Psychotherapy Research

ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: http://www.tandfonline.com/loi/tpsr20

Emotion categories and patterns of change in

experiential therapy for depression

Imke R. Herrmann, Leslie S. Greenberg & Lars Auszra

To cite this article: Imke R. Herrmann, Leslie S. Greenberg & Lars Auszra (2014): Emotion
categories and patterns of change in experiential therapy for depression, Psychotherapy
Research, DOI: 10.1080/10503307.2014.958597

To link to this article: http://dx.doi.org/10.1080/10503307.2014.958597

Published online: 29 Sep 2014.

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 Psychotherapy Research, 2014
http://dx.doi.org/10.1080/10503307.2014.958597

EMPIRICAL PAPER

Emotion categories and patterns of change in experiential therapy for

depression

IMKE R. HERRMANN1, LESLIE S. GREENBERG2, & LARS AUSZRA1

1
Institut für Emotionsfokussierte Therapie, Munich, Germany & 2Department of Psychology, York University, Toronto,
Ontario, Canada
(Received 8 October 2012; revised 13 August 2014; accepted 19 August 2014)
Downloaded by [218.22.187.66] at 12:47 05 November 2015

Abstract
Objective: This investigation examined the relationship between in-session types of emotional experience operationalized
by the emotion category coding system and the reduction of depressive symptoms in emotion-focused therapy (EFT).
Method: Segments of videotaped sessions were coded and the different emotion categories were related to reduction in
depressive symptoms in a sample of 30 clients who received EFT for depression. Results: Both fewer secondary and more
primary adaptive emotions, in the working phases of therapy, were found to significantly predict outcome. Moderate levels
of primary maladaptive emotion in the middle working session were associated with outcome and the frequency with which
clients moved from primary maladaptive to primary adaptive emotions in this session-predicted outcome. Conclusions:
Results of this study support a transformational model of changing emotion with emotion.

Keywords: emotional processing; process; emotion categories; emotion-focused therapy; depression

Emotion and its processing has become increasingly
recognized as an important therapeutic change pro-
cess (Foa & Kozak, 1986; Fosha, 2002; Greenberg,
2002; Greenberg & Pascual-leone, 2006; Greenberg
& Safran, 1987; Hayes, Beevers, Feldman, Lauren-
ceau, & Perlman, 2005; Mennin & Farach, 2007;
Samoilov & Goldfried, 2000). Bountiful research has
related emotion processes to therapeutic outcome.
Emotional arousal (Carryer & Greenberg, 2010;
Diener, Hilsenroth, & Weinberger, 2007; Greenberg
& Pascual-Leone, 2006; Jaycox, Foa, & Morral,
1998; Missirlian, Toukmanian, Warwar, & Green-
berg, 2005) and emotional experiencing (Caston-
guay, Goldfried, Wiser, Raue, & Hayes, 1996;
Goldman, Greenberg, & Pos, 2005; Pos, Greenberg,
Goldman, & Korman, 2003; Pos, Greenberg, &
Warwar, 2009) as well as affect integration (Gude,
Monsen, & Hoffart, 2001; Solbakken, Hansen,
Havik, & Monsen, 2012) have been shown to relate
to change in psychotherapy. Also client emotional
productivity (Auszra, Greenberg, & Herrmann, 2013;
Greenberg, Auszra, & Herrmann, 2007) and emo-
tional arousal plus higher order reflective processing
(Boritz, Angus, Monette, Hollis-Walker, & Warwar,
2011; Missirlian et al., 2005; Pascual-Leone, 2009;
Pascual-Leone & Greenberg, 2007) have been demon-
strated to relate to outcome.
Similarly to other approaches, such as affect-
focused short-term dynamic psychotherapy (STDP;
McCullough, Larsen, Schanche, Andrews, & Kuhn,
2003; McCullough & Magill, 2009) or accelerated
experiential-dynamic psychotherapy (Fosha 2002,
2009), emotion-focused therapy (EFT) has proposed
that not all emotions are the same. According to
EFT distinctions need to be made between primary,
secondary, and instrumental, as well as adaptive and
maladaptive emotionality. In addition, EFT has pro-
posed a particular sequence involved in change
(Greenberg, 2002, 2010). It is the purpose of this
study to test hypotheses about the emotional trans-
formation process put forward by EFT by coding
emotion categories and relating them to outcome.

Correspondence concerning this article should be addressed to Imke R. Herrmann, Institut für Emotionsfokussierte Therapie, Munich,
Bavaria, Germany. Email: herrmann@ieft.de

© 2014 Society for Psychotherapy Research

 2 I. R. Herrmann et al.
EFT holds that emotion schemes play a core role
in the formation of every self. When an emotion
schematic structure (Elliott, Watson, Goldman, &
Greenberg, 2004; Greenberg, 2002; Greenberg,
Rice, & Elliott, 1993; Greenberg & Safran, 1987) is
activated, a multitude of sensorimotor and repres-
entational processes is set in motion to precon-
sciously and automatically produce emotional
responses and action tendencies that provide our
sense of personal meaning and help anticipate future
outcomes (Greenberg et al., 1993; Leventhal &
Scherer, 1987; Oatley & Jenkins, 1992). Emotional
reactions reflect past experiences (Damasio, 1994;
Greenberg & Pascual-Leone, 2001) and, therefore,
can be adaptive or maladaptive in the present
moment, depending on the nature of the past
experiences and the way these emotional experiences
were processed. So fundamentally, emotions are
adaptive, but can become maladaptive when they
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represent an attempt at adaptation to aversive situa-
tions and persist despite changed circumstances later
in life. According to EFT (Greenberg, 2002, Green-
berg et al.,1993; Greenberg & Paivio, 1997), primary
emotions are our first fundamental visceral responses
to situations, which are usually adaptive but can
become maladaptive, as has been discussed. Second-
ary emotions are secondary reactive responses to
primary adaptive or primary maladaptive emotional
reactions that are perceived as threatening or over-
whelming. They generally serve to avoid and regu-
late the more primary responses. Instrumental
emotions are expressed with the purpose of achieving
a desired effect. Comparing this emotion categoriza-
tion system to a system described by Fosha (2002),
we see that primary adaptive emotions in EFT are
similar to her concept of core emotions, primary
maladaptive similar to her concept of pathogenic
affects, and the concept of secondary emotions bears
some similarity to defensive emotions. McCullough
and colleagues (2003; McCullough & Magill,
2009) using a different affect categorization system,
the Achievement of Therapeutic Objectives Scale
(ATOS; McCullough et al., 2003), differentiate
between activating affects (a category similar to
EFT’s primary adaptive emotions) and inhibitory
affects (similar to not only EFT’s primary maladap-
tive emotions but also including some aspects of
EFT’s secondary emotions). Using aspects of the
ATOS system data from a randomized controlled
clinical trial comparing a STDP treatment
group with a group receiving cognitive treatment,
Schanche, Stiles, McCullough, Svartberg, and Niel-
sen (2011) found that decrease of inhibitory affects
and increase of activating affects during treatment
were significantly associated with higher self-com-
passion toward the end of therapy and that increase
in self-compassion across therapy predicted decrease
in psychiatric symptoms.
EFT differs in its view of pathogenic affect from
the emotion-focused psychodynamic approaches
described above in the following manner: The latter
see pathogenic affect either as affective reactions to
the experience of adaptive affect (Fosha, 2002;
McCullough et al., 2003) such as crying or feeling
depressed when angry (this is secondary emotion
according to EFT) or as avoidance of affect (McCul-
lough et al., 2003), whereas EFT considers patho-
genic affect as learned emotional responses, often
from failures in the environment to support of a
person’s development. Initially adaptive emotional
reactions to failures in support during past events
then become maladaptive emotional responses to
current situations. According to EFT, emotional
change occurs mainly through the activation and
processing of primary maladaptive emotion. A core
hypothesis in EFT is that emotional change involves
moving from secondary symptomatic emotions such
as hopelessness to primary maladaptive emotion
such as shame and processing the primary maladap-
tive emotion to get to the associated unmet need,
thereby being able to generate more primary adapt-
ive emotion such as angry assertion (three-step
sequence; Greenberg, 2002, 2010; Greenberg &
Paivio, 1997). In this view, secondary emotions first
have to be explored to gain access to their underlying
primary determinants, namely primary maladaptive
emotions. For change to occur, primary maladaptive
emotions have to be activated, processed, and
transformed. This occurs by the activation and util-
ization of more adaptive primary emotional
responses (Greenberg, 2002, 2010; Greenberg &
Paivio, 1997; Greenberg & Pascual-Leone, 2006).
Primary adaptive emotions then are used both to
inform and to move toward healthier functioning.
The process of transformation is theorized to be
facilitated by undoing the effect of one emotion by
the effect of another opposing emotion (e.g., the
physiology and action tendency of primary adaptive
boundary-setting anger undoes the physiology and
withdrawal tendency of primary maladaptive shame)
leading to the creation of new meaning (Greenberg,
2010; Greenberg & Pascual-leone, 2006; Pascual-
Leone & Greenberg, 2007). Deepening of experi-
ence here is thus a two-fold concept: (i) Deepening
as an in-session movement from secondary to prim-
ary emotional experiences (most often primary
maladaptive; Greenberg, 2010) and (ii) deepening
as a process that involves a focus on bodily experi-
ence and creation of new meaning.
In looking more closely at the process of emo-
tional transformation, Pascual-Leone and Greenberg
(2007) developed and tested a model for resolving

global distress, showing that their model of emo-
tional processing predicted positive in-session
effects, and that clients experienced the emotional
model components in a sequential pattern. In
resolving global distress, clients moved from states
of high arousal and low meaning to the states of low
arousal and high meaning. In a later study, Pascual-
Leone (2009) converted his measure for classifying
affective-meaning states (CAMS) into an ordinal
scale, with each model component representing a
successively higher step in productive emotional
processing, thus measuring “progress in emotional
transformation” (p. 117). He was able to show that
clients with good in-session outcome suffered pro-
gressively shorter collapses toward lower model
components within the session and showed steady
improvement in emotional processing according to
the model with the overall pattern being “2-steps-
forward, 1-step-back” (p. 1). In this, it is important
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to note that Pascual-Leone and Greenberg (2007)
described early model components like “Global
Distress” as secondary emotional experience, inter-
mediate model components like “Shame/Fear” as
primary maladaptive emotional experiences, and
advanced model components like “Assertive Anger,”
“Self-Soothing,” and “Hurt/Grief” as primary adapt-
ive emotional experiences. Results thus indicated
that clients with effective in-session processing
experienced progressively less secondary and primary
maladaptive emotions, accessing progressively more
primary adaptive emotional states during the session.
Pascual-Leone and Greenberg (2007) were thus the
first to give empirical support to “the three-step
model of emotional transformation in EFT”
(p. 885) from secondary to primary maladaptive to
primary adaptive emotion (Greenberg, 2002, 2010).
Their model of emotional processing was built on a
task analytic model of resolving global distress draw-
ing on Greenberg and Paivio’s (1997) model of
resolving “bad feelings.” Their CAMS measure
included global categories, some of which are emo-
tions such as “Assertive Anger” or “Hurt/Grief,” and
some of which are not such as “Need” or “Negative
Evaluation.” Their model predicted positive in-ses-
sion effects, but the authors did not relate it to overall
treatment outcome. In order to offer more support to
the three-step sequence described above as a general
process of change, the current study attempts to
relate the emotion categories described in EFT,
primary adaptive, primary maladaptive, secondary,
and instrumental emotion to final treatment outcome
(Greenberg, 2002; Greenberg & Paivio, 1997).
For the purpose of this study, the different emo-
tion types based on the EFT model were operatio-
nalized, and a coding scale, the emotion category
coding system (ECCS; Herrmann, Greenberg, &
Psychotherapy Research 3
Auszra, 2007), was developed to allow for the
reliable categorization of activated emotional experi-
ence in the therapy hour.
Emotion Category Coding System
The ECCS includes a coding manual with rating
rules, an emotion list (adapted from the Client
Emotional Arousal Scale–III-R; Warwar & Green-
berg, 1999), and a coding system with definitions
and indicators of the different emotion categories. In
the coding system of the ECCS, each emotion
category is defined and indicators are outlined that
clearly characterize one category in contrast to
another. In the following section, definitions and
some typical indicators as described in the coding
system of the ECCS will be outlined shortly.
Primary emotions. According to the EFT
model, a primary emotion is a person’s first scheme-
based emotional visceral response to a stimulus
situation (Greenberg et al., 1993; Greenberg &
Paivio, 1997).
Primary adaptive emotions. Primary adaptive
emotions are defined in the ECCS as those auto-
matic emotions in which the implicit evaluation,
verbal or nonverbal emotional expression, action
tendency, and degree of emotion regulation fit the
stimulus situation and are appropriate for preparing
the individual for adaptive action in the world,
helping to get the person’s needs met. Examples
are sadness at loss that reaches out for comfort, fear
at threat, anger at violation that is empowering (see
also Pascual-Leone and Greenberg (2005) “Assertive
Anger”), grief that lets go of what is irrevocably lost,
disgust at intrusion, and hopelessness that lets go of
a need that cannot be met (Greenberg, 2002, 2010;
Greenberg & Paivio, 1997). Primary adaptive emo-
tions are neither under- nor overregulated, namely
the implicitly regulated intensity of the emotion is
such that it allows the person to act on it in an
adaptive manner. They strengthen attachment
bonds, affirm the self, and facilitate coping with the
situation (Greenberg & Paivio, 1997). When work-
ing with the representation of a degrading parent in
empty chair-work, a client said: “I did not deserve to
be treated like this! This wasn’t right!” in a clear
voice accompanied by some small gestures of asser-
tion like pointing a finger at the other. This would be
coded as primary adaptive anger/assertion.
Primary maladaptive emotions. Primary mala-
daptive emotions are also a person’s first automatic
emotional response to a situation but they are based
on traumatic learning (Greenberg & Paivio, 1997)
 4 I. R. Herrmann et al.
often due to failures early on in the dyadic regulation
of affect (Schore, 2003; Stern, 1985) and do not
prepare the individual for adaptive action in the
present. They once represented an attempt at
optimal adaptation to aversive circumstances, but
as circumstances have changed, they are no longer
adaptive. For example, experiences of separation
from a partner and resulting feelings of abandon-
ment might activate intense feelings of fear of “not
being able to survive alone” from intense experiences
of abandonment or loss in childhood. This fear in
the abandoned child had an adaptive aspect and
might have triggered caretaking behavior in adults
and motivated the child to actively seek out support-
ive attachment relationships. However, it leads to
maladaptive behavior in the adult, as the core fear has
not changed despite changed circumstances. In
primary maladaptive emotions, as defined in the
ECCS (Herrmann et al., 2007), the automatic evalu-
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ation, verbal or nonverbal emotional expression,
emotional action tendency, and/or regulation are
more a reflection of past unresolved issues than
reactions to the present situation. An emotion is
considered primary maladaptive, when the expressed
emotion and resulting view of self do not match the
situation and the action tendency does not fit the
goals, needs, and concerns of the person in the
present situation, or the emotion is underregulated.
Maladaptive emotions are often described by the
client as a “familiar, old feeling,” tend to be chronic
of nature, and have thus become part of a person’s
identity. Although any emotion can be adaptive,
maladaptive, secondary, or instrumental, it appears
that fear of not being able to survive alone and the
shame of feeling unworthy are the most prevalent
maladaptive emotions that arise in affective disorders
(Greenberg & Paivio, 1997; Greenberg & Watson,
2006; Pascual-Leone & Greenberg, 2007). Other
typical maladaptive emotions that appear are sadness
and loneliness often related to fear of abandonment,
deep helplessness resulting from experiences of
abuse, and hair trigger rage (Greenberg, 2010).
When faced with his own self-criticism, a client sunk
into his chair, eyes cast down, and said in a low and
focused voice (Rice & Kerr, 1996), “I feel so worth-
less, so like a nothing … I just want to disappear.”
This would be coded as primary maladaptive shame
according to the ECCS. Another client, when talking
about how she felt in her childhood, being constantly
criticized and rejected by her mother, said in a tearful
voice “I always felt like living in a glass bubble in outer
space. I could see the others living their lives, having
fun. And I always felt that I would never be able to
have that, never be a part of it. Always be alone.” This
would be coded as primary maladaptive emotion and
labeled as loneliness.
Secondary emotions. A secondary emotion is
not a person’s first fundamental emotional response
to an internal or external stimulus, but rather a
secondary reactive response to a more primary
emotion which can be adaptive (e.g., anger at
violation) or maladaptive (e.g., shame of being
unlovable) (Greenberg & Paivio, 1997). A secondary
emotion is not associated with a primary need and it
obscures the more primary experience. Secondary
emotions are often part of the symptom the client
suffers from (e.g., anxiety, depression, hopelessness,
irritability). There are two main classes of secondary
emotions: (i) An emotion as a secondary response to
another more primary emotion (e.g., feeling scared
or ashamed but expressing anger) or to thought
(e.g., feeling anxious after excessive worrying); and
(ii) an emotion about another emotion (e.g., feeling
guilty about feeling angry or feeling ashamed of
one’s fear). Here the emotion is about another
emotion, not about the self or situation, similarly to
what Hayes, Strosahl, and Wilson (1999) calls
“meta-emotions.”
When the secondary emotional process is a
response to another emotion (see (i) above), thus
shielding the person from a primary underlying
emotion, there are several possible indicators
(described in further detail in the ECCS [Herrmann
et al., 2007]): One indicator is that the emotion does
not fit the situation, as the emotional expression does
not fit the implicit evaluation of the situation. For
example, a client might feel ashamed or afraid but
expresses anger, disgust, or contempt. This anger
might not necessarily have a whining or complaining
(fused) quality, but it has a strong external focus,
uses you-language, often expresses a sequence of
accusations, and/or uses swearing or name-calling
(similarly to what Pascual-Leone and Greenberg
(2005) call “Rejecting Anger”). Similarly, a client
might feel violated but express sadness not anger.
Another indicator for secondary emotion can be a
fused quality, when more than one emotion appears
in a fused manner, creating a qualitatively new
emotional state thus obscuring the more primary
emotion or emotions, which can be adaptive or
maladaptive primary emotions. Neither emotion is
fully acknowledged and allowed separately nor does
the client elaborate on his or her internal emotional
experiences, but rather speaks with an external focus.
This can be indicated by labels or by two action or
expressive tendencies like crying and angrily accus-
ing at the same time or a sarcastic or resigned quality
where one emotion like sadness is fused with hope-
lessness. The latter is often underlined by expressive
tendencies like shrugging or shaking the head.
A global quality is another indicator for a secondary
emotional reaction. Global emotions are not

differentiated into more specific emotions like fear or
loneliness, they have no clear action tendency and
often fuzzy labels like “upset,” “bad,” “down,” or
“frustrated.” Secondary emotions can also be a rea-
ction to thought. The emotion-producing thought is
part of the secondary processes that obscure one or
more underlying primary emotions (e.g., ruminating
thought processes to protect against anger, worry
that obscures shame, or different kinds of anxieties
and fear).
Most often in secondary emotions, the sequential
ordering (as in a primary emotional reaction acti-
vates a secondary emotional response) is not appar-
ent to the observer or perceptible by the client.
Secondary emotions often are like a “gully cover”
over primary emotional experience.
Emotional expressions that according to Pascual-
Leone and Greenberg (CAMS, 2005) would be
classified as “Global Distress” are examples of
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secondary emotional experiences. A client said with
tears running down her face with a “whining” quality
in her voice: “I can’t take this anymore. I want this to
change. I just want to feel good again!” Both a
painful emotional quality as well as an angry/fru-
strated quality are present in a fused manner in the
emotional expression. This would be coded as
secondary unspecified bad according to the ECCS
(as no clear label or clear emotional action tendency
is expressed, but emotion is clearly activated). The
following is an example of secondary anger accord-
ing to the ECCS. When faced with her rejecting
mother in the empty chair, a client said with tears in
her eyes but a clear and agitated voice: “I just don’t
understand how you could say something like that to
me! I even told you what I needed and you just said
–“ Well I can’t give you that, but you have everything
else.” No mother can be so stupid to say something
like that to her child!” This anger expression would
be coded as secondary, as the focus of the anger is on
accusing the other. It does not have the empowering,
boundary asserting quality of adaptive anger (see
also Pascual-Leone and Greenberg (2005) “Assertive
Anger”) but rather comes from a stance of standing
with one’s back against the wall, lashing out at the
other (in this case indicated by content and manner
of expression as well as angry tears).
Instrumental emotions. Lastly, instrumental
emotions are learned expressive behaviors or experi-
ences that are used to influence or manipulate others
(Greenberg & Paivio, 1997). This process might be
conscious or nonconscious. The emotion can be
manipulative and/or have a secondary gain. Typical
examples are the expression of anger to control or to
dominate or “crocodile tears” to evoke sympathy.
Psychotherapy Research 5
Coding rules. For the purpose of this study, three
sessions in which chair-work was used were coded
using the manual, namely the first chair-work session,
the best chair-works session (as described below), and
one session preceding the best chair-work session.
In the coding manual of the ECCS explicit rules for
coding are outlined. Coders first have to decide
whether an emotion is merely talked about or whether
the emotion schematic process is activated. An emo-
tion is considered activated, for example, if clear
nonverbal emotion behavior is present, e.g., arousal
level of four or more on the Client-Expressed-Arousal
Scale-III-R (Warwar & Greenberg, 1999). This
implies that arousal is moderate in voice and body
and an emotional voice is present indicated by
moderately disrupted speech patterns and some
emotional overflow into the voice (Warwar &
Greenberg, 1999). Or, if no nonverbal emotional
behavior is present (e.g., no crying, screaming, deep
sigh or breaking voice is present), the client
expresses the emotion verbally and the focus is on
her/his subjective felt flow of experience. This
implies the client does not talk about but from an
emotional experience. (e.g., “I sat there at my
parents’ table with everyone talking around me …
loudly … and … I felt so alone … so different from
everyone else.”) If no clear emotional behavior is
present the client also has to speak in a focused or a
contact voice (Rice & Kerr, 1996), or his/her eyes
are cast down or inwards for an emotional expres-
sion to be coded as activated. If no emotion is
present or an emotion is considered not activated,
the code no activated emotion is given. If considered
activated, the emotion is categorized as secondary/
instrumental, primary maladaptive, primary adaptive
or mixed/uncodable according to the ECCS, which
offers detailed descriptions of indicators, examples
of which are given above. Raters first decide whether
an activated emotion is explicitly secondary/instru-
mental or not. If not, coders decide whether the
given emotional expression is primary adaptive or
primary maladaptive. If a coder is unclear as to a
specific emotion category, the code mixed/uncod-
able is given. The categorized emotion is then
labeled according to an emotion list of 17 labels
(adapted from Warwar & Greenberg, 1999).
The coding system was developed in the following
way: An EFT trained therapist and an originator of
EFT observed 35 sessions of EFT therapy taken
from 15 different cases, to refine theoretical notions
of types of emotional experience in the therapy hour.
Operationalizations of the theoretical notions of each
emotion category were developed and refined pro-
gressively by observation of the tapes one at a time.
Operationalizations for emotional expression and
emotion activation as well as particular rating rules
 6 I. R. Herrmann et al.
were developed in a similar fashion, until it was
decided that the scale could be applied and yield an
acceptable level of agreement between raters.
Research Question
This study set out to investigate the following research
questions: Do different types or categories of emo-
tional experience hypothesized by the emotion-
focused model of change predict therapy outcome?
According to EFT, in good-outcome therapies,
secondary emotions should appear less as the treat-
ment progresses; primary maladaptive emotions
should appear at a moderate frequency in the work-
ing phase of therapy and be transformed through the
emergence of primary adaptive emotions (Green-
berg, 2002, 2010; Greenberg & Paivio, 1997). In
successful therapies, there should be a high degree of
primary adaptive emotional experience in the work-
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ing phases of the treatment.
It was thus hypothesized:
(1) First, that the proportion of activated
emotional experience alone in the middle working
session (a session in which core therapeutic pro-
cess is considered to take place) would predict
outcome. In this study, coded segments are
embedded in personally and therapeutically mean-
ingful contexts, in which scheme activation is
considered beneficial for successful therapy pro-
cess (Baker, 2007; Missirlian et al., 2005; Warwar
& Greenberg, 2000). It was not expected to find a
significant relationship with outcome in the first
working session, as activation does not take into
account, if the person is currently distressed or
working though distress. As the best working
session represents process close to resolution and
is thus expected to be comparatively low in
emotion activation, activation in the best working
session was not expected to be significantly related
to outcome either. (See also Pascual-Leone (2009)
and Pascual-Leone and Greenberg (2007) for in-
session resolution of distress.)
(2) Second, it was hypothesized that the low levels
of secondary/instrumental emotions in the later
phase of therapy, namely the best working session
(representing process close to resolution) and the
working session leading up to it (middle and best
working session combined—will be called working
phase in the text), would predict outcome over and
above emotion activation. High levels of second-
ary/instrumental emotions in the working phase of
therapy are considered as hindering the emotional
transformation process (see also McCullough et al.,
2003; Pascual-Leone, 2009; Pascual-Leone &
Greenberg, 2007; Schanche et al., 2011).
(3) Third, it was hypothesized that moderate
levels of primary maladaptive emotions in the
middle working session would be associated with
good therapy outcome. EFT assumes that too
much or too little aroused painful emotion is not
therapeutic (Greenberg, 2010). EFT works to
activate primary maladaptive emotions as treat-
ment progresses in order to change them. Middle
working sessions were viewed as a good place to
test for this assumption.
(4) Fourth, it was hypothesized that the frequency
with which primary maladaptive emotion was
followed by primary adaptive emotion would be
predictive of outcome over and above emotion
activation. EFT hypothesizes that accessing prim-
ary adaptive emotion changes primary maladap-
tive emotion.
(5) And fifth, it was hypothesized that the propor-
tion of primary adaptive emotions in the combined
middle and best working sessions (working phase)
would be the best predictor of outcome over and
above the other variables tested. The emergence of
primary adaptive emotions in the working phase
of therapy is considered essential for emotional
transformation to take place (see also McCullough
et al., 2003; Pascual-Leone & Greenberg, 2007;
Schanche et al., 2011).
Given the consistent finding in the literature that
the therapeutic working alliance accounts for a
significant portion of the variance of the outcome
variables (e.g., Lambert & Ogles, 2004), the working
alliance was included in this study. This was done to
better be able to detect the independent predictive
utility of the different emotion categories.
Method
Participants
Clients. The sample consisted of 30 clients
originally recruited as part of two clinical trials on
depression completed at an urban University Psy-
chotherapy Research Clinic between 1992 and 1999
(York I and II; see Goldman, Greenberg, & Angus,
2006; Greenberg & Watson, 1998). Because of the
labor intensive nature of the coding process, a
sample of 30 clients was selected from a pool of 42
clients who had received emotion-focused treatment
for depression. The sample was collected in the
following way: Standardized pre–post Beck Depres-
sion Inventory (BDI) residual gain scores were
calculated for each client. The residuals were then
rank ordered to perform a median split. Fifteen
clients were then randomly selected from the “bet-
ter” and the “poorer” half to form the sample of 30.
All clients were diagnosed with major depression
 Psychotherapy Research 7

according to DSM-IV criteria using the Structured treatments were judged as adhering to treatment on
Clinical Interview for DSM-IV (Spitzer, Williams, the same adherence criteria in both studies (Gold-
Gibbon, & First, 1990, 1995). Clients in this sample man et al., 2006; Greenberg & Watson, 1998).
were between the ages of 22 and 63 (M = 41.70,
SD = 11.00). There were 20 females and 10 males.
Twelve clients were married, 7 were separated or Treatment
divorced, and 11 were single. The ethnic back-
Emotion-focused therapy. EFT works from
ground of the participants was predominantly Euro-
within a CC relational framework providing the
pean (28 out of 30) with one East-Asian and one
relational conditions of prizing, empathy, and genu-
South-Asian client. Clients’ level of education ran-
ineness. It integrates gestalt interventions, such as
ged from secondary through graduate school: 1 had
(amongst others) two chair dialog in response to self-
some high school education, 8 had completed high
critical splits or at points of self-interruption, empty
school, 3 had some college or university education,
chair-work to address unresolved lingering bad feel-
13 were college graduates and 2 had some post-
ings toward a significant other, and experiential
graduate experience, and 3 had completed post-
interventions such as focusing (Gendlin, 1981) in
graduate education. Overall, 11 clients were
response to an unclear felt sense and systematic-
diagnosed with at least one Axis II personality
evocative unfolding at a marker of puzzling or prob-
disorder: 6 clients were diagnosed with avoidant, 3
lematic reactions (Rice & Greenberg, 1984). These
with obsessive-compulsive, 1 with paranoid, and 1
marker-guided process-directive interventions are
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with dependent personality disorder. One client who

had been diagnosed with obsessive-compulsive per-
sonality disorder received second and third Axis II
diagnosis, namely additional diagnoses of antisocial
and self-defeating personality disorders. None of the
clients were functionally impaired according to the
Global Assessment of Functioning Scale (GAS,
DSM-IV; APA, 1994).
Therapists and therapist training. Of the
therapists who participated in the clinical trials this
study is based on, 17 were female and five were male
therapists. Twelve of these therapists were advanced
clinical psychology doctoral students, 9 had Ph.D.s
in clinical psychology and 1 was a psychiatrist. On
average, the therapists had 5.5 years of experience in
client-centered (CC) therapy. One of the therapists
was originally trained in cognitive-behavioral therapy
but received 12 weeks of prior training and supervi-
sion in CC therapy. The procedures for therapist
training were identical in both studies. Before the
training began, therapists had all received at least
one year of prior training in each of the two
treatment modalities, namely CC and EFT. Thera-
pists received an additional 48 hr of training, 2 hr
weekly for 24 weeks, before the start of either
project. They were trained according to the manuals
for EFT (Greenberg et al., 1993) and CC therapy
(Rogers, 1975). All therapists received training in
CC therapy for 8 weeks. They also were trained in
specific EFT interventions such as systematic-evoc-
ative work unfolding for 6 weeks, two chair-work for
6 weeks, and empty chair-work for 4 weeks, by the
authors of the manuals for these interventions.
Treatment adherence during therapy sessions was
monitored through audio and videotape. Therapists
received supervision on a weekly basis and
used in order to facilitate resolution of affective-
cognitive processing problems. The primary objective
of therapy is seen as the accessing and restructuring of
maladaptive emotion schemes that are considered to
be the source of depression (Greenberg & Watson,
2006). The therapy is based on the assumption that
by helping the client access alternative adaptive
emotion schemes in the session, more adaptive
emotional responses in terms of the client’s needs
become available to the client, which help organize
him or herself in more functional ways. The emotion-
focused treatment followed the manual developed by
Greenberg, Rice, and Elliott (1993) in which, after
the formation of a strong alliance, therapists were
encouraged to introduce at least one experiential
intervention every two or three sessions. The length
of treatment in this study’s sample ranged from 10 to
20 sessions with a mean of 18.2 sessions.
Process Measure
Emotion Category Coding System. The ECCS
(Herrmann et al., 2007) was developed for this
project as an instrument for the systematic observa-
tion of emotions in the therapy session. It contains
four category codes for emotionally activated states
that indicate which emotion type or category is
currently activated, namely secondary/instrumental
(SEC/INS), primary maladaptive (PMA), primary
adaptive (PA), or mixed/uncodable; and one code
for no activated emotion. Activated emotions are
given an emotion category (EC) code and an emotion
name (from a list of 17 emotion labels adapted from
Warwar and Greenberg, (1999) such as anger, sad-
ness, and fear). Reliability for the coding of emotion
categories is reported as part of the results.
 8 I. R. Herrmann et al.
Post-session Measures
Working Alliance Inventory. The Working
Alliance Inventory (WAI; Horvath & Greenberg,
1989) is a 36-item self-report questionnaire designed
to assess the quality of the therapeutic alliance based
on Bordin’s (1979) conceptualization of the working
alliance. The WAI is made up of three subscales that
assess three primary dimensions of the working
alliance, namely agreement on therapy goals, agree-
ment on therapy tasks, and quality of the client–
therapist bond. The internal consistency of the
whole scale in this study was .88.
Degree of Resolution Scales. On the two
Degree of Resolution Scales (DRS; Hirschheimer &
Greenberg, 1996) for the major chair-work tasks,
namely conflict splits and unfinished business, the
therapist indicates on a 7-point scale how much a
client has progressed along the steps of the task
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toward resolution.
Outcome Measure
The BDI. The BDI (Beck, 1972; Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961) is a 21-item,
self-report inventory designed to measure severity of
depression by capturing characteristic attitudes and
symptoms of depression (range = 0–63). In a review
of 10 years of research using the BDI, Beck, Steer,
and Garbin (1988) report validity coefficients ran-
ging from .66 to .86 and internal consistency
coefficients ranging from .73 to .93. Moreover, the
BDI has been shown to have good discriminant and
concurrent validity (Beck et al., 1988). The test–
retest reliability of the BDI has been reported at .65
(Ogles, Lambert, & Sawyer, 1995).
Procedure
Session Selection
For the purpose of this study, three sessions of each
client’s complete set of sessions were coded. In order
to examine parts of therapy most likely to evoke
emotion, only sessions in which chair-work was used
were selected for coding. First, each client’s chair-
work sessions were identified.
The first chair-work session was chosen as the
“first working session.”
Next, the “best working session” was selected
using the DRS (Hirschheimer & Greenberg, 1996)
described above. “Best” was defined as the session in
which a client had progressed furthest toward
resolution in one or both kinds of tasks involving
chair-work. If two or more sessions were “best,” the
latest of the best sessions was selected.
Finally in an attempt to reflect good therapeutic
process, the best (with regard to the DRS) of the three
sessions preceding the “best session” was selected as
the ”middle working session.” Again, if there were two
sessions preceding the “best” session, in which clients
had progressed equally far toward resolution, the last
of these preceding sessions was selected.
In this way, the first chair-work session (i) was
coded, and two chair-work sessions from the work-
ing phase of treatment leading up toward resolution
(middle working session (ii) and best working
session (iii)). “First working sessions” ranged from
Session 2 to 7, “middle working sessions” ranged
from Session 6 to 18, and “best sessions” ranged
from Session 10 to 20. For the purpose of analysis
middle and best working sessions were later com-
bined to represent the “working phase” of treatment.
Data Collection
Videotapes of the selected therapy sessions were
used for coding the process variables. Only chair-
work within the session was coded. Raters were blind
to the therapeutic outcome of all clients they were
rating.
Emotion Category Coding System
Rater training for the ECCS. The primary rater
trained a second rater in the differentiation of the
relevant emotion states (Herrmann et al., 2007). The
training consisted of 40-hr training including an
introduction into relevant coding criteria, studying of
training videos specifically composed for this purpose
and practice coding of video material that was not
used as part of the study. The secondary rater was
trained until acceptable reliability was achieved.
Rating procedure for the ECCS. The primary
rater began coding at the beginning of chair-work in
the selected sessions. Coding was done continuously
(see Pascual-Leone & Greenberg, 2007); and each
change in code was rounded to the nearest unit of
30 s. A code was maintained across sequential units
of 30 s, unless there were clear indicators that a
change in category had occurred. Coders did not
reconsider a code in every successive unit, but
maintained the code previously given, unless there
were clear indicators that the code had to be changed;
a change in code occurred, for example, when the
emotion category changed from secondary to primary
adaptive emotion, or there was a change from no
activated emotion to activated emotion or vice versa.
This procedure can be considered an adapted form of
a procedure that is common in the field of ethology
and referred to as “continuous cross-classification”

(see Pascual-Leone & Greenberg, 2007). Pascual-
Leone and Greenberg (2007) first applied this pro-
cedure to psychotherapy process research and used it
to code emotional events. It has been applied here in
a similar, however, not identical fashion. Only emo-
tions expressed in the “experiencing chair” in the
chair dialogs were categorized, as this is the site of the
emotions of the self. Emotions that were expressed by
the client in the “other chair” were coded as “no
activated emotion.” Coding emotional experiences of
clients in chair-work in the “self-chair” ensured that
codes were given to emotional experiences in person-
ally and therapeutically meaningful contexts. Cate-
gorized emotions were given an emotion label (from a
list of 17 emotion labels adapted from Warwar and
Greenberg (1999)).
Inter-rater reliability procedure. Inter-rater
reliability for the scale was established in the follow-
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ing way: The primary rater rated all 90 sessions with
regard to emotion category and emotion label. The
secondary rater coded 60 sessions which were
randomly selected. When continuous classification
is used, different forms of reliability have to be
calculated depending on how the data are being
used (see Pascual-Leone & Greenberg, 2007).
Agreement between raters on when an emotion was
considered to be activated was first established. In a
second step, reliability was established on what
specific emotion category code was assigned to the
respective activated emotion. The coding of emo-
tional states was done in the context of a continuous
process. Changes in code were rounded to the
closest unit of 30 s; in this way a code for each unit
which best represented that specific unit was
obtained. Thus, for determining agreement with
respect to episodes of activated emotion, a kappa
table could be established to indicate the number of
units where both independent raters showed agree-
ment with regard to activation (yes/yes and no/no)
and the number of units where raters did not (yes/no
and no/yes). In a second step, reliability was estab-
lished with regard to the categorization of activated
emotion. As the phenomenon that was coded,
namely activated emotional experience, does not
have clear onset- and offset-times by nature, disag-
reement about the presence of activation in a specific
segment can be for one of two reasons: First, it can
be due to the fact that one rater sees an emotional
experience emerging or disappearing earlier than the
other; or second it can be due to the fact that raters
have a “real” disagreement as to whether an emotion
is activated or not (Pascual-Leone & Greenberg,
2005, 2007). To be sure that reliability was only
calculated on units in which emotional activation
was “truly” occurring (Pascual-Leone & Greenberg,
Psychotherapy Research 9
2007), only units where raters showed agreement
with regard to activation were used for the reliability
analysis of emotion category and emotion label
coding. Reliability was then established with regard
to the emotion category codes given to the successive
time units. A kappa table was established to show the
agreements and disagreements (“full errors”)
between the independent raters with regard to the
emotion category codes for the successive time
segments. In a last step, the 17 emotion labels were
grouped together as unpleasant emotions (sadness,
pain, loneliness, fear, hopelessness/helplessness,
shame/guilt, anger–sadness, surprise/shock, unspeci-
fied bad), anger emotions (anger, contempt/disgust),
and pleasant emotions (contentment/calm/relief,
pride/self-confidence, joy/excitement, love, pride–
anger). A kappa table was established to show
agreements and disagreements between the inde-
pendent raters with regard to emotion label groups
as described above.
Working Alliance Session Selection
The working alliance was measured by the WAI
(Horvath & Greenberg, 1989) administered after
Session 4. Session 4 was chosen since research on
the therapeutic working alliance suggests that the
nature of the alliance becomes established after the
third session (Horvath & Bedi, 2002). For those
clients for whom no session four WAI score was
available, the WAI score obtained after Session 3
was used.
Results
Data Preparation
There was no missing data for this sample. Standar-
dized residualized gains of pre-post treatment scores
were calculated for the BDI and used as the outcome
measure in all the analyses. Tests were done for
multicollinearity; assumptions of normality includ-
ing skewness and kurtosis; linearity and homoske-
dasticity between predicted dependent variable
scores and errors of prediction; and independence
of residuals. No gross violations of assumptions were
found. For the purpose of this study, emotion
categories (SEC/INS, PMA, and PA) were calcu-
lated as percentages of a specific EC of all segments
in which emotional activation was present (the latter
being calculated as all coded segments minus seg-
ments with category “no activated emotion” in the
session of interest or overall, respectively). The
percentage of primary adaptive emotions was thus
the percentage of “primary adaptive segments” of all
segments in which activated emotion was present.
 10 I. R. Herrmann et al.
Reliability
The inter-rater agreement for the identification of
emotion activation using Cohen’s Kappa was k =
.887, p < .01. The inter-rater reliability for emotion
categories on those segments both raters had agreed
on as showing activated emotion was k = .825, p <
.01. Inter-rater agreement on emotion label groups
(unpleasant emotion, anger emotion, pleasant emo-
tion) for those segments both raters had agreed on as
showing activated emotion was k = .841, p < .01.
Relationships between Emotion Categories
(ECs), WAI, Activation and Outcome
None of the emotion categories (secondary/instru-
mental, primary maladaptive, primary adaptive) were
highly correlated with either early working alliance,
as measured by the WAI (correlations were between
Pearson’s r = –.002 and .351) or scheme activation
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(correlations were between Pearson’s r = –.003
and .346).
No significant product–moment correlations
(Pearson) were found between WAI scores in Ses-
sion 4 and change on the BDI or on any of the
emotion categories overall or in the first, middle, or
best working sessions. The WAI also failed to
significantly predict change on the BDI (F(1,28) =
1.64, p = .21). Due to the lack of significant
correlations between WAI scores and BDI change
as well as ECs, and the failure to show relevant
β-effects when regressing BDI on WAI scores, the
role of the WAI in predicting outcome was not
considered in further analyses.
Relationship between Activation and Outcome
To shed light on the relationship between mere
emotional activation and symptom reduction, the
BDI was regressed on the percentage of emotion
activation in each of the coded sessions. In line with
Table I. Means and standard deviations of emotion categories, SEQ and number of segments of the respective ECs overall and by session.
Overall First working session
SEC/INS M = 33.50% (SD = 24.81) M = 32.47% (SD = 35.31)
PMA M = 32.57% (SD = 22.56) M = 36.34 % (SD = 33.44)
PA M = 31.67% (SD = 25.93) M = 24.14 % (SD = 28.66)
SEQ M = 1.6 (SD = 1.65) M = .40 (SD = .86)
Nr of segments
SEC/INS M = 28.63 (SD = 21.29) M = 9.67 (SD = 13.39)
PMA M = 29.03 (SD = 21.45) M = 9.77 (SD = 9.97)
PA M = 32.67 (SD = 32.12) M = 8.50 (SD = 15.58)
Note. n = 30.
SEC/INS = percentage of secondary/instrumental emotions; PMA = percentage of primary maladaptive emotions; PA = percentage of
primary adaptive emotions; SEQ = frequency of the sequence primary maladaptive to primary adaptive emotion; Nr of segments = number
of 30 second segments coded in the respective ECs (SEC/INS, PMA, PA); BDI = standardized residualized gain score of the Beck
Depression Inventory; M = mean; SD = standard deviation.
the first hypothesis, activation in the middle working
session was found to significantly predict outcome on
the BDI residualized gain score (F(1, 28) = 5.710;
p < .05) explaining 14% of the outcome variance, with
a higher proportion of activated segments being
related to symptom reduction. The regression of
BDI on activation in the first (F(1, 28) = 4.182;
p = .05) and best (F(1, 28) = .968; p = .334)
working sessions failed to be significant at the p = .05
level.
Emotion Categories
The mixed/uncodable category hardly ever appeared
and was thus not further considered in this analysis.
As hardly any instrumental emotions appeared
within the secondary/instrumental category (less
than 2%), this category will be called “secondary
emotion” in the text. Means and standard deviations
of emotion categories as well as mean and standard
deviation of actual time spent in the respective
ECs (as number of 30-s segments) are presented in
Table I. No significant correlations (Pearson) were
found between BDI pre-treatment scores and ECs
overall as well as in the different working sessions,
indicating that the types of emotions expressed in
therapy were not a function of severity of clients’
depressive symptomatology.
Inter-correlations of ECs and correlations
between ECs and the frequencies of the
sequence primary maladaptive to primary
adaptive emotion (SEQ). Means and standard
deviations for SEQ overall and in the different
sessions are reported in Table I. Inter-correlations
between emotion categories and correlations
between ECs and SEQ in the different sessions can
be viewed in Tables II and III. The highest correla-
tion between emotion categories was Pearson’s r =
–.654. Between ECs and SEQ the highest correlation
Middle working session Best working session
M = 27.93% (SD = 31.70) M = 32.94% (SD = 30.93)
M = 31.63 % (SD = 33.49) M = 31.87 % (SD = 27.12)
M = 33.29 % (SD = 30.79) M = 35.06 % (SD = 33.99)
M = .63 (SD = .93) M = .57 (SD = .77)
M = 7.10 (SD = 7.33) M = 11.87 (SD = 13.53)
M = 9.17 (SD = 9.85) M = 10.10 (SD = 10.10)
M = 12.53 (SD = 15.02) M = 11.63 (SD =13.59)
 Psychotherapy Research 11
Table II. Inter-correlations among emotion categories by sessions.

Emotion categories 1 2 3 4 5 6 7 8 9

First working session

1. SEC/INS
2. PMA –.573**
3. PA –.429* –.283
Middle working session
4. SEC/INS –.033 .208 –.214
5. PMA –.176 .308 .004 –.502**
6. PA .011 –.383* .317 –.437* –.389**
Best working session
7. SEC/INS .094 –.034 .053 .486** –.340 –.264
8. PMA .199 .103 –.208 –.168 .552** –.434* –.320
9. PA –.244 –048 .117 –.307 –.128 .584** –.654** –.507**

Note. n = 30.
SEC/INS = percentage of secondary/instrumental emotions; PMA = percentage of primary maladaptive emotions; PA = percentage of
primary adaptive emotions.
*p < .05, **p < .01.
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that was found was Pearson’s r = .490, both thus
below the limit of .7, which Tabachnick and Fidell
(2007) consider to be a conservative estimate for
danger of collinearity among independent variables.
The different emotion categories and the frequency
of the sequence primary maladaptive to primary
adaptive emotion were thus treated as independent
variables in further analyses.
Relationship between ECs and outcome. Sig-
nificant correlations were found between BDI
change and the proportion of secondary emotions
in the middle working session (r = .431, p < .05) and
the best working session (r = .580, p < .01).
Relationships between BDI change and the propor-
tion of primary adaptive emotion in the middle
working session (r = –.577, p < .01) and the best
working session (r = –.732, p < .01) were also found
to be significant. While a higher proportion of
primary adaptive emotions in therapy was found to
be associated with symptom reduction in depressive
symptoms, the opposite was true for the experience
of secondary emotion.
As had been hypothesized, no significant linear
relationship was found for change in BDI and
primary maladaptive emotion (overall (F(1, 28) =
.959; p = .336), in the first working session (F(1,28)
= 2.490; p = .126), the middle working session (F(1,
28) = .002; p = .962), and the best working session
(F(1, 28) = 1.968; p = .172)). The possibility that
these variables were actually related, but that there
was merely no linear relationship, was tested. A
linear regression model including a quadratic term
for primary maladaptive emotions in predicting
outcome was tested for significance. The model
was found to be significant for the middle working

Table III. Correlations between emotion categories and SEQ by sessions.

Emotion categories SEQ First working session SEQ Middle working session SEQ Best working session

First working session

1. SEC/INS –.347 .094 –.137
2. PMA .202 –.037 .124
3. PA .292 .102 .126
Middle working session
4. SEC/INS –.146 –.356 –.008
5. PMA .281 .166 .212
6. PA –.046 .302 –.116
Best working session
7. SEC/INS .069 –.380* –.173
8. PMA –.239 –.178 .000
9. PA .130 .490** .161

Note. n = 30.
SEQ = frequency of the sequence primary maladaptive to primary adaptive emotion; SEC/INS = percentage of secondary/instrumental
emotions; PMA = percentage of primary maladaptive emotions; PA = percentage of primary adaptive emotions.
*p < .05, **p < .01.
 12 I. R. Herrmann et al.
Table IV. Results from regression model including quadratic
term for PMA in the middle working session in predicting change
on BDI.
Independent Total F Standardized
variables adjusted R2 change df β weights
PMA –1.973*
PMA
Squared .272 6.410 2, 27 2.044*
Note. n = 30.
PMA = percentage of primary maladaptive emotions.
*p < .05.
session (β = 2.044, adjusted R2 = .272, p < .05;
see Table IV), indicating a curvilinear relationship
(U-curved) between primary maladaptive emotion
and outcome, indicating that a moderate proportion
of maladaptive emotion, not too much or too little,
was associated with symptom reduction.
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Hierarchical regression analyses
BDI on secondary and primary adaptive
emotions. Due to the small sample size (N = 30),
it was possible to include only a limited number of
variables in the hierarchical regression analyses in
order to avoid picking up spurious relationships. As
middle working and best working sessions are close
together in time with one session leading up to the
other representing the working phase of treatment
leading up toward resolution, they were combined to
represent the working phase of therapy. The per-
centage of secondary emotions in the working phase
significantly predicted outcome on reduction in BDI
(the lower, the better the outcome), both for when
early levels of secondary emotions were controlled
for, (F(2, 27) = 9.57, β = .651, p < .01) explaining
an additional 41% of the variance, and when work-
ing phase activation was controlled for (F(2, 27) =
12.47, β = –.600, p < .01) explaining an additional
35% of the variance. In line with the second
hypothesis, lower levels of secondary emotions in
the working phase predicted symptom reduction on
the BDI. Early levels and activation respectively
failed to be significant predictors of outcome.
In line with Hypothesis 5, the percentage of
combined phase primary adaptive emotion signifi-
cantly predicted change on the BDI, when early
levels were controlled for, (F(2, 27) = 17.31,
β = –.740, p < .01) explaining an additional 48% of
the variance. The same was true when activation was
controlled for (F(2, 27) = 18.85, β = –.705, p < .01)
explaining an additional 46% of the outcome vari-
ance. The direction of change was such that the
higher levels of primary adaptive emotions in the
working phase predicted symptom reduction on
the BDI. Early levels and activation in the working
phase respectively failed to be significant predictors
of outcome.
BDI on frequency of the sequence primary
maladaptive to primary adaptive emotion.
With regard to the sequence primary maladaptive
emotion to primary adaptive emotion, we found that
the frequency of this sequence in the middle working
session was significantly correlated with outcome
(Pearson r = –.532, p < .01). As expected, a
hierarchical regression showed that the frequency of
how often clients moved from primary maladaptive
emotion to primary adaptive emotion uninterrupted
by another emotion in the middle working session
was predictive of outcome over and above mere
emotional activation in that session (F(2, 27) = 6.82,
β = –.440, p < .05) explaining an additional 15%
of the outcome variance. When the frequency of the
sequence was entered in the second step of the
analysis, activation was no longer a significant pre-
dictor of outcome. The more often clients moved
from primary maladaptive emotion to primary adapt-
ive emotion the better the outcome on the BDI.
Primary adaptive emotion as the best
predictor of outcome. In order to test the hypo-
thesis that primary adaptive emotion would be the
best predictor of outcome considering all relevant
other variables, another hierarchical regression ana-
lysis was performed. The forward selection method
was used to determine the order in which potential
confounding variables of interest were entered into a
model, to form the confounder model against which
the predictive utility of primary adaptive emotion
was tested. Based on the previous analyses, working-
phase secondary emotion and the frequency of the
sequence primary maladaptive emotion to primary
adaptive emotion in the middle working session were
included as potential confounding variables in this
regression analysis. As no significant linear relation-
ship between primary maladaptive emotion and
outcome could be found, primary maladaptive emo-
tion was not included in this analysis. As the
hierarchical regression analyses above had shown,
the variables of interest predicted outcome over and
above mere emotional activation. Emotional activa-
tion was therefore not included as a potential
confounding variable. Of the two potential confound-
ing variables, proportion of secondary emotions in
the working phase showed the higher adjusted R²
value (= .380; β = .634), explaining 38% of the
outcome variance of the BDI (see Table V). Second-
ary emotion was a significant predictor of outcome
(p < .01), with lower levels of secondary emotions
predicting symptom reduction on the BDI. When in
Step 2 the frequency of the sequence primary
 Psychotherapy Research 13
Table V. Results of hierarchical regression analysis: BDI on working phase primary adaptive emotion including potential confounding
variables.

Independent variable Total adjusted R2 Adjusted R2 change F change df Standardized β weights

Step 1
SEC/INS .380 18.782 1, 28 .634**
Step 2
SEC/INS .498*
SEQ .488 .108 12.848 2, 27 –.323*

SEC/INS .211
SEQ –.239
PA .655 .167 16.470 3, 26 –.527*

Note. n = 30.
SEC/INS = percentage of secondary/instrumental emotions in the working phase; SEQ = frequency of the sequence primary maladaptive to
primary adaptive emotion in the middle working session; PA = percentage of primary adaptive emotions in the working phase.
*p < .05, **p < .01.

maladaptive emotion to primary adaptive emotion in
the middle working session was added to the model,
it explained an additional 11% of the outcome
variance and was significant (β = –.323, p < .05). A
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of primary adaptive emotions, procedures according
to Baron and Kenny (1986) were followed. As
shown in Table VI, percentage of secondary emo-

tions in the working phase (independent variable)

higher frequency of the described sequence in the
middle working session predicted symptom reduc-
tion on the BDI. The effect of secondary emotion
remained significant in this step (β = .498, p < .05).
Finally, working phase primary adaptive emotion
explained 17% of the outcome variance over and
above the variance explained by the other two
variables and was significant (β = –.527, p < .01).
In the final three-predictor model, both percentage of
secondary emotions and the sequence described
above were no longer significant. Working-phase
primary adaptive emotion alone significantly and
independently predicted therapeutic improvement
and accounted for 66% of the outcome variance.
Mediational analyses. These results indicated
that working-phase primary adaptive emotion
mediated the effect of both working phase secondary
emotion and of the frequency of the sequence
primary maladaptive emotion to primary adaptive
emotion in the middle working session on thera-
peutic improvement. In order to test for the signi-
ficance of a potential mediating effect of percentage
Table VI. Hierarchical regression of percentage of secondary/instrumental emotions on outcome mediated by percentage of primary
adaptive emotions.
significantly predicted the mediator, namely percent-
age of primary adaptive emotion in the working
phase and the dependent variable, the standardized
residual of the BDI. In the last step, a hierarchical
regression was performed to test whether the medi-
ator (percentage of primary adaptive emotion in the
working phase) would predict outcome when con-
trolling for the independent variable (percentage of
secondary emotions in the working phase). The
model significantly predicted outcome with the
weight of secondary emotions dropping from .634
to .280 when percentage of primary adaptive emo-
tions was included in the model. Percentage of
secondary emotions became non-significant as a
predictor, indicating that percentage of primary
adaptive emotions in the working phase fully
mediated the relationship between secondary emo-
tions and outcome. It has to be noted, however, that
the beta-coefficient did not drop to zero. Results
from the Sobel test confirmed the statistical signific-
ance of the mediational pathway found through
regression analysis.

IV DV Total adjusted R2 F change df Standardized β weights Sobel test (p)

SEC PA .353 16.813 1,28 –.613*

SEC BDI .380 18.782 1,28 .634*

SEC BDI .280 2.864

PA .581 21.093 2,27 –.577* (.004)

Note. n = 30.
IV = independent variable; DV = dependent variable; SEC = percentage of secondary/instrumental emotions in the working phase; PA =
percentage of primary adaptive emotions in the working phase; BDI = standardized residualized gain score of the Beck Depression
Inventory.
*p < .01.
 14 I. R. Herrmann et al.
The relationship between the frequency of the
sequence primary maladaptive to primary adaptive
emotion and outcome was tested in a similar fashion.
Results indicated that the described sequence (inde-
pendent variable) significantly predicted the medi-
ator, percentage of primary adaptive emotion in the
working phase, and the dependent variable, standar-
dized residual of the BDI. The weight of the
sequence dropped from –.532 to –.284 when per-
centage of primary adaptive emotions in the working
phase was entered into the regression model. The
relationship between the independent and the
dependent variable remained significant and per-
centage of primary adaptive emotions also signifi-
cantly predicted outcome while controlling for the
independent variable, indicating that percentage of
primary adaptive emotions only partially mediated
the effect of the frequency of the sequence primary
maladaptive to primary adaptive emotion on out-
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come. Last, results from the Sobel test confirmed the
statistical significance of the mediational pathway
found through regression analysis (see Table VII).
Labels of primary adaptive emotions. The
emotion labels given by the coders (according to the
emotion list of the ECCS) were categorized into
unpleasant, pleasant, and anger emotions. Unpleas-
ant emotions constituted 35.70% of all primary
adaptive emotions and included: Sadness, pain,
loneliness, fear, hopelessness/helplessness, shame/
guilt, anger–sadness, and surprise/shock. Anger
emotions constituted 39.20% of all primary adaptive
emotions and included: Anger, contempt/disgust.
Pleasant emotions constituted only 19.50% of all
primary adaptive emotions and included: Content-
ment/calm/relief, pride/self-confidence, joy/excite-
ment, love, and pride–anger. The majority of
primary adaptive emotions thus fell into the sub-
categories unpleasant and anger emotions (74.9%).
Table VII. Hierarchical regression of frequency of the sequence
primary maladaptive to primary adaptive emotion on outcome
mediated by percentage of primary adaptive emotions.
Total
adjusted F Standardized Sobel
IV DV R2 change df β weights test (p)
SEQ PA .121 4.994 1, 28 .389*
SEQ BDI .258 11.077 1, 28 –.532*
SEQ BDI –.284* –2.070
PA .602 22.923 2, 27 –.638** (.038)
Note. n = 30.
IV = independent variable; DV = dependent variable; SEQ =
sequence primary maladaptive to primary adaptive emotion in the
middle working session; PA = percentage of primary adaptive
emotions in the working phase; BDI = standardized residualized
gain score of the Beck Depression Inventory.
*p < .05, **p < .01.
Experiencing an adaptive emotion is thus not the
same as “feeling happy.”
Discussion
The main goal of this study was to further clarify the
role of different types of in-session emotional experi-
ence in the therapeutic process of change. It was
sought to gain a better understanding of the rela-
tionship of certain emotion types and their patterns
and sequences with treatment outcome. For this
purpose, a coding system, the ECCS was developed
to reliably categorize different types of emotional
experience.
Activation and Outcome
Emotional experiences were coded with regard to
emotion category within personally meaningful con-
texts, namely within expressions of the self in chair-
work. Activation of underlying emotion schematic
structures in the self in these interventions is
considered a prerequisite of successful process
(Greenberg, 2010; Greenberg et al., 1993). We
thus expected emotional activation in the middle
working session to predict symptom reduction. As
mentioned above, we did not expect activation in the
first working session to predict outcome, as early
activation is generally more a sign of distress than of
the working through of that distress (Greenberg,
2002; Kennedy-Moore & Watson, 1999; Missirlian
et al., 2005; see also Pascual-Leone and Greenberg
(2007) for a differentiation of distress and trans-
formation of distress within the session). Similarly,
activation in the best working session was not
expected to be associated with outcome, as accord-
ing to the Emotion-focused model clients move
from states of high activation to states of low
activation and high meaning as the process comes
to resolution (Greenberg, 2002, 2010; Pascual-
Leone & Greenberg, 2007). Pascual-Leone and
Greenberg (2007) were able to empirically support
this movement from high arousal and low meaning
to low arousal and high meaning in resolving states
of global distress within the session. As expected, in
looking at activation over the course of treatment, we
found emotional activation in the middle working
session to predict outcome.
Emotion Categories and Outcome
Early levels in the different emotion categories were
not significantly related to therapy outcome and did
not show significant interactions with levels later in
therapy. Moreover, working phase levels in second-
ary and primary adaptive emotions were found to

significantly predict outcome when early levels were
controlled for, while early levels did not significantly
predict outcome. Emotion categories thus seem to
be therapy process variables and do not merely
reflect individual tendencies or traits. We found
percentage of secondary symptomatic emotions in
the working phase to significantly predict poor
outcome even when activation was controlled for.
Clients who still had high proportions of secondary
emotional experiences in the middle sessions leading
up to resolution tended to have poorer treatment
outcomes, while those with lower proportions
tended to improve more. The importance of redu-
cing secondary reactive, mostly symptomatic emo-
tionality during treatment, is recognized by theorists
across treatment modalities. This finding thus does
not seem surprising but gives support to the con-
struct validity of the scale (Allen & Yen, 1979). What
is interesting is that we found the frequency with
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which clients moved from primary maladaptive
emotions to primary adaptive emotions predicted
outcome over and above the effect of mere emo-
tional activation on outcome. It also predicted
outcome independently of the effect of secondary
emotions. Moreover, we found the relationship
between secondary emotions in the working phase
and treatment outcome to be fully mediated by the
proportion of primary adaptive emotions in that
phase. The relationship of the frequency of the
sequence primary maladaptive to primary adaptive
emotions and symptom reduction in contrast, only
proved to be partially mediated by the effect of
primary adaptive emotions on outcome. What do
these findings imply?
Reducing secondary emotions in experiential
treatment, such as hopelessness, seems to be import-
ant, but only to the extent that the client succeeds in
accessing primary adaptive emotionality such as
empowered anger. This, however, still does not
appear to be the whole story. Primary maladaptive
emotions appear to play a central role in the process
of therapy. As expected, we found that moderate
levels of primary maladaptive emotions such as
shame or fear in the middle working session were
associated with outcome. Moreover, we found that
clients who experienced and went through primary
maladaptive emotions of say shame and then
accessed and experienced primary adaptive emo-
tions, say empowered anger or sadness, in the
middle working session more frequently tended to
have better treatment outcomes, than those who did
not, independently of clients’ level of activation.
“Feeling bad” then neither means that this is thera-
peutically bad or good. What seems to matter is for
clients to experience their core painful primary
maladaptive emotions at moderate levels, to work
Psychotherapy Research 15
through them and to access adaptive emotional
resources. And the more frequently this is done the
better. This is in line with Pascual-Leone (2009),
who found heightened emotional flexibility in their
“affective meaning states” some of which are emo-
tions which can be categorized as secondary, primary
maladaptive and primary adaptive as described
above, to be associated with better in-session out-
come. It thus seems that a mere focus on reducing
symptomatic emotional experience in therapy, such
as global depressive hopelessness, symptomatic fear,
or secondary defensive anger, is not enough. A focus
on arriving at core primary maladaptive experiences,
which have often become part of the client’s identity,
such as shame of not being good enough or fear of
being too weak to survive alone, and then accessing
primary adaptive emotional experiences, such as
anger against a degrading inner voice, sadness of
having lost a happy childhood, pride/self-confidence,
or self-compassion seems of central importance.
Of all the variables considered in this study
proportion of primary adaptive emotions in the
working phase was found to be the best predictor
of outcome. Clients with good treatment outcome
succeeded in accessing more adaptive emotional
resources, potentially counteracting and undoing
the effect of automatic primary maladaptive and
secondary emotional responses, leading to better
outcome. Results of this study thus support the
hypotheses that primary adaptive emotions play a
role in transforming primary maladaptive and sec-
ondary emotions and the EFT principle of changing
emotion with emotion. How much some other
variables such as therapist influence are operating
to promote these processes however has not been
studied.
Working Alliance and Outcome
In this sample, we did not find early working alliance
measured by the WAI in Sessions 3 and 4 to be
significantly related to symptom reduction on the
BDI. Given, that the working alliance has been
established as a robust predictor of outcome in the
literature (Grawe, 1998; Horvath & Bedi, 2002;
Lambert & Ogles, 2004; Orlinsky, Rønnestäd, &
Willutzki, 2004; Weerasekera, Linder, Greenberg, &
Watson, 2001), with early alliance measures showing
a consistently significant relationship with therapy
outcome (Horvath & Symonds, 1991), the failure to
find a significant relationship between early alliance
and outcome in this study needs to be explained.
One reason for this might lie in the relatively small
sample size (N = 30).
Another reason for this might lie in the fact that in
EFT chair-work is only implemented after Session 3,
 16 I. R. Herrmann et al.
and for 13 of the 30 participants in this sample the
WAI score used for the analyses was measured in
Session 3, not in Session 4 (as WAI scores for
Session 4 were not available). Weerasekera et al.
(2001), using a partly overlapping sample, found
that WAI scores in Session 4 were significantly
correlated with symptom reduction on the BDI,
but that the WAI in Session 3 was not. Moreover,
Pos et al. (2009) found that individual differences in
capacity to experience influenced whether or not
alliance was important to outcome. They showed
that clients who started high on experiencing could
achieve a good outcome without establishing an early
working alliance.
The ECCS
As results of this study relating emotion categories to
outcome and predicting outcome variance were in
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line with expectations, the construct validity of the
scale was enhanced. None of the emotion categories
were highly correlated with either early working
alliance or emotional activation, which further
enhances the predictive validity and the construct
validity (discriminant validity) of the ECCS. There is
thus some evidence that the ECCS actually measures
what it claims to measure, namely different emotion
categories. Future research is needed to further
establish validity of the coding system.
Clinical Implications
Results of this study suggest that in experiential
therapy discriminating what type of emotion clients
are expressing seems to be useful in terms of
indicating to the therapist in which stage of the
transformation process the client is currently engaged
and informing therapist interventions. In this trans-
formation process, the decrease of secondary emo-
tional experience and the accessing and deepening of
primary maladaptive emotions to moderate levels of
emotional experience (see Table IV) seems to play an
important role. However, activation of primary
adaptive emotions appears to be especially important.
Therapists can work to help clients gain access to
their primary adaptive emotional resources by paying
attention to newly emerging adaptive experience,
directing clients’ attention to, and helping to sym-
bolize adaptive emotional experience. However,
based on the current study, it remains unclear, if
and how therapist interventions can actually influ-
ence client process and whether the transformational
process described only applies to emotion-focused
treatments.
Limitations
There are several limitations to this study. One
limitation is the small sample size (N = 30). Results
have to be replicated with a larger sample to see
whether the findings are generalizable. Second, as
participants selected for this study were suffering
from one or several moderate to severe episodes of
major depression, it remains to be clarified in future
research, whether the findings can be generalized to
a more severely impaired population or other dis-
orders. Moreover, as only the BDI was used as an
outcome measure, it remains unclear, whether a
more comprehensive assessment of outcome as well
as the inclusion of follow-up measures may have
yielded different findings. Another limitation and at
the same time inspiration for future research con-
cerns the question of the generalizability of these
results to other therapeutic approaches and the
transportability of the coding system. It remains to
be established, whether results of this study would be
replicated in analyzing other treatment approaches,
which do not specifically focus on activated emo-
tional experience as a target of intervention in the
session. In addition, this study has focused on client
process and not therapist actions, and so it remains
unclear as to how much therapist directiveness can
or does influence client process.
A further issue concerns the question of transport-
ability of the ECCS to coders not trained in experi-
ential treatment approaches. The ECCS was
designed with the aim of being comprehensible to
coders of different backgrounds and applicable to
different treatment approaches. Whether this goal
has been attained, however, still needs to be shown.
References
Allen, M. J., & Yen, W. M. (1979). Introduction to measurement
theory. Monterey, CA: Brooks/Cole.
APA. (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Auszra, L., Greenberg, L. S., & Herrmann, I. R. (2013). Client
emotional productivity-optimal client in-session emotional
processing in experiential therapy. Psychotherapy Research, 23(6),
732–746.
Baker, R. (2007). Emotional processing (1st ed.). Oxford: Lion.
Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator
variable distinction in social psychological research: Concep-
tual, strategic, and statistical considerations. Journal of Person-
ality & Social Psychology, 51, 1173–1182. doi:10.1037/0022-
3514.51.6.1173
Beck, A. T. (1972). Depression: Causes and treatment. Philadelphia:
University of Philadelphia Press.
Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric
properties of the Beck Depression Inventory: Twenty-five years
of evaluation. Clinical Psychology Review, 8(1), 77–100.
doi:10.1016/0272-7358(88)90050-5
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh,
J. (1961). An inventory for measuring depression. Archives of

General Psychiatry, 4, 561–571. doi:10.1001/archpsyc.1961.0
1710120031004
Bordin, E. S. (1979). The generalizability of the psychoanalytic
concept of the working alliance. Psychotherapy: Theory, Research
& Practice, 16(3), 252–260.
Boritz, T. Z., Angus, L., Monette, G., Hollis-Walker, L., &
Warwar, S. (2011). Narrative and emotion integration in
psychotherapy: Investigating the relationship between autobio-
graphical memory specificity and expressed emotional arousal
in brief emotion-focused and client-centred treatments of
depression. Psychotherapy Research, 21(1), 16–26. doi:10.1080/
10503307.2010.504240
Carryer, J. R., & Greenberg, L. S. (2010). Optimal levels of
emotional arousal in experiential therapy of depression. Journal
of Consulting and Clinical Psychology, 78, 190–199. doi:10.1037/
a0018401
Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., &
Hayes, A. M. (1996). Predicting the effect of cognitive therapy
for depression: A study of unique and common factors. Journal
of Consulting and Clinical Psychology, 64, 497–504. doi:10.1037/
0022-006X.64.3.497
Damasio, A. R. (1994). Descartes' error: Emotion, reason and the
human brain. New York, NY: A Grosset/Putnam Book.
Downloaded by [218.22.187.66] at 12:47 05 November 2015
Diener, M. J., Hilsenroth, M. J., & Weinberger, J. (2007).
Therapist affect focus and patient outcomes in psychodynamic
psychotherapy: A meta-analysis. The American Journal of Psy-
chiatry, 164(6), 936–941.
Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S.
(2004). Learning emotion-focused therapy. Washington, DC:
American Psychological Association.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear:
Exposure to corrective information. Psychological Bulletin,
99(1), 20–35. doi:10.1037/0033-2909.99.1.20
Fosha, D. (2002). The activation of affective change processes in
accelerated experiential-dynamic psychotherapy (AEDP). In F.
W. Kaslow & J. J. Magnavita (Eds.), Comprehensive handbook of
psychotherapy: Psychodynamic/object relations (Vol. 1, pp. 309–
343). Hoboken, NJ: John Wiley & Sons.
Fosha, D. (2009). Emotion and recognition at work: Energy,
vitality, pleasure, truth, desire & the emergent phenomenology
of transformational experience. In D. Fosha, D. J. Siegel, & M.
F. Solomon (Eds.), The healing power of emotion: Affective
neuroscience, development & clinical practice (pp. 172–203).
New York, NY: W. W. Norton.
Gendlin, E. T. (1981). Focusing (2nd ed.). New York, NY:
Bantam Books.
Goldman, R. N., Greenberg, L. S., & Angus, L. (2006). The
effects of adding emotion-focused interventions to the client-
centered relationship conditions in the treatment of depression.
Psychotherapy Research, 16, 537– 549. doi:10.1080/105033006
00589456
Goldman, R. N., Greenberg, L. S., & Pos, A. E. (2005). Depth of
emotional experience and outcome. Psychotherapy Research, 15,
248–260. doi:10.1080/10503300512331385188
Grawe, K. (1998). Psychologische therapie [Psychological therapy].
Göttingen: Hogrefe.
Greenberg, L. S. (2002). Emotion-focused therapy. Coaching clients
to work through their feelings. Washington, DC: American
Psychological Association.
Greenberg, L. S. (2010). Emotion-focused therapy. Theory, practice and
research. Washington, DC: American Psychological Association.
Greenberg, L. S., Auszra, L., & Herrmann, I. R. (2007). The
relationship among emotional productivity, emotional arousal
and outcome in experiential therapy of depression. Psychother-
apy Research, 17(4), 482–493.
Greenberg, L. S., & Malcolm, W. (2002). Resolving unfinished
business: Relating process to outcome. Journal of Consulting and
Psychotherapy Research 17
Clinical Psychology, 70, 406–416. doi:10.1037/0022-006X.70.
2.406
Greenberg, L. S., & Paivio, S. C. (1997). Working with emotions in
psychotherapy. New York, NY: The Guilford Press.
Greenberg, L. S., & Pascual-Leone, J. (2001). A dialectical
constructivist view of the creation of personal meaning. Journal
of Constructivist Psychology, 14, 165–186. doi:10.1080/10720530
151143539
Greenberg, L. S., & Pascual-Leone, A. (2006). Emotion in
psychotherapy: A practice-friendly research review. Journal of
Clinical Psychology, 62, 611–630. doi:10.1002/jclp.20252
Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating
emotional change: The moment by moment process. New York, NY:
Guilford Press.
Greenberg, L. S., & Safran, J. D. (1987). Emotion in psychotherapy:
Affect, cognition and the process of change. New York, NY:
Guilford Press.
Greenberg, L. S., & Watson, J. C. (1998). Experiential therapy of
depression: Differential effects of client-centered relationship
conditions and process experiential interventions. Psychotherapy
Research, 8, 210–224. doi:10.1080/10503309812331332317
Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused ther‐
apy for depression Washington, DC: American Psychological
Association.
Gude, T., Monsen, J. T., & Hoffart, A. (2001). Schemas, affect
consciousness, and cluster c personality pathology: A prospect-
ive one-year follow-up study of patients in a schema-focused
short-term treatment program. Psychotherapy Research, 11(1),
85–98. doi:10.1080/713663854
Hayes, A. M., Beevers, C. G., Feldman, G. C., Laurenceau, J.-P.,
& Perlman, C. (2005). Avoidance and processing as predictors
of symptom change and positive growth in an integrative
therapy for depression. International Journal of Behavioral
Medicine, 12(2), 111–122. doi:10.1207/s15327558ijbm1202_9
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance
and commitment therapy: An experiential approach to behavior
change. New York, NY: Guilford Press.
Herrmann, I., Greenberg, L. S., & Auszra, L. (2007). Emotion
category coding system. In I. Herrmann (Ed.), Emotion
categories and patterns of change in experiential therapy for
depression (pp. 203–231; Doctoral thesis). Ludwig-Maximilians
Universität, München.
Hirschheimer, S., & Greenberg, L. S. (1996). Degree of resolution
scale. Unpublished manuscript. Toronto, ON: York Psycho-
therapy Research Clinic, York University.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C.
Norcross (Ed.), Psychotherapy relationships that work: Therapist
contributions and responsiveness to patients. London: Oxford
University Press.
Horvath, A. O., & Greenberg, L. S. (1989). Development and
validation of the Working Alliance Inventory. Journal of
Counseling Psychology, 36, 223–233. doi:10.1037/0022-0167.
36.2.223
Horvath, A. O., & Symonds, B. D. (1991). Relation between
working alliance and outcome in psychotherapy: A meta-
analysis. Journal of Counseling Psychology, 38(2), 139–149.
doi:10.1037/0022-0167.38.2.139
Jaycox, L. H., Foa, E. B., & Morral, A. R. (1998). Influence of
emotional engagement and habituation on exposure therapy for
PTSD. Journal of Consulting and Clinical Psychology, 66, 185–
192. doi:10.1037/0022-006X.66.1.185
Kennedy-Moore, E., & Watson, J. C. (1999). Expressing emotion:
Myths, realities and therapeutic strategies. New York, NY: The
Guilford Press.
Lambert, M. J., & Ogles, B. M. (2004). The efficacy and
effectiveness of psychotherapy and behavior change. In M. J.
Lambert (Ed.), Bergin and Garfield's handbook of psychotherapy
 18 I. R. Herrmann et al.
and behavior change (5th ed., pp. 139–193). New York, NY:
John Wiley & Sons.
Leventhal, H., & Scherer, K. (1987). The relationship of emotion
to cognition: A functional approach to a semantic controversy.
Cognition and Emotion, 1(1), 3–28. doi:10.1080/0269993870
8408361
McCullough, L., Larsen, A., Schanche, E., Andrews, S., & Kuhn,
N. (2003). Achievement of Therapeutic Objectives Scale (ATOS).
Boston, MA: Harvard Medical School.
McCullough, L., & Magill, M. (2009). Affect-focused short-term
dynamic therapy. In R. A. Levy & J. S. Ablon (Eds.), Handbook
of evidence-based psychodynamic psychotherapy: Bridging the gap
between science and practice (pp. 249–277). Totowa, NJ:
Humana Press.
Mennin, D., & Farach, F. (2007). Emotion and evolving treat-
ments for adult psychopathology. Clinical Psychology: Science
and Practice, 14, 329–352. doi:10.1111/j.1468-2850.2007.
00094.x
Missirlian, T. M., Toukmanian, S. G., Warwar, S. H., & Green-
berg, L. S. (2005). Emotional arousal, client perceptual
processing, and the working alliance in experiential psycho-
therapy for depression. Journal of Consulting and Clinical
Psychology, 73, 861–871. doi:10.1037/0022-006X.73.5.861
Downloaded by [218.22.187.66] at 12:47 05 November 2015
Oatley, K., & Jenkins, J. M. (1992). Human emotions: Function
and dysfunction. Annual Review of Psychology, 43(1), 55–85.
doi:10.1146/annurev.ps.43.020192.000415
Ogles, B. M., Lambert, M. J., & Sawyer, J. D. (1995). Clinical
significance of the National Institute of Mental Health Treat-
ment of Depression Collaborative Research program data.
Journal of Consulting and Clinical Psychology, 63, 321–326.
doi:10.1037/0022-006X.63.2.321
Orlinsky, D. E., Rønnestäd, M. H., & Willutzki, U. (2004). Fifty
years of process-outcome research: Continuity and change. In
M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psycho-
therapy and behavior change (5th ed., pp. 307–389). New York,
NY: John Wiley & Sons.
Pascual-Leone, A. (2009). Dynamic emotional processing in
experiential therapy: Two steps forward, one step back. Journal
of Consulting and Clinical Psychology, 77(1), 113–126.
Pascual-Leone, A., & Greenberg, L. S. (2005). Classification of
affective-meaning states. In A. Pascual-Leone (Ed.), Emotional
processing in the therapeutic hour: Why ‘The only way out is through
(pp. 289–366; Unpublished doctoral thesis). York University,
Toronto, ON.
Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional
processing in experiential therapy: Why ‘the only way out is
through’. Journal of Consulting and Clinical Psychology, 75, 875–
887. doi:10.1037/0022-006X.75.6.875
Pos, A. E., Greenberg, L. S., Goldman, R. N., & Korman, L. M.
(2003). Emotional processing during experiential treatment of
depression. Journal of Consulting and Clinical Psychology, 71,
1007–1016. doi:10.1037/0022-006X.71.6.1007
Pos, A. E., Greenberg, L. S., & Warwar, S. H. (2009). Testing a
model of change in the experiential treatment of depression.
Journal of Consulting and Clinical Psychology, 77, 1055–1066.
doi:10.1037/a0017059
Rice, L., & Greenberg, L. S. (Eds.). (1984). Patterns of change: An
intensive analysis of psychotherapeutic process. New York, NY:
Guilford Press.
Rice, L. N., & Kerr, G. P. (1986). Measures of client and therapist
vocal quality. New York, NY: Guilford Press.
Rogers, C. R. (1975). Empathic: An unappreciated way of being.
The Counseling Psychologist, 5(2), 2–10. doi:10.1177/00110000
7500500202
Samoilov, A., & Goldfried, M. R. (2000). Role of emotion in
cognitive-behavior therapy. Clinical Psychology: Science and
Practice, 7, 373– 385. doi:10.1093/clipsy.7.4.373
Schanche, E., Stiles, T. C., McCullough, L., Svartberg, M., &
Nielsen, G. H. (2011). The relationship between activating
affects, inhibitory affects, and self-compassion in patients with
cluster C personality disorders. Psychotherapy, 48, 293–303.
doi:10.1037/a0022012
Schore, A. N. (2003). Affect dysregulation and disorders of the self.
New York, NY: W W Norton.
Solbakken, O. A., Hansen R. S., Havik, O. E., & Monsen, J. T.
(2012). Affect integration as a predictor of change: Affect
consciousness and treatment response in open-ended psycho-
therapy. Psychotherapy Research, 22, 656–672. doi:10.1080/
10503307.2012.700871
Spitzer, R., Williams J., Gibbon, M., & First, M. (1990). User’s
guide for the structured clinical interview for DSM-III-R: SCID.
Washington, DC: American Psychiatric Association.
Spitzer, R., Williams J., Gibbon, M., & First, M. (1995).
Structured clinical interview for DSM-IV. New York, NY:
American Psychiatric Press Inc.
Stern, D. N. (1985). The interpersonal world of the infant: A view
from psychoanalysis and developmental psychology. New York,
NY: Basic Books.
Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate
statistics (5th ed.). Boston, MA: Allyn & Bacon/Pearson
Education.
Warwar, S. H., & Greenberg, L. S. (1999). Client Emotional
Arousal Scale-III-R. Unpublished manuscript. Toronto, ON:
York Psychotherapy Research Clinic, York University.
Warwar, S. H., & Greenberg, L. S. (2000). Catharsis is not enough:
Changes in emotional processing related to psychotherapy outcome.
Paper presented at the International Conference of the Society
of Psychotherapy Research, Chicago, IL.
Weerasekera, P., Linder, B., Greenberg, L. S., & Watson, J.
(2001). The working alliance in client-centered and process-
experiential therapy of depression. Psychotherapy Research, 11,
221–223. doi:10.1093/ptr/11.2.221