Journal of Consulting and Clinical Psychology Copyright 1995 by the American Psychological Association, Inc.

1995. Vol. 63, No. 3,419-425 0022-006X/95/S3.00

Resolving "Unfinished Business": Efficacy of Experiential Therapy

Using Empty-Chair Dialogue
Sandra C. Paivio Leslie S. Greenberg
University of Saskatchewan York University

In this study, 34 clients with unresolved feelings related to a significant other were randomly assigned
to either experiential therapy using a Gestalt empty-chair dialogue intervention or an attention-
placebo condition. The latter was a psychoeducational group offering information about "unfinished
business." Treatment outcomes were evaluated before and after the treatment period in each condi-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

tion and at 4 months and 1 year after the experiential therapy. Outcome instruments targeted general
This document is copyrighted by the American Psychological Association or one of its allied publishers.

symptomotology, interpersonal distress, target complaints, unfinished business resolution, and per-
ceptions of self and other in the unfinished business relationship. Results indicated that experiential
therapy achieved clinically meaningful gains for most clients and significantly greater improvement
than the psychoeducational group on all outcome measures. Treatment gains for the experiential
therapy group were maintained at follow-up.

Recent emotion theory (e.g., Lazarus, 1991) suggests that
therapeutic procedures that access emotion activate a complex
associative network making it available for exploration and re-
structuring (Greenberg, Rice, & Elliott, 1993). Such an as-
sumption is evident in areas such as posttraumatic stress (e.g.,
Foa, Rothbaum, Riggs, & Murdock, 1991) or bereavement dis-
orders (e.g., Marmar & Freeman, 1988), where it is becoming
recognized that repeated emotional re-experiencing in therapy
of aspects of traumatic events leads to permanent change in the
trauma memory. Thus, experiential therapeutic procedures,
aimed specifically at accessing client emotion, are potentially
powerful agents in promoting long-term change. However, with
a few notable exceptions (e.g., Beutler, Engle, Oro-Beutler,
Daldrup, & Meredith, 1986; Greenberg & Webster, 1982),
there is little published outcome research on these types of
interventions.
In line with the trend toward greater specificity and differen-
tial diagnosis and treatment (e.g., Beutler et al., 1991),
Greenberg and his colleagues (Greenberg et al., 1993;
Greenberg & Safran, 1987) have suggested that complex clini-
cal syndromes such as anxiety and depression are composed
of different cognitive-affective processing difficulties. Thus,
different people within the same diagnostic group have different
problem determinants that require different interventions
(Goldfried, Greenberg, & Marmar, 1990). Several specific pro-
cessing difficulties and interventions aimed at addressing them
have been identified, and the process of resolving these tasks
have been investigated (cf., Greenberg, 1991; Greenberg et al.,
1993). However, again, there is little evidence that resolving
these difficulties is related to long-term outcome.
Sandra C. Paivio, Department of Psychology, University of Saskatch-
ewan, Saskatoon, Saskatchewan, Canada; Leslie S. Greenberg, Depart-
ment of Psychology, York University, Toronto, Ontario, Canada.
Correspondence concerning this article should be addressed to San-
dra C. Paivio, Department of Psychology, University of Saskatchewan,
Saskatoon, Saskatchewan, Canada S7N 5A5.
419
One of the major affective tasks in therapy specified by
Greenberg and his colleagues (Daldrup, Beutler, Engle, &
Greenberg, 1988; Greenberg et al., 1993; Greenberg & Safran,
1987) is the resolution of "unfinished business." Markers of un-
finished business or lingering negative feelings toward a signifi-
cant other commonly occur in therapy, and there is agreement
across orientations that unresolved anger and sadness are
among the generating conditions of anxiety, depression, and a
variety of interpersonal problems (e.g., Beck, 1984; Daldrup et
al., 1988; Strupp, 1988). Drawing on Gestalt therapy tech-
niques (Perls, Hefferline, & Goodman, 1951), an intervention
for resolving such unfinished emotional issues has been devised
(Daldrup etal., 1988; Greenberg etal., 1993). Empty-chair di-
alogue intervention (ECH), in which the client engages in an
imaginary dialogue with the significant other, is designed to ac-
cess restricted feelings allowing them to run their course and be
restructured in the safety of the therapy environment.
The process of resolving unfinished business using ECH has
been rigorously modeled (Greenberg et al., 1993; Greenberg
& Safran, 1987), and the model has been empirically verified
(Foerster, 1990). Resolution consists of changed perceptions of
self and other so that clients shift from viewing themselves as
weak and victimized to a stance of greater self-empowerment
and either view the significant other with greater understanding
or hold them accountable for harm. Preliminary analogue re-
search (King, 1989) indicated that, in terms of immediate out-
come, ECH compared with empathic reflection led to greater
tolerance of and increased self-confidence in relation to the sig-
nificant other. There is a need to establish whether the ECH
achieves more lasting effects in an actual treatment study.
The purpose of the present research, therefore, was to test the
efficacy of experiential therapy using ECH for resolving unfin-
ished business. To evaluate the treatment, we compared ECH
with an attention-placebo minimal treatment condition. This
was a psychoeducational group (FED) that offered group sup-
port and information about resolving unfinished emotional
business without the in-therapy experiential component. In
 420 SANDRA C. PAIVIO AND LESLIE S. GREENBERG

view of the current popularity of self-help groups and lectures Therapists

for these issues (e.g., Bradshaw, 1990), it was reasoned that the
FED group would be perceived by participants as a credible
treatment.
Our hypotheses were that, in comparison with clients in the
FED condition, ECH clients would achieve statistically and
clinically significant improvements on measured dimensions of
clinical distress as well as reduced hostility toward the signifi-
cant other who was the focus of treatment.
Method
Participants
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Therapists and group leader were eight doctoral (two male, six
female) students in clinical psychology (including Sandra C. Paivio,
who also conducted both PED groups). The average age was 35 years
(range, 26 to 49). All therapists had clinical internship experience of at
least 1 year and clinical experience ranged from 1 to 15 years. Therapists
received a minimum of 3 hr a week of specific training, over 14 weeks,
in the ECH conducted by Leslie S. Greenberg. This included discussion
of the model of resolution and the therapy manual (Greenberg et al.,
1993), as well as weekly small group supervision of audiotaped therapy
with pilot or "practice" clients.
Throughout the study, therapy sessions were audiotaped and video-
taped and the PED lecture series was audiotaped. There was weekly
small-group supervision in which Leslie S. Greenberg reviewed video-

tapes to ensure adherence to protocol and quality of therapy. Each ther-

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Participants were recruited through newspaper and radio features apist was assigned two or three clients. After attrition, three therapists
that described the research project as offering free counseling for unre- saw 3 clients each, three saw 2 clients, and two completed therapy with
solved emotional issues with a significant other. More than 250 respon- 1 client each.
dents were screened by telephone using a standardized script and the
following criteria: (a) age above 18 years, (b) absence of current psy-
chosocial treatment, (c) absence of medication that affects mood, (d) Treatments
absence of reported drug or alcohol problems, (e) absence of current
Experiential therapy using ECH. ECH therapy was a 12-week treat-
self-harm potential or other crisis, and ( f ) absence of current involve-
ment (with the option of two extra sessions depending on individual
ment in a violent relationship. The interview was terminated when a
need). There were weekly 50-min sessions with ECH as the primary
caller failed to meet a criterion, and the individual was then referred to
intervention. The general style was client-centered, involving empathic
an appropriate community service. Suitable callers were scheduled for
responding plus active process-directive intervention (Greenberg et al.,
an assessment interview.
1993). Thus, at in-session markers of unfinished business, the therapist
Subsequently, 97 semistructured interviews were conducted by four
guided clients through an imaginary dialogue with their significant
doctoral-level graduate students. Suitability was assessed on the basis of
other, encouraging clients to express their unresolved feelings to the
commonly accepted criteria for short-term therapy (e.g., Malan, 1976)
other. This intervention was guided by the model delineating the steps
including motivation, capacity to focus on a circumscribed issue, and
to resolution. A detailed description of the intervention and model of
capacity to form a therapy relationship. Prospective clients completed
resolution can be found in a published treatment manual (Greenberg et
the Symptom Checklist—90—Revised (SCL-90-R; Derogatis, 1983)
al., 1993).
after the interview and a cutoff/ score of 60 (outpatient norms) on the
Treatment was explicitly focused and structured around the task of
Global Severity Index (GSI) was used to screen for symptom severity.
resolving clients' unfinished business with a specified other person. The
Participants also were excluded if they were judged to be severely func-
first two sessions were devoted to relationship building and structuring,
tionally impaired. The Global Assessment of Functioning Scale of the
and the final session was devoted to termination.
Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.;
PED. The PED condition consisted of two groups of 8 to 12 mem-
DSM-HI-R; American Psychiatric Association, 1987) was used as a
bers each who participated in three 2-hr lectures-discussions held con-
guideline in making this clinical judgment.
currently over the same 3-month period as ECH therapy. Content of the
Participants were included if they met criteria for the presence of
lectures paralleled the information component of ECH and was derived
unfinished business as the clinically predominant issue. Guidelines for
from Greenberg et al.'s (1993) conceptualization of unfinished busi-
this judgment were as follows: (a) the identification of a specific signifi-
ness. It included information on (a) the characteristics of unfinished
cant other with whom the person had unfinished business, (b) behav-
business; (b) the role of emotion in the development, maintenance, and
ioral "markers" of unfinished business (i.e., expressions of lingering
resolution of unfinished business; and (c) important components of res-
negative feelings toward the other, (c) lingering unresolved feelings from
olution such as heightened awareness, grieving, and restructuring
the past as distinguished from ongoing interpersonal problems that
beliefs.
might be better addressed through couples therapy or interpersonal
The group followed a lecture-discussion format so that participants
therapy, (d) unfinished business distinguished from current develop-
sat in a semicircle and the leader used a chalkboard at the front of the
mental issues of separation from a parent (thus, participants were re-
room. There was contact among the members, but the focus was in-
quired to be over 18 and not living in their parental home), and (e) structional rather than interactive. There was no experiential compo-
unfinished business distinguished from normal grieving or from adjust- nent, no pressure to self-disclose, and no individual, empathic relation-
ment to separation or divorce so that there had to be 2 years since a loss
ship with the leader. Content and protocol were manualized (Paivio,
occurred. These, rather than traditional diagnostic criteria, defined the
1992) and used with both psychoeducational groups.
clinical problem. Participants who failed to meet criteria were referred
elsewhere.
Forty-two clients were accepted into the study. Immediately after the Measures
acceptance decision, clients were alternately assigned to either the ECH
condition or the PED condition. Participants in both groups were told An outcome battery of self-report measures was administered to as-
that they could participate in the alternate treatment once their original sess change in specific domains. All clients were assessed before treat-
assignment was completed. Four participants withdrew from treatment ment and at termination, and the follow-up data at 4 months and 1 year
in each group, leaving a total of 34 completers, 17 in each group. Both were collected for the ECH therapy group.
ECH and PED were delivered at the psychotherapy research facility at SCL-90-R. The SCL-90-R is a widely used 90-item questionnaire
York University, Toronto, Ontario, Canada. that measures general symptom distress. Derogatis (1983) reported in-
 RESOLVING UNFINISHED BUSINESS 421

ternal consistency ranging from .77 to .90 and test-retest reliability be-
tween .80 and .90 over a 1-week interval.
Inventory of Interpersonal Problems (IIP). The IIP (Horowitz et
al., 1988) is a self-report instrument, consisting of 127 items, that mea-
sures distress arising from interpersonal sources. Horowitz et al. re-
ported test-retest reliability between .89 and .98 and internal consis-
tency ranging from .89 to .94.
Target Complaints (TC). The TC (Battle et al., 1966) Discomfort
and Change scales were used. These specify up to three problems iden-
tified by the client who rates the degree of distress and change since the
beginning of treatment, on each problem. Battle et al. reported high
correlations with other outcome measures and test-retest reliability, be-
tween pre- and postintensive psychiatric interviews, of .68.
Unfinished Business Resolution Scale (VFB-RS). The UFB-RS
(Singh, 1994) is an 11 -item instrument developed for this study. Clients
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Follow-Up
Clients in ECH therapy were contacted by phone for a follow-up as-
sessment 4 months after the end of treatment and either came into the
facility or were mailed the self-report questionnaires. Follow-up data
were not collected on the FED group because 10 of these participants
continued in individual therapy after the group therapy.
Results
Participants
Table 1 presents demographic data for the 34 clients who com-
pleted treatment. A one-way multivariate ANOVA (MANCAA) in-

rate the degree of unfinished business resolution with a specific other

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dicated no significant demographic differences between the groups

person (e.g., "I have come to terms with not getting what I want from
this person"). Singh reported test-retest reliability, over 1 month, be-
tween .73 and .81 and high correlations between change on the UFB-
RS and change on other outcome measures used in the present study.
Structural Analysis of Social Behavior (SASB). The SASB short
form questionnaires (Benjamin, 1988) measure the degree of interde-
pendence (separate-dependent) and affiliation (hostile-friendly) in a
specific relationship. For example, "He likes me and tries to see my
point of view even if we disagree" is an item reflecting affiliation. Sixteen
items each measure the perceptions of the significant other in the rela-
tionship and the perceptions of self in the relationship. Eight items mea-
sure the introject or relationship to self. For all the SASB question-
naires, affiliation dimension scores were used as the dependent measure.
This consists of a weighted average of all the items on each questionnaire
calculated according to the method reported by Quintana and Meara
(1990). Scores range from -800 (hostile) to 800 (affiliative) on the
Self and Other questionnaires, and from -400 to 400 on the Introject
measure. Benjamin reported reliabilities for the long form ranging from
.67 to .90 and has reported that there is substantial evidence for the
construct validity of the SASB and internal reliability of the short-form
items.
Working Alliance Inventory (WAI). The WAI (Horvath &
Greenberg, 1989) consists of 36 items that ask clients to rate how accu-
rately each item describes their current therapy experience. Horvath
and Greenberg reported estimated alphas ranging between .87 and .93
and nontrivial correlations with other relationship indicators.
at pretreatment, F(4, 28) = .807, p = .53. Thus, the typical client
was in his or her early 40s, married, had some college or university
education, and had some form of previous therapy experience.
At intake, the mean GSI on the SCL-90-R was .76, with ele-
vated depression, anxiety, and interpersonal sensitivity scores.
The / scores on these subscales, with outpatient norms for the
SCL-90-R, ranged from 42 to 47, indicating that this was a
mildly distressed outpatient population. Clinical assessments
indicated mild-to-moderate impairments in social, occupa-
tional, or school functioning.
The relationship with the significant other, assessed at pre-
treatment through SASB questionnaires, can be described as
somewhat hostile, with a mean score of — 162, and somewhat
autonomous, with a mean interdependence score of 175. Table
2 presents the unfinished business issues that were the focus of
therapy for each group. About half of the clients focused on
general developmental issues of intimacy or control with a par-
ent; 9 dealt with unresolved feeling associated with sexual
abuse, physical abuse, or both; 4 clients worked on issues of
loss or abandonment (2 of these concerned parental suicide); 3
clients focused on unresolved feelings toward an ex-partner, 1
focused on an adult child, and 1 on a former employer.

Table 1
Treatment Adherence Sample Characteristics
ECH FED
The adherence checklist for ECH therapy, adapted from the treat- Variable (n = 17) (n=17)
ment manual (Greenberg & Minden, 1989; Greenberg et al., 1993),
consists of 16 categories of therapist interventions (defined as a com- Gender
plete therapist statement). A minimum of one third of the "working" n female 11 11
sessions was required to contain at least 20 min of ECH to meet adher- Age (years)
ence criteria. M 40 42
SD 8.15 11.81
Adherence checks were carried out on ECH therapy by two trained Education (years)
raters who rated audiotapes of all therapist statements in forty-eight 5- High school 0 1
min segments of ECH. These segments were selected randomly from College or university 12 12
the beginning, middle, and final sessions of each therapy dyad. Three Postgraduate 5 4
sessions of each ECH therapy were rated. Each rater rated two thirds of Marital status
the segments, and they overlapped ratings on one third of the segments Single 4 3
to establish reliability. Married 6 9
Separated or divorced 7 5
Adherence checks for the FED group were carried out by one rater n who had previous therapy 13 14
who listened to complete audiotapes of all group sessions and judged
that they adhered to procedures and content outlined in the treatment Note. ECH = experiential therapy with empty-chair dialogue; PED =
manual (Paivio, 1992) devised for the group. psychoeducational group.
 422 SANDRA C. PAIVIO AND LESLIE S. GREENBERG

Table 2 ECH and the FED groups at pretreatment. However, a repeated

Unfinished Business Issues
Issue
General development
Abuse (physical or sexual)
Loss or abandonment
Ex-partner
Other
Note. ECH = experiential therapy with empty-chair dialogue; FED =
psychoeducational group.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ECH(n= 17) PED(«= 17)
7 9
5 4
2 2
1 2
2 0
measures MANOVA of pre- and posttreatment means yielded a
highly significant Group X Time interaction, F( 1,25) = 5.115,
p = .001. Subsequent univariate Ftests were carried out on each
of the seven dependent variables, and a separate univariate anal-
ysis was performed on the TC Change scores.
Symptom and interpersonal distress. Univariate analyses
revealed a significant Group X Time interaction both on the
SCL-90-R, F(1, 31) = 10.07, p = .005 and the IIP, F( 1, 31)
= 17.53, p = .000. These results indicate that the ECH group
reported significantly greater reductions than the FED group
on symptom and interpersonal distress after therapy.
TC discomfort and change scales. There was a significant

Mortality interaction on the TC Discomfort scale, F( 1, 31) =. 15.18, p =

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.001. An ANOVA comparing ECH and FED at posttreatment

Dropouts were defined as clients who withdrew and were un- on the TC Change scale revealed significantly more change after
available to complete posttreatment questionnaires. All with- ECH therapy, F( 1,31) = 31.56, p = .000. Together, these results
drawals occurred before Session 5 of ECH and the third FED indicate that the ECH group reported less distress and more
session. Completers were clients who completed a termination change on identified problems at posttreatment than the FED
session and posttreatment questionnaires. A MANOVA re- group.
vealed no significant difference between dropouts and complet- Unfinished business resolution. A univariate analysis
ers on clinical dimensions, F(7, 33) = 1.77, p = .13. As well, yielded a significant Group X Time interaction on the UFB-
the unfinished business issues presented by those who withdrew RS, F( 1, 31) = 30.33, p = .000, indicating that the ECH group
(n = 8) did not appear different from those who completed
treatment. However, a comparison of demographic means indi-
cated that the four ECH therapy dropouts were more predomi-
nantly single (75% vs. 24%), male(75% vs. 35%), and less edu- Table 3
cated (75% with high school as highest level vs. 0%) than those Means and Standard Deviations at Pretreatment and
who completed therapy. Posttreatment for Dependent Measures
M (and SO) M(andSD)
Adherence Measure and group pretreatment posttreatment
One client was found not to adhere, and the data for this cli- SCL-90-R
ent were omitted from the analysis, leaving 16 in the ECH con- ECH" 0.80(0.53) 0.29 (0.20)
dition. Eleven therapies were 12 sessions in length, two were 15 FED" 0.71(0.46) 0.65 (0.43)
sessions, and three were 6, 8, and 14 sessions each. Fifty-three IIP
percent of the sessions contained ECH dialogue that lasted ECH 1.43(0.49) 0.68 (0.40)
FED 1.50(0.63) 1.31(0.69)
longer than 20 min. TC Discomfort
A total of 698 therapist statements were coded according to ECH 9.05(1.68) 3.78(2.13)
16 interventions specified in the adherence checklist. Ninety- FED 9.54(1.60) 7.39(2.30)
three percent of these adhered to protocol. As well, raters TC Change
ECH 7.70(1.28)
achieved 89% agreement in categorizing 236 of the interven- FED 4.85(1.55)
tions with a Cohen's (1968) weighted kappa coefficient of .87. UFB-RS
The WAI was administered to clients after Session 3. The ECH 41.37(7.38) 19.50(7.32)
mean client score was 5.83 on a 7-point scale, suggesting a high FED 41.35(6.10) 34.53(8.42)
degree of perceived collaboration in the alliance. Together, these SASB Other
ECH -224 (236) -21(346)
results indicate that the ECH treatment was delivered with con- FED -202 (252) -153(231)
sistency and a high degree of adherence to protocol in the SASB Self
context of a good working alliance. ECH -98(278) 35(354)
FED -117(232) -152(214)
SASB Introject
Treatment Effects ECH 101(180) 202(128)
FED 77 (204) 73(168)
Table 3 presents the means and standard deviations pre- and
posttreatment for both groups on the SCL-90-R, IIP, TC Dis- Note. Decimals are deleted for SASB data. ECH = experiential ther-
comfort and Change scales, the UFB-RS, and the three SASB apy with empty-chair dialogue; FED = psychoeducational group; SCL-
90-R = Symptom Checklist—90—Revised; IIP = Inventory of Inter-
variables. personal Problems; TC = Target Complaints; UFB-RS = Unfinished
After preliminary examination of the data, MANOVAs were Business Resolution Scale; SASB = Structural Analysis of Social Be-
chosen as the most appropriate data-analytic strategy. An over- havior.
all MANOVA revealed no significant difference between the "«=16. "n=17.
 RESOLVING UNFINISHED BUSINESS 423

reported greater unfinished business resolution, at posttreat-
ment, than the FED group.
Perceptions of self and other. In terms of perceptions of sig-
nificant other in the unfinished business relationship, a univar-
iate F test revealed significantly more change for the ECH
group, F( 1, 31) = 3.83, p = .059. Although this result is not
significant at the .05 level, a one-tailed test (justifiable because
the direction of change was specifically predicted) places the
significance level at .03. Thus, results indicate that the ECH
group reported perceiving the other as significantly less hostile
after therapy than the FED group.
In terms of perceptions of self, again, a univariate F test re-
vealed a significant interaction, F( 1, 31) = 5.55, p = .02. This
indicates that, on average, the ECH clients perceived themselves
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
(a pre-post difference score greater than 9), compared with 35%
of FED clients.
Therapist Effects
We conducted analyses to determine whether any of the ther-
apists contributed more than others to overall treatment out-
come. After withdrawals, two therapists completed therapy with
only 1 client each, which precluded their inclusion in ANOVAs.
Analyses with the remaining six therapists as factor contained
only 2 or 3 clients per cell, resulting in little statistical power
to detect differences. Nevertheless, analyses of covariance, with
therapist as factor and pretreatment scores as covariate, were
performed on appropriate dependent measures (the SCL-90-

R, IIP, and three SASB measures). The average p value for these
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as less hostile in the relationship after treatment. These percep-

tions shifted to a significantly greater degree than those of the
FED group.
Finally, a univariate F test revealed a significant interaction
on the SASB Introject dimension, F(l, 31) = 4.36, p = .04.
The ECH group reported a significantly greater increase in self-
affiliation or self-acceptance at posttreatment than the FED
group.
Clinically Significant Change
measures was .61. In view of the small cell sizes, it is possible
that this underestimates the presence of therapist effects.
Therefore, an additional regression of post- on pretreatment
scores was plotted for each client of each of the eight therapists,
on each dependent measure. No recognizable consistent pat-
terns emerged. Although the presence of therapist effects cannot
be ruled out, together these results suggest that the experimental
design, which used a small therapist-to-client ratio, was success-
ful in controlling for individual therapist effects in the ECH
therapy.

Two measures of clinically meaningful change advocated by Follow-Up

Jacobson and Truax (1991) were calculated. One is the propor-
tion of clients who are distressfree after treatment, and another Follow-up data were collected 4 months after therapy on 15
is the Reliable Change Index (RC), which measures change be- ECH clients who could be contacted. Table 4 presents the
yond random fluctuations in the instrument. Proportions of means and standard deviations for those clients who completed
symptomfree and reliably changed clients in the present study questionnaires at pretreatment, posttreatment, and 4-month
are based on the number of clients who began treatment in the follow-up.
clinically distressed range. A repeated-measures MANOVA revealed a significant overall
Symptom and interpersonal distress. Results were averaged effect for time, F( 14, 46) = 10.65, p = .00. Subsequent univar-
for the SCL-90-R and the IIP: These indicated that, at pre-
treatment, 44% of clients in both conditions were below outpa-
tient thresholds for distress (SCL-90-R = .60, IIP = 1.29). Af-
ter therapy, 89% of ECH clients were below these thresholds. Table 4
This represents an improvement of 45% for the ECH clients. Means and Standard Deviations for ECH Therapy (n = 15)
By comparison, 59% of FED clients were free of symptom and
interpersonal distress after the group therapy, which represents M(nndSD)at.
an improvement of only 15%.
4-Month
Again, averaging gains on the SCL-90-R and the IIP, 73% of Measure Pretreatment Posttreatment follow-up
ECH clients who began treatment in the distressed range met
RC criteria for improvement after therapy (a pretreatment- SCL-90-R 0.74 (0.49) 0.29 (0.20) 0.33 (0.36)
posttreatment [pre-post] difference score greater than .53 on IIP 1.43(0.51) 0.71(0.39) 0.78 (0.46)
the SCL-90-R and greater than .61 on the IIP). On the other TC
Discomfort 9.10(1.73) 3.92(2.13) 4.10(1.98)
hand, only 10% of distressed FED clients reliably improved in Change" 7.58(1.13) 7.20(1.46)
these domains. UFB-RS 40.93 (7.42) 19.66(7.54) 22.00(4.61)
Unfinished business resolution. The threshold for clinically SASB
meaningful change in unfinished business resolution was a post- Other -211(238) -39(350) -10(356)
Self -112(281) 21(362) 100(357)
treatment score more than 2 standard deviations below the pre- Introject 106(185) 191(125) 219(133)
treatment mean (below 28). The proportion of clinically im-
proved clients is based on all clients, because all were distressed Note. Decimals are deleted for SASB data. ECH = experiential ther-
on this dimension at pretreatment. In ECH therapy, 81% of cli- apy with empty-chair dialogue; SCL-90-R = Symptom Checklist—
ents reported unfinished business resolution at posttreatment, 90—Revised; IIP = Inventory of Interpersonal Problems; TC = Target
Complaints; UFB-RS = Unfinished Business Resolution Scale; SASB
whereas only 29% of the FED clients were resolved. Ninety- = Structural Analysis of Social Behavior.
three percent of ECH clients met RC criterion for improvement ' Not included in multivariate analysis.
 424 SANDRA C. PAIVIO AND LESLIE S. GREENBERG
iate F tests revealed a significant effect for time on all seven de-
pendent measures. Orthogonal contrasts confirmed that, on
each dimension, there was no significant difference between
posttreatment and 4-month scores and that there was a signifi-
cant difference between pretreatment and collapsed posttreat-
ment and follow-up scores. These results indicate that the ECH
group maintained gains 4 months after therapy.
The same procedure was followed for 10 ECH clients who
could be contacted 1 year after therapy. A repeated-measures
MANOVA of pretreatment, posttreatment, and the 1-year data
revealed a significant overall effect for time, F( 14, 22) = 32.20,
p = .000. Orthogonal contrasts revealed a significant difference
between pretreatment and collapsed posttreatment and 1-year
scores on each measure except the SASB Introject measure.
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This failure to reach significance on the Introject measure is
This document is copyrighted by the American Psychological Association or one of its allied publishers.
likely attributable to the large variance on the SASBs and the
small 1-year sample size. Overall, results suggest that at 1 year
after therapy ECH clients maintained treatment gains.
Post Hoc Analyses
Post hoc analyses were conducted on the four abuse cases in
ECH therapy because, although posttreatment scores on six
measures improved for these clients, perceptions of hostility in-
creased, rather than decreased, on the SASB Self and Other
measures. A MANOVA comparing the abuse subgroup with the
12 nonabuse cases revealed no significant overall difference on
clinical dimensions at pretreatment. However, a repeated-mea-
sures MANOVA comparing these subgroups pre- and posttreat-
ment on the SASB Self and Other measures, revealed a signifi-
cant interaction on both the Other measure, F( 1, 14) = 9.78, p
= .007, and the Self measure, F( 1, 14) = 9.16, p = .009. Thus,
analyses suggest that clients dealing with issues of abuse formed
a distinct subgroup of the client population: one characterized
by posttreatment increases, rather than decreases, in hostile
perceptions of the relationship with their abuser.
Discussion
This study identified for the first time a population of individ-
uals for whom unfinished business was a predominant prob-
lematic state and the focus of short-term therapy. We compared
experiential therapy for resolving these issues to an attention-
placebo minimal treatment condition. Our results support all
hypotheses and indicate that ECH brought about clinically
meaningful improvements for most clients and statistically sig-
nificant changes on all dimensions that largely were maintained
at the 1-year, 4-month follow-up. Although the FED group
achieved some gains, ECH therapy was significantly more
effective in reducing symptom and interpersonal distress, re-
ducing discomfort and increasing change on target complaints,
and achieving unfinished business resolution. The magnitude
of change on these dimensions was substantial and comparable
with effect sizes reported in meta-analytic and other successful
individual outcome studies (cf. Lambert, Shapiro, & Bergin,
1986). As well, on average, ECH therapy effectively reduced
perceptions of hostility in the relationship that was the focus of
therapy and increased self-acceptance. These findings support
the mode) of resolution (Greenberg, 1991), which posits a shift
to greater understanding of the other and self-empowerment as
important components of resolution. The average decreased
hostility in perceptions of self and other for the ECH group is
impressive in light of the large variability and the 4 abuse clients
who reported increased hostility at posttreatment. Such in-
creased hostility, again, is consistent with the model in which
holding the other accountable or responsible for harm is an-
other form of resolution and suggests possible unique aspects of
therapy for issues related to abuse.
One factor contributing to the success of ECH could have
been the degree of specificity in selecting clients with the same
cognitive-affective processing difficulties. Thus present findings
are consistent with observations (Lambert et al., 1986) that
treatments addressing specific target problems show larger
effect sizes. The explicit focus on accesssing emotion in the
ECH therapy also likely contributed to treatment effects. This
is consistent with findings in the treatment of anxiety disorders
(Lang, Melamed, & Hart, 1970), for example, in which pa-
tients who profited most were those who were able to experience
anxiety during imagery. Accessing of the emotion memory in
therapy allows new information to be admitted and the memory
structure to be modified (Foa & Kozak, 1986). Present results
also partially can be attributed to lower levels of pretreatment
symptomotology. Such a conclusion is consistent with reports
(e.g., Follette, Alexander, & Follette, 1991) that higher func-
tioning and less severely distressed clients tend to have better
prognoses. On the other hand, it is more difficult to get statisti-
cal effects with lower symptomotological scores, suggesting that
changes in the ECH therapy were substantial.
The mild symptom distress of the ECH client population, as
well as use of solicited clients, however, limit generalizability
of present findings. As well, insufficient data on dropouts and
treatment "failures" preclude making firm recommendations
regarding treatment applicability. An additional caveat in inter-
preting the present results concerns the possible presence of al-
legiance effects and experimenter bias in view of our theoretical
bias and participation in supervision or treatment. However, use
of a treatment manual, adherence checks, and a small therapist-
client ratio likely minimized the effects of these confounds.
Finally, an important limitation of the present study stems
from the research design using an attention-placebo control
condition. Blasham (1986) argues that attention-placebo con-
ditions in psychotherapy research frequently fail to control for
expectancies and support. Thus, although clients in the present
study expressed a preference for both conditions, expectancies
were not measured and the PED group could have been per-
ceived by some clients as less preferable. As well, PED clients
likely received less support than those in individual psychother-
apy. Thus, only future research comparing more equivalent
treatments can reach firm conclusions about mechanisms of
change in ECH therapy.
However, it was our intention in this study to evaluate the
effectiveness of this approach. Despite methodological limita-
tions, the evidence strongly supports the effectiveness of ECH
therapy for a outpatient population that is mild to moderately
distressed and seeking help for troublesome emotional issues
with a significant other.
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Received April 15, 1994
Revision received October 17, 1994
Accepted October 19, 1994 •