

5.70 (4.34)


Note.CC = client-centered; EFT = emotion-focused therapy. BDI = Beck Depression Inventory. a Axis II diagnosis at pretreatment.

Table 2

Intent-To-Treat, Completed Treatment, and Treatment Responder Rates


Treatment Condition





Intent-to-treat, n




Completed, n




Responders, n












Note. Intent-to-treat included those participants who where randomized to a treatment condition. Completed included those participants who completed at least 11 treatment sessions. Responders included those participants who reported minimal or no depressive symptoms (Psychiatric Status Rating of 1 or 2) for at least 8 consecutive weeks posttreatment on the LIFE-II interview. CC = client-centered; EFT = emotion-focused therapy. a Percent of all clients entering treatment;

b Percent of all clients completing treatment.


Table 3

Rates of Relapse Among Treatment Responders During Follow-Up


Treatment condition





6-month follow-up
Responders, n



No Relapse, n (%)

18 (85.7)

22 (100.0)

χ 2 (1, N = 43) = 3.38, p = 108.

Relapse, n (%)

3 (14.3)

0 (0)

18-month follow-up
Responders, n



No Relapse, n (%)

10 (47.6)

17 (77.3)

χ 2 (1, N = 43) = 4.04, p = .044*

Relapse, n (%)

11 (52.4)

5 (22.7)

Note. Responders included those participants who reported minimal or no depressive symptoms (Psychiatric Status Rating of 1 or 2) for at least 8 consecutive weeks posttreatment on the LIFE-II interview. CC = client-centered; EFT = emotion-focused therapy. *p < .05.

Table 4

Mean Number of Well Weeks Among Treatment Responders During Follow-up

Treatment Condition



Well Week






Responders, n



6 months





F(1, 43) = 3.15, p = .083

18 months





F(1, 53) = 5.18, p = .024*

Note. Responders included those participants who reported minimal or no depressive symptoms (Psychiatric Status Rating of 1 or 2) for at least 8 consecutive weeks posttreatment on the LIFE-II interview. CC = client-centered; EFT = emotion-focused therapy. *p < .05.

Table 5

Means and Standard Deviations of BDI, SCL-90-R GSI, RSE, and IIP by Treatment Group at Each Follow-Up Period For All Acute Phase Treatment Completers


Follow-up period

Treatment Condition


(n = 29)


(n = 27)





BDI    Pretreatment





6 months





18 months





SCL-90-R GSI    Pretreatment





6 months





18 months





RSE    Pretreatment





6 months





18 months





IIP    Pretreatment





6 months





18 months






Note. CC = client-centered; EFT = emotion-focused therapy; BDI = Beck Depression Inventory; SCL-90-R GSI = Symptom Checklist-90-Revised Global Severity Index; RSE = Rosenberg Self-Esteem; IIP = Inventory of Interpersonal Problems. * p < .0125 (adj. for multiple comparisons).

Figure Captions

Figure 1. CONSORT flow chart. CC = client-centered therapy; EFT = emotion-focused therapy.

Figure 2. Survival curves for time to first relapse among treatment responders across follow-up (N = 43). CC = client-centered therapy; EFT = emotion-focused therapy.

Figure 3. BDI by Treatment Group Across Follow-up (N = 56). CC = client-centered therapy;

EFT = emotion-focused therapy. Pre = pretreatment; 6-Month = 6-month follow-up; 18-Month =

18-month follow-up.

Figure 4. SCL-90-R by Treatment Group Across Follow-up (N = 56). CC = client-centered

therapy; EFT = emotion-focused therapy. Pre = pretreatment; 6-Month = 6-month follow-up; 18-

Month = 18-month follow-up.

Figure 5. RSE by Treatment Group Across Follow-up(N = 56). CC = client-centered

therapy; EFT = emotion-focused therapy. Pre = pretreatment; 6-Month = 6-month follow-up; 18-

Month = 18-month follow-up.

Figure 6. IIP by Treatment Group Across Follow-up (N = 56). CC = client-centered

therapy; EFT = emotion-focused therapy. Pre = pretreatment; 6-Month = 6-month follow-up; 18-

Month = 18-month follow-up.

Randomized (N = 83)

Allocated to client-centered therapy (CC; n = 41)

Completed treatment (n = 36)

Did not complete treatment (n = 5)

Therapist nonadherent;

transferred to EFT at client

request following session 3 (n = 1)

Began other psychotherapeutic

treatment (n = 1)

Client-initiated treatment

termination before session 11 and

not followed (n = 2)

Unable to contact (n = 1)


Allocated to emotion-focused therapy (EFT; n = 42)

Completed treatment (n = 36)

Did not complete treatment (n = 7)

Serious medical illness (n = 1)

Sudden move (n = 1)

Began other psychotherapeutic

treatment (n = 2)

Client-initiated treatment

termination before session 11 and not

followed (n = 1)

Unable to contact (n = 2)




Second study – Emotion-Focused Therapy: A Clinical Synthesis

Leslie S Greenberg

York University, Toronto




A summary of an Emotion-focused approach to therapy (EFT) and its research base is presented. In this view, emotion is seen as foundational in the construction of the self and is a key determinant of self–organization. People, as well as simply having emotion, also live in a constant process of making sense of their emotions. In EFT, distinctions between different types of emotion provide therapists with a map for differential intervention. Six major empirically supported principles of emotion processing guide therapist interventions and serve as the goals of treatment. A case example illustrates how the principles of EFT helped a patient overcome her core maladaptive shame and basic insecurity in a relatively brief treatment of depression.


Key words: Emotion, assessment, change,

Emotion–Focused Therapy: A Clinical Synthesis

Emotion-focused treatment was developed as an empirically-informed approach to the practice of psychotherapy grounded in contemporary psychological theories of functioning. Emotion focused therapy was developed by my colleagues and myself in the nineteen eighties out of empirical studies of the process of change (1, 2, 3, 4, 5, 6) and has developed into one of the recognized evidence based treatment approaches for depression and marital distress as well as showing promise for trauma, eating disorders, anxiety disorders ands interpersonal problems.

Emotion-focused Therapies (EFTs) have been shown to be effective in both individual and couples forms of therapy in a number of randomized clinical trials (7, 8). A manualized form of Emotion-focused therapy of depression in which specific emotion activation methods were used within the context of an empathic relationship has been found to be highly effective in treating depression in three separate studies, (9, 10, 11, 12). In these studies EFT was found to be equally or more effective than a Client Centered (CC) empathic treatment, and a Cognitive Behavioral treatment (CBT). Both the treatments with which it was compared were themselves also found to be highly effective in reducing depression, but EFT was found to be more effective in reducing interpersonal problems than both the CC and CBT treatment and promoting more change in symptoms than the CC treatment and highly effective in preventing relapse (77% non relapse) (13). Emotion Focused Therapy also has been found effective in treating abuse (14), resolving interpersonal problems and promoting forgiveness (15, 16). Emotion-focused couple therapy is recognized as one of the most effective approaches in resolving relationship distress (17, 8). EFT also has more research than any other treatment approach on the process of change, having demonstrated a relationship between outcome and empathy, the alliance, depth of experiencing, emotional arousal, making sense of aroused emotion, productive processing of emotion and particular emotions sequences (18, 19, 20).


A major premise of EFT is that emotion is fundamental to the construction of the self and is a key determinant of self-organization. At the most basic level of functioning, emotions are an adaptive form of information-processing and action readiness that orient people to their environment and promote their well being (21, 2, 22, 23). Emotions are seen by contemporary emotion theorists as significant because they inform people that an important need, value, or goal may be advanced or harmed in a situation. Emotions, then, are involved in setting goal priorities (24) and are biologically-based tendencies to act that result from the appraisal of the situation based on these goals, needs, and concerns (23, 2).

Emotion is a brain phenomenon vastly different from thought. It has its own neuro-chemical and physiological basis and is a unique language in which the brain speaks. The limbic system is fundamentally involved in basic emotional responses (25). It governs many of the body’s physiological processes and thereby influences physical health, the immune system and most major body organs. Le Doux (25) found that there are two different paths for producing emotion: The shorter and faster amygdala pathway which sends automatic emergency signals to brain and body, and produces gut responses, and the longer, slower neo-cortex pathway which produces emotion mediated by thought. This developed because clearly it was adaptive to respond quickly in some situations, but at other times better functioning resulted from the integration of cognition into emotional response by reflecting on emotion.

EFT suggests that the developing cortex added to the emotional brain’s in-wired emotional responses the ability for complex learning and to form internal organizations (neural networks) that produced emotional responses to learned signs of what had evoked emotion in a person’s own life experience. Emotional memories of lived emotional experience are seen as being formed into emotion schemes (5, 26, 27). By means of these internal organizations or neural programs people react automatically from their emotion systems, not only to inherited cues, such as looming shadows or comforting touch, but also to cues that they had learned were dangerous, like fear of one’s father’s impatient voice, or life enhancing, like a loved symphony, and these reactions are rapid and without thought. Emotion schemes are organized response- and experience-producing units stored in memory networks.

Thus rather than being governed simply by biologically and evolutionarily-based affect motor programs, emotional experience is are seen as being produced by the synthesis of highly-differentiated structures that have been refined through experience and are bound by cultural learning into emotion schemes (5, 28) Emotion schematic processing is the principal source of emotional experience and the target of intervention and therapeutic change in emotion-focused therapy (5, 26).

Emotion schemes are seen as being formed from emotional events such as betrayals or abandonments that result in emotional reactions. The emotion will fade unless it is “burned” into memory. The more highly aroused the emotion the more the experience and the evoking situation will form a memory. An emotion scheme is thus formed by emotions being connected to memories of the self in the situation. As a result the emotional response can be recreated again and again long after the event. Then a memory of the painful event or a reminder of it stimulates an emotional response.

Changing the emotion schematic memory structures in therapy most likely occurs through

the recently investigated process of memory reconsolidation (29, 30). The classic view of

memory suggests that immediately after learning there is a period of time during which the memory is fragile and labile, but that after sufficient time has passed, the memory is more or less permanent. During the consolidation period, it is possible to disrupt the formation of the memory; once this time window has passed, the memory may be modified or inhibited, but not eliminated. Recently however an alternative view of memory has been developed suggesting that every time a memory is retrieved, the underlying memory trace is once again labile and fragile – requiring another consolidation period, called reconsolidation. This reconsolidation period allows another opportunity to disrupt the memory. The possibility of disrupting a previously acquired emotion schematic memory by blocking reconsolidation has important clinical implications.

A Dialectical Constructivist View: Integrating Biology and Culture

As well as simply having emotion, people also live in a constant process of making sense of their emotions. An integration of reason and emotion is achieved via an ongoing circular process of making sense of experience by symbolizing bodily-felt sensations in awareness and articulating them in language, thereby constructing new experience (31, 32, 5, 33, 28, 34, 35, 36). How emotional experience is symbolized influences what the experience becomes in the next moment. Therapists therefore need to work with both emotion and meaning making and facilitating change in both emotional experience and the narratives in which they are embedded (37).

Emotion Assessment

We have proposed a system of process diagnoses in which it is important to make distinctions in the therapy session between different types of emotional experiences and expression that require different types of in-session intervention (26, 38). Primary emotions are the person’s most fundamental, direct initial reactions to a situation, such as being sad at a loss. Secondary emotions are responses to one’s thoughts or feelings rather than to the situation, such as feeling angry in response to feeling hurt or feeling afraid or guilty about feeling angry.

The next crucial distinction to be made is between primary states that are adaptive and are accessed for their useful information and primary states that are maladaptive and need to be transformed. Maladaptive emotions are those old, familiar feelings that occur repeatedly and do not change. They are feelings, such as a core sense of lonely abandonment, the anxiety of basic insecurity, feelings of wretched worthlessness, or shameful inadequacy that plague one all one’s life. These maladaptive feelings neither change in response to changing circumstance nor provide adaptive directions for solving problems when they are experienced.

Primary adaptive emotions need to be accessed for their adaptive information and capacity to organize action, whereas maladaptive emotions need to be accessed and regulated in order to be transformed. Secondary emotions need to be reduced by exploring them to access their more primary cognitive or emotional generators.


EFT intervention is based on two major treatment principles: The Provision of a therapeutic relationship and the Facilitation of therapeutic work (5). The relational style is Person centered (39), which involves a way of being with patients characterized by entering the clients internal frame of reference, and empathically following the clients experience. This is combined with a more guiding, process directive Gestalt therapy style (40) of engaging in experiments to deepen experience. The overall therapeutic style thus combines being with doing and following with leading.

The hallmark of EFT is that in addition to providing an empathic relationship the therapist also guides clients emotional processing in different ways at different times. In this process certain client in-session states which are markers of underlying affective/cognitive processing problems are seen as offering opportunities for differential interventions best suited to help facilitate productive work on that problem state.

Markers and Tasks

A defining feature of EFT is that intervention is marker guided and process directive. Research has demonstrated that clients enter specific problematic emotional processing states that are identifiable by in-session performances that mark underlying affective problems and that these afford opportunities for particular types of affective intervention (5). Client markers indicate not only the type of intervention to use but also the client’s current readiness to work on this problem. EFT therapists are trained to identify markers of different types of problematic emotional processing problems and to intervene in specific ways that best suit these problems. Each of the tasks has been studied both intensively and extensively and the key components of a path to resolution and the specific form that resolution takes has been specified. Thus models of the actual process of change acts as a map to guide the therapist intervention.

The following main markers and their accompanying interventions have been identified (5): 1) Problematic reactions expressed through puzzlement about emotional or behavioral responses to particular situations. For example a client saying “on the way to therapy I saw a little puppy dog with long droopy ears and I suddenly felt so sad and I don’t know why”. Problematic reactions are opportunities for a form of intervention that involves vivid evocation of experience to promote re-experiencing the situation and the reaction to finally arrive at the implicit meaning of the situation that makes sense of the reaction (5). Resolution involves a new view of self-functioning. 2) An unclear felt sense in which the person is on the surface of, or feeling confused and unable to get a clear sense of his/her experience, “I just have this feeling but I don’t know what it is” An unclear felt sense calls for focusing (41) in which the therapist guides clients to approach the embodied aspects of their experience with attention and with curiosity and willingness, to experience them and to put words to their bodily felt sense. A resolution involves a bodily felt shift the creation of new meaning. 3) Conflict splits in which one aspect of the self is critical or coercive towards another aspect, for example a woman in therapy says “I feel inferior to them, Its like “I’ve failed and, I’m not as good as you”. Self critical splits offer an opportunity for two-chair work. In this two parts of the self are put into live contact by dialoguing with each other. Thoughts, feelings and needs within each part of the self are explored and communicated in a dialogue to achieve a softening of the critical voice. Resolution involves an integration between sides and self-acceptance. 4) Self-interruptive splits arise when one part of the self interrupts or constricts emotional experience and expression, “I can feel the tears coming up but I just tighten and suck them back in, no way am I going to cry”. Two chair enactment is used to make the interrupting part of the self explicit. Clients are guided to become aware of how they interrupt and to enact the ways they do it,be it by physical act (choking or shutting down thevoice), metaphorically (caging), etc., or verbally (“shut up, don’t feel, bequiet, you can’t survive this”), so that they can experience themselves as an agent in the process of shutting down. They then are invited to react to and challenge the interruptive part of the self. Resolution involves expression of the previously blocked experience. 5) An unfinished business marker involves the statement of a lingering unresolved feeling toward a significant other such as the following said in a highly involved manner, “my father, he was just never there for me. I have never forgiven him, deep down inside I don’t think I’m grieving for what I probably didn’t have and know I never will have”. Unfinished business toward a significant other calls for an empty-chair intervention. Using an empty-chair dialogue, clients activate their internal view of a significant other and experience and express their unresolved feelings and needs . Shifts in views of both the other and self occur. Resolution involves holding the other accountable or understanding or forgiving the other. 6) vulnerability is a state in which the self feels fragile, deeply ashamed, or insecure, “I just feel like I’ve got nothing left. I’m finished. It’s too much to ask of myself to carry on”. Vulnerability calls for affirming empathic validation. When a person feels deeply ashamed or insecure about some aspect of his/her experience, above all else, clients need empathic attunement from the therapist who must not only capture the content of what the client is feeling but also note the vitality affects of the client mirroring the tempo rhythm and tone of the experience. In addition the therapists need to validate and normalize the client’s experience of vulnerability. Resolution involves the strengthened sense of self that results from empathic attunement to affect.

A number of additional markers and interventions such as, trauma and narrative retelling, alliance repair at ruptures, self compassion at markers of self contempt, self-soothing at anxious dependence, meaning making at markers of emotional high distress, and clearing a space at markers of confusion, and more, have been added to the original six markers and tasks (see 42, 12).

Principles of Emotional Intervention

From the EFT perspective change occurs by helping people make sense of their emotions through awareness, expression, regulation, reflection, transformation and corrective experience of emotion in the context of an empathically attuned relationship that facilitates these processes. These are described below. It is important to note that these principles are discussed below in relation to working with emotion in therapy not with reference to managing emotion in life.


Increasing awareness of emotion, or naming what one feels, is the most fundamental overall goal of treatment. Lieberman et al. (2004) have shown that naming a feeling in words helps decrease amygdala arousal. Once people know what they feel they reconnect to their needs and are motivated to meet them. Becoming aware of and symbolizing core emotional experience in words provides access both to the adaptive information and the action tendency in the emotion. It is important to note that emotional awareness involves feeling the feeling not talking about it.

EFT therapists help patients approach, accept, tolerate and symbolize emotions rather than avoid them. Patients are helped to make sense of what their emotion is telling them, identify the goal/need /concern which it is organizing them to attain and the action tendency provided and to use these to improve coping. Emotion is used both to inform and to move.

Emotional Expression

Emotional expression has been shown to be a unique aspect of emotional processing that predicts adjustment to such things as breast cancer (43) interpersonal emotional injuries, and trauma (44, 12, 45). Expressing emotion in therapy does not involve the venting of secondary emotion but rather overcoming avoidance to experience and express previously constricted primary emotions. Expressive coping helps patients attend to and clarify central concerns and promotes pursuit of goals.

There is a strong human tendency to avoid expressing painful emotions. So clients must be encouraged to overcome avoidance and approach painful emotion in sessions by attending to their bodily experience, often in small steps. This may involve changing explicit beliefs like “anger is dangerous” or “men don’t cry” governing their avoidance or helping them face their fear of dissolution (46, 47). Then clients must allow and tolerate being in live contact with their emotions. These two steps of approach and tolerate are consistent with notions of exposure. There is a long line of evidence on the effectiveness of exposure to previously avoided feelings (45). From the EFT perspective, however, approach, arousal and tolerance of emotional experience is necessary but not sufficient for change. Optimum emotional processing in our view involves the integration of cognition and affect (38, 31). Once contact with emotional experience is achieved, clients must also cognitively orient to that experience as information, and explore, reflect on, and make sense of it.


The third principle of emotional processing involves the regulation of emotion. It is clear that emotional arousal and expression is not always helpful or appropriate in therapy or in life and that, for some clients, training in the capacity for emotional down-regulation must precede or accompany utilization of emotion. Emotion needs to be regulated when distress is so high that the emotion no longer informs adaptive action (20).

The first step in helping emotion regulation in the provision of a safe, calming, validating and empathic environment. Being able to soothe the self develops initially by internalization of the soothing functions of the protective other (48, 49). Internal security develops by feeling that one exists in the mind and heart of the other, and the security of being able to soothe the self develops by internalization of the soothing functions of the protective other (50, 48, 49). Over time this is internalized and clients develop implicit self-soothing, the ability to regulate feelings automatically without deliberate effort.

Emotion regulation and distress tolerance (51) skills also need to be taught. Such things as, identifying triggers, avoiding triggers, identifying and labeling emotions, allowing and tolerating emotions, establishing a working distance, increasing positive emotions, reducing vulnerability to negative emotions, self-soothing, breathing, and distraction improve coping. Forms of meditative practice, which involve observing ones emotions and letting them come and go, breathing and acceptance are helpful in achieving a working distance from overwhelming core emotions.

Emotion can be down-regulated by soothing at a variety of different levels of processing. Physiological soothing involves activation of the parasympathetic nervous system to regulate heart rate, breathing and other sympathetic functions that speed up under stress. Another important aspect of regulation is developing clients’ abilities to self-soothe. Promoting clients’ abilities to receive and be compassionate to their emerging painful emotional experience is the first step towards helping them tolerate emotion and self-soothe followed by relaxation, development of self- compassion and positive self-talk.


In addition, to symbolizing emotion in words, reflection on emotional experience helps people make narrative sense of their experience. What we make of our emotional experience makes us who we are. Reflection helps to create new meaning, promotes the assimilation of unprocessed emotion into ongoing narratives and helps develop new narratives to explain experience (52, 37). Pennebaker (53) has shown the positive effects of writing about emotional experience on autonomic nervous system activity, immune functioning, and physical and emotional health and concludes that through language, individuals are able to organise, structure and ultimately assimilate both their emotional experiences and the events that may have provoked the emotions.

The meanings of situations that have evoked emotion are made sense of, and patterns in relationships are recognized. The result of this reflection based on aroused emotion is deep experiential self-knowledge. The unsayable is made sayable, situations are understood in new ways, experiences are reframed and this leads to new views of self other and world.


Probably the most important way of dealing with emotion in therapy involves the transformation of emotion by emotion. This applies most specifically to transforming primary maladaptive emotions such as fear, shame and the sadness of being abandoned or alone with other adaptive emotions (38). Maladaptive emotional states are best transformed by undoing them by activating other more adaptive emotional states. Darwin (54) was the first to note that “An emotion cannot be restrained nor removed unless by an opposed and stronger emotion” (Ethics IV, p.195). While thinking usually changes thoughts, only feeling can change primary emotions. In EFT an important goal thus is to arrive at maladaptive emotion, not for its good information and motivation, but in order to make it accessible to transformation. In time the co-activation of the more adaptive emotion, along with or in response to the maladaptive emotion, helps transform the maladaptive emotion.

It is important to note that the process of changing emotion with emotion goes beyond ideas of catharsis, completion and letting go, exposure, extinction or habituation, in that the maladaptive feeling is not purged, nor does it simply attenuate by the person feeling it. Rather another feeling is used to transform or undo it. Although dysregulated secondary emotions such as the fear and anxiety in phobias, obsessive compulsiveness and panic may be overcome by mere exposure, primary maladaptive emotions such as the shame of feeling worthless and the anxiety of basic insecurity are best transformed by other emotions. Thus change in previously avoided primary maladaptive emotions such as core shame or fear, is brought about by the activation of an incompatible, adaptive experience, such as empowering anger or self – compassion that undoes the old response rather than attenuate it. This involves more than simply feeling or facing the feeling leading it to its diminishment. Rather, for example the withdrawal tendencies of primary maladaptive emotion are transformed by activating the approach tendencies in anger or comfort seeking. Withdrawal emotions from one side of the brain are replaced with approach emotions from another part of the brain or vice-versa (55).

Frederickson (56) has shown that a positive emotion may loosen the hold that a negative emotion has on a person’s mind by broadening a person’s momentary thought action repertoire. The experience of joy and contentment were found to produce faster cardiovascular recovery from negative emotions than a neutral experience. Resilient individuals have been found to cope by recruiting positive emotions to undo negative emotional experiences (57). Thus bad feelings can be transformed by happy feelings, not by deliberately trying to look on the bright side, but by the evocation of meaningfully embodied experience that undoes the neurochemistry, physiology and experience of negative feeling.

This principle applies not only to positive emotions changing negative ones but to changing maladaptive emotions by activating dialectically opposing adaptive emotions (6). Thus, in therapy, maladaptive fear of abandonment or annihilation, once aroused, can be transformed into security by the activation of more empowering, boundary-establishing emotions of adaptive anger or disgust, or by evoking the softer soothing feelings of sadness and need for comfort. Similarly maladaptive anger can be undone by adaptive sadness. Maladaptive shame can be transformed by accessing both anger at violation and self-compassion and by accessing pride and self worth. Similarly anger is an antidote to hopelessness and helplessness. Thus the tendency to shrink into the ground in shame or collapse in helplessness can be transformed by the thrusting forward tendency in newly accessed anger at violation or the reaching out fro contact in sadness. Once the alternate emotion has been accessed it transforms or undoes the original state and a new state is forged. Often a period of regulation or calming of the maladaptive emotion in need of change is needed before the activation of an opposing emotion.

How does the therapist help the client access new emotions to change emotion? A number of ways have been outlined (38). Therapists can help the client access new subdominant emotions in the present by a variety of means, including shifting attention to different aspects of the situation or to emotions that are currently being expressed but are only ‘on the periphery’ of a client’s awareness; or focusing on what is needed and thereby mobilizing a new emotion is a key means of activating a new emotion (6). The newly accessed, alternate feelings are resources in the personality that help change the maladaptive state. For example, bringing out implicit adaptive anger can help change maladaptive fear in a trauma victim. When the tendency to run away in fear is combined with anger’s tendency to thrust forward, this leads to a new relational position of holding the abuser accountable for wrongdoing, while seeing oneself as having deserved protection, rather than say feeling guilty and unsafe. It also is essential both to symbolize, explore and differentiate the primary maladaptive emotion, in this case fear, and regulate it by breathing and calming, before cultivating access to the new more adaptive emotion, in this case anger.

Other methods of accessing new emotion involve using enactment and imagery to evoke new emotions, remembering a time an emotion was felt, changing how the client views things, or even the therapist expressing an emotion for the client (6). Once accessed, these new emotional resources begin to undo the psycho-affective motor program previously determining the person’s mode of processing. New emotional states enable people to challenge the validity of perceptions of self/other connected to maladaptive emotion, weakening its hold on them.

In our view enduring emotional change occurs by generating a new emotional response not through a process of insight, or understanding alone. EFT works on the basic principle that people must first arrive at a place before they can leave it. You have to feel it to heal it! Maladaptive emotion schematic memories of past childhood losses and traumas are activated in the therapy session in order to change these by memory reconstruction. As we have said introducing new present experience into currently activated memories of past events has been shown to lead to memory reconsolidation by the assimilation of new material into past memories (30). By being activated in the present the old memories are restructured by the new experience of both being in the context of a safe relationship and by experiencing more adaptive emotional responses and new adult understanding to the old situation. The memories are reconsolidated in a new way by incorporating these new elements. The past in fact can be changed, at least the memories of it can.

Corrective emotional experience

Finally a key way of changing an emotion is to have a new lived experience that changes an old feeling. New lived experience with the therapist provides a corrective emotional experience. Experiences that provide interpersonal soothing, disconfirm pathogenic beliefs or offers new success experience can correct patterns set down in earlier times. Thus an experience in which a client faces shame in a therapeutic context and experiences acceptance, rather than the expected disgust or denigration has the power to change the feeling of shame. Corrective emotional experiences in EFT occur predominantly in the therapeutic relationship although success experience in the world is also encouraged.

Phases of treatment

EFT treatment has been broken into three major phases, each with a set of steps to describe its course over time (12). The first phase involves bonding and emotional awareness, the middle phase involves evoking and exploring core maladaptive emotion schemes. Therapy concludes with a transformation phase that involves constructing alternatives through generating new emotions, and reflecting on aroused emotion to create new narrative meaning.

Case Formulation.

EFT has developed a context sensitive approach to case formulation to help promote the development of a focus (58). Case formulation relies on process diagnosis, development of a focus on underlying determinants and theme development rather than person or syndrome diagnosis. In a process-oriented approach to treatment, case formulation is an ongoing process, as sensitive to the moment and the in-session context as it is to an understanding of the person as a case. In a process diagnostic approach there is a continual focus on the client’s current state of mind and current cognitive/affective problem states. The therapist’s main concern is one of following the client’s process and the identification of core pain which leads to identification of markers of current emotional concerns and accessing the maladaptive schemes underlying the presenting. Painful emotions and markers of different problematic experiential states guide intervention more than a picture of the persons enduring personality or a core pattern. It is the clients presently felt experience that indicates what the difficulty is, and indicates whether problem determinants are currently accessible and amenable to intervention.

Diverse disorders

EFT theory of both the affective disorders and of eating disorders is discussed briefly below as examples of the application of the general theory to specific types of disorders. We argue that many disorders stem from the same basic underlying processes – core maladaptive emotion schemes, affect avoidance and problems in affect regulation.

The EFT model of depression and anxiety (12) centers on the vulnerability of a disempowered self. Early experiences of abuse, neglect, abandonment, or consistent experiences of being misunderstood can handicap the person’s processing of emotional distress, so that emotion becomes overwhelming and cannot be effectively used as the basis for adaptive responding. Subsequently, loss or failure events trigger core implicit emotion schemes of the self as deeply inadequate, insecure or blameworthy, along with related emotion memories plus secondary emotions. The self is thereby organized in terms of vulnerabilities and impoverished coping resources and in depression collapses into feeling powerless, trapped, defeated, contemptuous of self, and ashamed and in anxiety into feeling helpless, insecure, worried and avoidance. The person loses access to their sense of mastery and their ability to process their emotional experiences in terms of strengths and resources. Resilience is lost and the person experiences the self as powerless or reprehensible, insecure and helpless that is, as bad or weak.

Overview of Treatment of Affective Disorders

Intense feelings of self–contempt for the damaged self, and shame form the core of self- critical depressions. Intense feelings of the core insecurity of being unable to cope with loss or abandonment form the core of dependent depressions (58). On the other hand catastrophizing anxiety, protective fear and basic insecurity, form the maladaptive affective core of anxiety. Adequate processing of sadness at loss and anger at violation often form the adaptive core of the treatment of both depression and anxiety. Core anxiety and secondary helplessness, in addition to core shame and secondary hopelessness, are important emotions in the affective disorders. In depression the sadness, anxiety and neediness experienced by a childhood sense of loss and deprivation are experienced as evidence of personal inadequacy or in anxiety the inability to be soothed at times of threat confirms the uncontrollability of affect and the environment. Whatever the antecedents, empowerment by access to adaptive emotions, reconnection and soothing appears to be the antidote. Reviving the capacity to feel adaptive anger and sadness and the ability to feel compassion for the self and self-soothe are key affective elements to overcoming depression and anxiety and the powerlessness and insecurity of these disorders. EFT thus focuses on helping clients process their emotional experiencing so that they are able to access primary adaptive emotional responses to situations, such as empowering anger at violation or interpersonally-open sadness at loss.

Eating Disorders

Emotion, especially distressing emotion plays an important role in eating disorders.

Use of the eating disorder to manage affect regulation difficulties may result in either underregulation or overregulation of affect. Stereotypical clinical presentation, for example, would include the individual with anorexia nervosa who has highly constricted, impoverished, “overregulated” affect; as well as the individual with bulimia nervosa who may display chaotic and unmodulated affective functioning, and whose symptoms may include other impulsive behaviours in addition to bingeing and purging such as shoplifting, cutting, or substance abuse.

Overview of the Treatment

Given that the eating disorder is in the service of avoiding, numbing, or soothing painful emotion, it follows that treatment should involve explicit attending to and accommodating to felt emotion in order to allow its experience and develop proficiency in accepting, modulating, soothing, and transforming it. Individuals experience renewed hope in the possibility that they may alter and improve their eating disorder by means of working to identify and alter emotion schemes, rather than thinking their only recourse is to keep trying harder to change intransigent eating patterns in the absence of a substitute for managing their distress.

Comparison with other treatments

EFT is itself an integration of Client centered, Gestalt and Existential approaches (6). Although it differs from psychodynamic therapy in focusing more on the here and now, it is similar to self psychology in the attention paid to empathic attunement, and it is dynamically informed, incorporating attachment theory, the importance of interpersonal processes and repairing alliance ruptures as part of the healing process. It differs from CBT in seeing emotion as more influential in thought and belief production than vice versa, and in placing an emphasis on in-session process and change rather than homework and extra-sessional change. It is similar to those CBT that promote exposure to avoided emotion. EFT overlaps with IPT in promoting grieving but does not focus on dealing with current maladaptive interpersonal interactions. In fact EFT views both CBT’s maladaptive beliefs and IPT’s current interpersonal difficulties as resulting form maladaptive emotion schemes and proposes that emotional transformation leads to enduring change in both beliefs and interpersonal interactions, which are viewed as symptoms of core painful emotional processes.

Case Presentation

At the assessment interview, the client a 39 year woman tearfully reports feeling depressed, saying that she has been depressed most of her life, but that the past year has been particularly bad, that she has not been working, and has fallen into a pattern of rarely leaving the house or answering the phone or the door. Her relationships with her family of origin members are difficult, and often painful. Her mother is an alcoholic with whom she and her three sisters no longer have contact. Her father is a concentration camp survivor. He has always been emotionally removed from the family, and is often perceived as critical and judgmental. There is a history of physical punishment throughout her childhood.

From the exploration of the first session, the therapist has a sense that throughout her childhood and into her adult life she has often experienced herself as alone and unsupported. She has internalized the critical voice of her parents and often judges herself to be a failure. Within the context of a physically and emotionally abusive past she often felt emotionally unsafe and abandoned.

From the first session the therapist observes that the client is able to focus on her internal experience, particularly in response to empathic responses that focus her internally. However, she tends to avoid painful and difficult emotions (as do most people). There appears to be an identifiable maladaptive emotional pattern, wherein she moves into states of helplessness and hopelessness whenever she starts to feel primary emotions of sadness or anger, and in response to experiencing needs for closeness and acceptance. She also appeared to have internalized her father’s self-criticism seeing herself as a failure. Unfinished business stemming from her early relationship with her father was also evident. She has unresolved resentment and sadness that has affected her own sense of security and self-worth. The goal of the treatment appeared to be to resolve her self-critical conflict split and to resolve her unresolved feelings towards her father

In session three, with the helps of the therapist’s empathic attunement she describes not having got approval from her father: “I believe I’m a bad person, but deep down inside I don’t think I’m a bad person… yeah, I’m grieving for what I probably didn’t have and know I never will have.” The therapist initiates an empty chair dialogue with her father in this session. In her emotional expression to her imaginary father in the empty chair, she begins to voice the meaning of the painful emotions related to her father. “You destroyed my feelings. You destroyed my life. Not you completely,– but you did nothing to nurture me and help me in life. You did nothing at all. You fed me and you clothed me to a certain point. That’s about it.” The therapist drawing on her previous narrative replies; “Tell him what it was like to be called a devil and have to go to church every….” She then continued; “It was horrible. You made me feel that I was always bad, I guess when I was a child. I don’t believe that now, but when I was a child I felt that I was going to die and I was going to go to hell because I was a bad person.”

By the end of session three, the thematic intrapersonal and interpersonal issues on which the therapy will focus have emerged clearly. They are clearly embedded in what the client reports as her most painful experience. First, the client has internalized self-criticism related to issues of failure that emerge in the context of her family relationships. This voice of failure and worthlessness initially was identified as coming from her sisters, but clearly has roots in earlier relationships with her parents. This becomes more evident later in therapy. Related to her self-criticism and need for approval is a need for love. Love has been hard to come by in her life. She has learned how to interrupt or avoid acknowledging this need as it has made her feel too vulnerable and alone. She has learned how to be self-reliant but this independence has had a price as it leaves her feeling hopeless, unsupported and isolated. This need for love is related to her unfinished business stemming from her early relationship with her father (and her alcoholic mother but her father is more central in her experience). She harbors a great deal of resentment toward her father over his maltreatment of her as a child and she has a tendency to minimize it as “being slapped was just normal.” She has internalized this as a feeling of worthlessness and as being unlovable. These underlying concerns lend themselves very clearly to the emotional processing tasks of both the two-chair for internal conflict splits and to the empty-chair for unresolved injuries with a significant other.

In a key dialogue in session three she speaks to her father, imagined in front of her in an empty chair and after blaming him for his mistreatment she moves to an expression of primary sadness and anger:

C: It hurts me that you don’t love me-yea-I-guess, you know, but…I’m angry at you and I needed love and you weren’t there to give me any love.”

Encouraged by the therapist she later tells the image of her father about her fear:

C: I was lonely. I didn’t know my father. My father-all I knew you as, was somebody that yelled at me all the time and hit me. That’s all-I don’t remember you telling me you loved me or that you cared for me or that you thought that I did well in school or anything. All I know you as somebody that I feared.

T: Tell him how you were afraid of being hit.

C: Yes, and you humiliated me. I was very angry with you because you were always hitting me, you were so mean and I heard Hitler was mean, so I called you Hitler.

Later on in the session, she expresses pain and hurt at her father’s inability to make her feel loved: “I guess I keep thinking that yea, you will never be a parent, that you would pick up the phone and just ask me how I’m doing. It hurts me that you don’t love me-yea-I guess, you know.” She ends the session with a recognition that what she had needed was acceptable. “I needed to be hugged once in a while as a child or told that I was OK. I think that’s normal”.

By accessing both pride and anger and grieving her loss, her core shame is undone (Greenberg, 2002). She thereby begins to shift her belief that her father’s failure to love her was because she was not worth loving. She says to him in the empty chair. “I’m angry at you because you think you were a good father, you have said that you never hit us and that’s the biggest lie on earth, you beat the hell out of us constantly, you never showed any love, you never showed any affection, you never ever acknowledged we were ever there except for us to clean and do things around the house”.

In a dialogue with the critic in session 4 her critical voice begins to soften and both her grief over having not been loved and a sense of worth emerge. “Even though mom and dad didn’t love me or didn’t show me any love, it wasn’t because I was unlovable, it was just because they were incapable of those emotions. They don’t know how to – they still don’t know how to love.” The client does not experience the hopelessness that had been so predominant in her earlier sessions again.

Later in session 7, the client and the therapist work to identify the way in which the client blocks her feeling of wanting to be loved to protect against the pain of having her needs not met. In session nine enacting her “interrupter” she says to herself “You’re wasting your time feeling bad cause you want them, they are not there. So it’s best for you to shut your feelings off and not need them. That’s what I do in my life. When people hurt me enough I get to that point where I actually can imagine, I literally cut them out of my life like I did with my mother.”

In sessions seven through nine, the client continues to explore the two different sides to her experience: the critic that attempts to protect her through controlling and shutting off needs and the experiencing self that wants to be loved and accepted. She continues to define and speak from both voices and expresses a range of sadness, anger, and pain/hurt. The hopelessness that was so dominant in the early sessions now is virtually non-existent. The voice that wants love and acceptance becomes stronger and the critic softens to express acceptance of this part of her. At the same time she is feeling much better and activation of her negative feelings decrease.

Having processed her anger and her sadness and transformed her shame she takes a more compassionate and understanding position to her father a key empirically demonstrated process of change. In an empty chair dialogue with her father in session 10 she says “I understand that you’ve gone through a lot of pain in your life and probably because of this pain, because of the things you’re seen, you’ve withdrawn. You’re afraid to maybe give love the way it should be given and to get too close to anybody because it means you might lose them. You know and I can understand that now, whereas growing up I couldn’t understand.” She is also able to hold him accountable for the ways that he disappointed and hurt her while also allowing her compassion to be central in the development of a new understanding of his inner struggles.

In talking about the dialogue at the end of the session, the client says “I feel relief that I don’t have this anger sitting on my chest anymore”. B y the end of this 14 session therapy her shame-based core maladaptive belief that “I am not worth loving” has shifted to include the emotional meaning that her father experienced his own pain in his life and that this pain led him to be less available to behave in loving ways toward her or her sisters. Needing to be loved no longer triggers hopelessness and she is now more able to communicate her needs, to protect herself from feeling inadequate and to be closer to her sisters.


The effectiveness of short-term EFT for individuals has been demonstrated in several research projects. EFT is an effective treatment for both depression and emotional trauma. EFT activates emotion during treatment in order to make deep change in automatically-functioning emotion schemes that are frequently the sources of problems. EFT combines both following and guiding clients’ experiential process, while emphasizing the importance of both relationship and intervention skills.


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Treatment responders according to the LIFE-II at posttreatment (n = 25)


Treatment responders according to the LIFE-II at posttreatment (n = 27)





Follow-up analyses

LIFE-II for treatment responders

(n = 21)

Unable to contact (n = 3)

Client declined participation in

follow-up period (n = 1)

Self-report for treatment completers

(n = 29)

Unable to contact (n = 4)

Declined participation in follow-up

period (n = 1)

Return to treatment excluded

(n = 2)



Follow-up analyses

LIFE-II for treatment responders

(n = 22)

Unable to contact (n = 4)

Client declined participation in

follow-up period (n = 1)

Self-report for treatment completers

(n = 27)

Unable to contact (n = 5)

Declined participation in follow-up

period (n = 1)

Return to treatment excluded

(n = 3)