Experiential Therapies for Depression 1

Running head: EXPERIENTIAL THERAPY AND RELAPSE PREVENTION

Maintenance of Gains Following Experiential Therapies for Depression

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

York University
 Experiential Therapies for Depression 2

Abstract

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

 Experiential Therapies for Depression 3

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
 Experiential Therapies for Depression 4

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
 Experiential Therapies for Depression 5

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
 Experiential Therapies for Depression 6

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.

Method

Participants

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
 Experiential Therapies for Depression 7

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 clients were 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.

Treatments

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

 Experiential Therapies for Depression 8

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
 Experiential Therapies for Depression 9

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
 Experiential Therapies for Depression 10

(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),.
 Experiential Therapies for Depression 11

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).

Procedure

Follow-up

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
 Experiential Therapies for Depression 12

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
 Experiential Therapies for Depression 13

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.

Results

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.

 Experiential Therapies for Depression 14

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
 Experiential Therapies for Depression 15

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.

 Experiential Therapies for Depression 16

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
 Experiential Therapies for Depression 17

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
 Experiential Therapies for Depression 18

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.

Discussion

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.

 Experiential Therapies for Depression 19

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.
 Experiential Therapies for Depression 20

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.

 Experiential Therapies for Depression 21

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 Experiential Therapies for Depression 27

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
 Experiential Therapies for Depression 28

Table 1

Demographic and Clinical Characteristics For Treatment Responders

Treatment Condition
CC EFT Total

Variable (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)

Age

M (and SD) 38.76 (11.62) 37.64 (7.27) 38.19 (9.54)

Range (n) 22-58 22-49
Marital Status, n (and %)

Single 9 (42.9) 7 (31.8) 16 (37.2)

Married 5 (23.8) 9 (40.9) 14 (32.6)

Divorced/Separated/Widowed 7 (33.3) 6 (27.3) 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.
 Experiential Therapies for Depression 30

Table 2

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

Treatment Condition
Variable CC EFT Total
Intent-to-treat, n 41 42 83
Completed, n 36 36 72
Responders, n 25 27 52
a
% 60.9 64.3 62.7
%b 69.4 75.0 72.2
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 =

a
client-centered; EFT = emotion-focused therapy. Percent of all clients entering treatment;
b
Percent of all clients completing treatment.
 Experiential Therapy for Depression 30

Table 3

Rates of Relapse Among Treatment Responders During Follow-Up

Treatment condition
Variable CC EFT χ2
6-month follow-up
Responders, n 21 22
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 21 22
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.

 Experiential Therapy for Depression 31

Table 4

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

Treatment Condition
CC EFT
Well Week M SD M SD F
Responders, n 21 22
6 months 23.05 2.52 24.0 0 F(1, 43) = 3.15, p = .083
18 months 47.43 20.97 60.18 15.47 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.

 Experiential Therapy for Depression 32

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

Treatment Condition
CC EFT
(n = 29) (n = 27)
M SD M SD
Follow-up period
BDI
Pretreatment 24.62 6.80 26.30 6.96
6 months 8.72 7.01 7.58 5.41
18 months 11.76 8.32 6.74* 5.81
SCL-90-R GSI
Pretreatment 1.26 0.47 1.38 0.45
6 months 0.57 0.50 0.50 0.36
18 months 0.75 0.60 0.45 0.33
RSE
Pretreatment 21.76 6.46 20.43 6.17
6 months 27.97 5.50 29.87 5.91
18 months 27.10 5.97 31.00* 6.04
IIP
Pretreatment 1.49 0.58 1.54 0.40
6 months 0.99 0.54 0.97 0.53
18 months 1.23 0.61 0.91 0.49
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).
 Experiential Therapy for Depression 33

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)
Treatment responders according to the
LIFE-II at posttreatment (n = 25)
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)
Experiential Therapy for Depression 34
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)
Treatment responders according to the
LIFE-II at posttreatment (n = 27)
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)
 Experiential Therapy for Depression 35

1.0
EFT

0.8
Cumulative Proportion Surviving

0.6 CC

0.4

0.2

0.0

10 20 30 40 50 60 70 80
Number of weeks before first relapse
 CC
EFT
CC

Experiential Therapy for Depression 36

CC

EFT
 EFT
CC

Experiential Therapy for Depression 37

CC

EFT
 EFT
CCT

Experiential Therapy for Depression 38

EFT

CC
 CCT
EFT

Experiential Therapy for Depression 39

CC

EFT