Experiential Therapies for Depression

Running head: EXPERIENTIAL THERAPY AND RELAPSE PREVENTION

Maintenance of Gains Following Experiential Therapies for Depression

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

Experiential Therapies for Depression

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

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

Experiential Therapies for Depression

Maintenance of Gains Following Experiential Therapies for Depression

Numerous researchers have investigated the effects of brief psychotherapies for the
treatment of unipolar depression, and a number of treatments have been found to be generally
effective in the treatment of Major Depressive Disorder (MDD; e.g., Dimidjian et al., 2006;
Elkin et al., 1989; Hollon, DeRubeis, & Evans, 1996; Hollon et al., 2005; Jacobson et al., 1996;
Shapiro, Barkham, Rees, Hardy, Reynolds, & Startup, 1994; Watson, Gordon, Stermac,
Kalogerakos, & Steckley, 2003). While beneficial effects have been identified within various
comparative outcome studies, earlier trials regarding enduring effects in the prevention of
depressive relapse following the administration of evidence-based, short-term psychotherapeutic
treatment packages have been variable and less promising (Agosti, 1999; Brown, Schulberg,
Madonia, Shear, & Houck, 1996; Gortner, Gollan, Dobson, & Jacobson, 1998; Kupfer et al.,
1992; McLean & Hakstian, 1990; Prien et al., 1984; Shapiro et al., 1994; Shapiro, Rees,
Barkham, Hardy, Reynolds, & Startup, 1995; Shea et al., 1992; Thase & Simons, 1992). There
has been more promising recent evidence of the long-term effects of cognitive-behavioral
therapies (CBT; Dobson, Hollon, Dimidjian, Schmaling, Kohlenberg, & Gallop, 2008; Hollon et
al., 2005; Hollon, Stewart, & Strunk, 2006). However, there has been relatively little or no
investigation of the long-term effects of experiential therapies.
Both client-centered therapy (CC; Greenberg & Watson, 1998; King et al., 2000) and
emotion-focused therapy (EFT; Goldman, Greenberg, and Angus, 2006; Watson et al., 2003)
have been showed to be efficacious in the treatment of MDD. These experiential approaches
place the therapeutic focus on the empathic relationship, deepening exploration, and the
facilitation of the moment-by-moment emotional experience of the client. In a randomized
controlled trial (RCT) comparing 36 CC and 36 EFT clients, Goldman et al. (2006) found large

Experiential Therapies for Depression

pre-post effect sizes for clients who received either CC or EFT, on the Beck Depression
Inventory (BDI), Global Severity Index (GSI) of the SCL-90-R (Symptom-Check-list-Revised),
Rosenberg Self-Esteem Measure (RSE), and Inventory of Interpersonal Problems (IIP). In
addition, EFT was found to have significantly larger effects on all of these indices, although
there were no significant differences in proportion of treatment responders in each group at
posttreatment.
Watson et al. (2003) compared short-term treatment effects of EFT and CBT for depression
in a RCT and found that EFT and CBT were equally effective in decreasing depressive
symptomatology, and EFT clients, on average, showed significantly greater decrease in selfreported problems in interpersonal functioning. In this study, 19 clients (58%) in EFT and 17
clients (52%) in CBT met the reliable change index (RCI; Jacobson & Truax, 1991; Ogles,
Lambert, & Sawyer, 1995) for the BDI, and there was not a significant difference between the
treatment groups on this index. Experiential treatments of depression therefore have been shown
to be effective. However, to date, there is no evidence of maintenance of gains following these
short-term experiential treatments that focus on emotion as the primary site of change.
In the present study, we compared the maintenance of gains in depression over 18 months
following short-term CC and EFT treatments. In CC therapy for depression, the main
therapeutic action is the therapeutic relationship in which core conditions of therapist empathy,
acceptance and genuineness (Rogers, 1951, 1975) are paramount. Within such a relational
environment, clients become more open to the exploration of emotional experiences and learn to
appreciate and value the informative nature of their emotional experience. These processes are
proposed to lead to a strengthening of the clients resilience and a change in their self-concept.
The CC therapists general stance is one of empathically following what is most poignant in the

Experiential Therapies for Depression

clients experience. In EFT for depression, emotion-focused, marker-guided interventions

designed to help clients resolve depressogenic affective-cognitive problems, such as self-critical
splits and unfinished business (Greenberg, Rice, & Elliot, 1993; Greenberg & Watson, 2006), are
added to the client-centered relational conditions. The primary EFT interventions for depression
are (a) focusing on an unclear bodily felt sense, (b) two-chair dialogue with ones critical internal
voice, (c) empty-chair dialogue with a significant other in an unfinished business situation, and
(d) systematic evocative unfolding in response to problematic reactions. The EFT therapist
guides clients, within the context of the core client-centered relational conditions, to be aware of,
regulate, transform, and reflect upon emotions that underlie and influence how they feel, think,
and (inter)act (Greenberg, 2002; Greenberg & Watson, 2006; Samoilov & Goldfried, 2000). The
EFT therapists general stance is one of balancing following and leading the clients experiential
processes within the context of marker-guided interventions.
The primary purpose of the present study was to determine the comparative rates of relapse
in CC and EFT across an 18-month follow-up period. Based on previous findings of enhanced
experiential process during EFT (Watson & Greenberg, 1996; Pos, Greenberg, Goldman, &
Korman, 2003), in addition to EFTs significantly greater efficacy at posttreatment when
compared to CC (Goldman et al., 2006), our expectation was that EFT clients who responded to
the acute phase of treatment would maintain gains more than CC clients.
We hypothesized that clients who responded to the EFT treatment, when compared with
those who responded to CC treatment, would : (a) experience significantly less depressive
relapse during each follow-up period; (b) on average, experience a significantly greater number
of well weeks (successive addition of weeks where clients reported minimal or no depressive
symptoms) (c) would survive, or not experience first relapse of depression, for a significantly

Experiential Therapies for Depression

longer cumulative period of time; and that (d) regardless of whether or not clients were treatment
responders, those in EFT, when compared to those in CC therapy, would report significantly
more change on self-report measures (BDI, SCL-90-R, RSE, and IIP) at follow-up evaluation
compared to CC clients.
Method
Participants
Original outcome study. Information regarding the original outcome study is summarized
below. More detailed information regarding the original acute phase treatment sample from
which the present pool of clients was derived (including therapist selection, manualized training,
and treatment adherence) can be found in the original outcome study paper (Goldman et al.,
2006).
Potential clients were initially screened by phone on inclusion and exclusion criteria
following recruitment through local referral and by means of radio and written media
to the
residents of a large metropolitan area.. They were provided with information about
the treatment and gave their informed consent to participate in the assessment phase (treatment
consent was obtained following determination of eligibility). The protocol was approved by the
relevant institutional ethics review committees. Clients considered for randomization included
those who met for met criteria for MDD based on the Structured Clinical Interview (Spitzer,
Williams, Gibbon, & First, 1992) for the Diagnostic and Statistical Manual of Mental Disordersthird edition-revised (DSM-III-R; American Psychiatric Association, 1987). Exclusion criteria
included current treatment (psychotherapy and/or medication) for depression, and/or a current
diagnosis of any of the following: bipolar I; panic disorder; substance dependence; eating

Experiential Therapies for Depression

disorders; psychotic disorder; two or more schizotypical features; and paranoid, borderline, or
antisocial personality disorders. Clients were also excluded if they were regarded as in need of
treatment focusing on others problems (e.g., recent suicide attempts or active suicidal state) or in
need of immediate crisis intervention, had the loss of a significant other in the last year, had
recently been or currently was a victim of incest or sexual abuse, or were currently involved in a
physically abusive relationship. Research assistants independent of the primary investigators
assigned code numbers to suitable clients, and clients were randomly assigned to receive either
CC or EFT for depression at a psychotherapy research clinic at an urban university.
Recruitment to follow-up occurred from 1993 to 2002. The total sample of clients
reported in Goldman et al. (2006) consisted of 36 CC and 36 EFT clients (see Figure 1). None of
these clients reported having been diagnosed with more than 3 previous depressive episodes, and
none had a Global Assessment of Functioning (GAF) score less than 50. Clients, on average, fell
within the moderate to severe range of depressive symptomatology on the BDI (Beck, Rush,
Shaw, & Emery, 1979). Therapists provided treatment in both conditions and had at least 1 year
of experience with both EFT and CC treatment approaches.
Treatments
Two brief (16-20 sessions) experiential therapies were implemented: CC and EFT. Both
treatments aim to increase and deepen the clients capacity for emotional processing within the
context of a supportive therapeutic relationship.
Client-centered treatment (CC). This approach was conducted according to a manual
developed by Greenberg, Rice, and Watson (1994), in addition to supplemental readings by
Rogers (1951, 1975). The three therapeutic relationship conditions that are most central in this
orientation are empathy, acceptance, and genuineness. The mainstay of CC is empathic

Experiential Therapies for Depression

responding to promote deeper client experiencing (emotional and meaning-making processes)

within a supportive, nonjudgemental therapeutic environment. The therapist attends to what is
most alive and poignant in the clients experience and empathically understands the clients
internal frame of reference. Depression is hypothesized to result, in part, from incomplete
processing of emotional experience (Greenberg & Paivio, 1997), and the facilitation of deeper
experiencing is understood as the primary goal and vehicle of change in this treatment. This is
seen as leading to change in the clients self-concept in a way that is more congruent with the
clients growth-oriented organismic tendencies (Rogers, 1975).
Emotion-focused treatment (EFT). This approach was conducted according to a manual
developed by Greenberg et al. (1993) and further explicated by Greenberg & Watson (2006).
EFT involves the essential elements of CC with specific supplementation of process-directive,
marker-guided interventions derived from experiential and gestalt therapies applied at in-session
intrapsychic and/or interpersonal targets. These targets are thought to play prominent roles in the
development and exacerbation of depressive experience. The major emotion-focused
interventions of EFT are: Gendlins (1996) focusing intervention at a marker of an unclear bodily
felt sense; gestalt empty-chair dialogues at markers of unfinished business where clients imagine
a significant other in an empty chair and communicate unresolved feelings to them; gestalt twochair dialogues at conflict split markers where clients engage in a dialogue with their critical
inner, often introjected, voice; and systematic evocative unfolding at points of problematic
reactions where clients are imaginally guided back to the problematic situation so that they may
re-experience and make sense of their reactions (Greenberg et al., 1993; Rice, 1974). These
specific interventions are hypothesized to facilitate the creation of new meaning from bodily felt
referents, letting go of anger and hurt in relation to another person, increasing acceptance and

Experiential Therapies for Depression

compassion for oneself, and developing a new view and understanding of oneself (Greenberg,
2002; Watson & Greenberg, 1996).
The first three sessions of the treatment focus on establishing a therapeutic alliance and
providing a facilitative therapeutic relationship. During this phase, only the three CC
relationship conditions are implemented. Thereafter, the EFT active interventions are
implemented, within the context of the facilitative conditions, when depressogenic affectivecognitive problem markers arise. The primary aims are: facilitating the clients symbolization of
particular aspects of subjective emotional experience, facilitating new emotional responses to old
situations, and making new meaning of ones experience based on new information that becomes
available through the reprocessing of emotional material (Greenberg & Watson 2006).
Outcome Measures
The Longitudinal Interval Follow-up Evaluation (LIFE-II; Keller et al., 1987) for
depression was administered at the beginning of each 6-, 12-, and 18-month interview to obtain
retroactive evaluations of the 6-month period prior to each follow-up evaluation (6-, 12-, and 18month periods). Four self-report questionnaires were administered at 6- and 18-month follow-up
periods: BDI, SCL-90-R, RSE, and IIP.
Longitudinal Interval Follow-up Evaluation (LIFE-II). The LIFE-II (Keller et al., 1987) is a
semi-structured interview and integrated rating system developed to assess the longitudinal
course of psychiatric disorders along various dimensions, such as depression, anxiety, and
psychosis according to the Diagnostic and Statistical Manual of Mental Disorders- third editionrevised (DSM-III-R; American Psychiatric Association, 1987) over the previous 6 months. The
interview provides retroactive information regarding psychosocial and psychopathologic status
and any return to treatment. The weekly psychopathology measures, or psychiatric status ratings

Experiential Therapies for Depression

10

(PSR), are ordinal symptom-based scales with categories consistent with levels of symptoms
used in the DSM-III-R for each particular disorder being assessed. Retroactive weekly PSR
ratings for depression during the previous 6 months were collected ranging from meeting criteria
for the index episode (rating of 5 or 6) to no residual symptoms (rating of 1).
A total of 5 advanced PhD student clinical evaluators, each whom had been trained by a
senior clinician with expertise in LIFE-II administration and who were blind to treatment
condition during the administration of the LIFE-II, conducted an equivalent number of
interviews. Queries regarding the clients experience of the treatment to which they had been
assigned occurred after LIFE-II administration, and no evaluator interviewed the same client on
more than one occasion during the outcome and follow-up periods. Audiotape interrater
reliability of the LIFE-II was conducted. Clinical evaluators were not informed which interviews
would be used for reliability purposes. A senior clinician with previous experience in
administering the LIFE-II and who was blind to treatment condition provided reliability ratings.
One-third of the interviews of treatment responders (N = 43) were randomly selected from the
18- month follow-up period and were rated by the senior clinician to obtain agreement on
whether depressive episodes had occurred. The average kappa coefficient (Cohen, 1960) for
these assessments was .87.
Beck Depression Inventory-Long Form (BDI). The BDI (Beck et al., 1979) is a 21-item
self-report measure that measures severity of depression. Responses are scored on a four-point
likert scale, with higher scores indicating greater severity of depression (scores may range from
0-63). Internal consistency for the BDI ranges from .73 to .92 with a mean of .86 and the
measure correlates highly with other self-report measures of depression (Beck, Steer, & Garbin,
1988),.

Experiential Therapies for Depression

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Symptom Check-List-Revised (SCL-90-R). The SCL-90-R (Derogatis, 1983) is a self-report

measure used to assess general symptom distress. On a five-point likert scale, clients indicate to
what extent they experienced each of 90 distress symptoms in the past week. The measure
provides a Global Severity Index (GSI) that indicates overall current symptomatology distress
level. Internal consistency for the SCL-90-R ranges from .77 to .90 and test-retest reliability
between .80 and .90 over a one-week period (Derogatis, Rickels, & Rock, 1976).
Rosenberg Self-Esteem Measure (RSE). The RSE (Rosenberg, 1965) was used to assess client
level of self-esteem. This is a 10-item measure which yields a total score with a higher score
indicating higher self-esteem. High internal reliability (.89 to .94) and test-retest reliability (.80
to .90) have been reported (Bachman & OMalley, 1977).
Inventory of Interpersonal Problems (IIP). The IIP (Horowitz, Rosenberg, Baer, Ureo, &
Villaseor, 1988) is a 127-item self-report measure of current difficulties in interpersonal
functioning. A total score is obtained to determine overall level of interpersonal difficulties.
High internal consistency, validity, and reliability have been reported, and this measure is
reported to be sensitive to clinical change (Horowitz, Rosenberg, Baer, Ureo, & Villaseor,
1988).
Procedure
Follow-up
Follow-up interviews were conducted at 6, 12, and 18 months posttreatment. Each
interview began with administration of the LIFE-II followed by open-ended questioning
regarding the 6 months prior to the interview and progressively focused on more specific areas of
interest within the following domains: (a) the clients experience of therapy; (b) changes in
relation to feelings, behaviors, view of self, and/or interactions with others that have occurred as

Experiential Therapies for Depression

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a result of therapy; (c) life events or challenges that they have encountered; (d) the role of social
support in their lives; and (e) whether they took part in continued treatment for depression. In
addition to the interview component, clients completed self-report outcome measures at 6- and
18-month follow-up evaluation.
Operational Criteria for Treatment Response and Relapse
Treatment responders were identified as client who had a minimum of 8 consecutive
weeks with minimal or no depressive symptoms (PSR of 1 or 2 on the LIFE-II) directly
following the end of the treatment phase. Treatment responders were considered to have
relapsed if they met criteria for a Major Depressive Episode on the LIFE-II (PSR of 5 or 6) for a
minimum of two consecutive weeks during the follow-up period. Relapse was also defined as
having occurred at the time of returning to treatment for depression (psychotherapy for
depression and/or antidepressant medication) during the follow-up phase, regardless of reported
depressive symptoms on the LIFE-II.
Data Analysis
The data analyses on relapse were conducted on all treatment responders. The statistical
tests in the follow-up sample of treatment responders must be interpreted with caution given the
follow-up sample no longer benefited from randomization as in the original sample. Post-hoc
power estimates were observed to be medium to large, depending on the analysis being
conducted. An alpha level of .05 was used for all statistical tests except the repeated measures
comparative analyses in which Bonferroni adjustment for multiple comparisons was used. Chisquare tests were used to compare treatment conditions for proportions of clients in the original
sample who responded to treatment and did not relapse across the follow-up period. Analyses of
variance were used to compare treatments in cumulative number of well weeks among treatment

Experiential Therapies for Depression

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responders across follow-up. Survival analysis was conducted to compare the time to first
relapse among treatment responders by condition. Lastly, we conducted repeated measures
comparative analyses, with treatment group (CC and EFT) as the between-subjects factor and
time (pretreatment, 6-month follow-up, and 18-month follow-up) as the within-subjects factor, at
each follow-up period on self-report outcome measures (BDI, SCL-90-R, RSE, and IIP). Clients
in the treated groups for whom complete self-report follow-up data had been obtained, regardless
of whether or not they were responders during the acute treatment phase, were included in these
analyses. An exception to this was the exclusion of treatment responders who has returned to
treatment for depression during the follow-up phase given that their responses on self-report
measures were expected to have been effected by intervention during follow-up and would not
have been reflective of experimental treatment effects.
Results
Sample Characteristics and Participant Flow
Figure 1 provides detail of participant flow. Fifty-two (25/36 CC and 27/36 EFT) clients
responded to the acute phase treatment and were considered for follow-up analyses. Two
treatment responders (1 CC and 1 EFT) declined taking part in the follow-up stage of the trial.
Four EFT and 3 CC treatment responders were lost due to attrition during the follow-up phase.
Three treatment responders (2 CC and 1 EFT) returned to treatment for depression during the
follow-up period. As noted, self-report data collected at 6- and 18-month follow-up evaluation
for these clients were excluded from the follow-up comparative analyses of outcomes measures
as these symptom reports would likely have been impacted by the return to treatment and would
not have been reflective of experimental treatment effects.

Experiential Therapies for Depression

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Only those clients for whom complete data had been collected were included in the
relapse analyses. Complete relapse data across the 18-month follow-up period were obtained for
43 (83%; 21 CC and 22 EFT) of 52 treatment responders, and these clients were compared on
relapse rates, number of asymptomatic or minimally symptomatic weeks, and survival times
across the 18-month follow-up period. Demographic and clinical characteristics for the acute
phase treatment responders upon whom the relapse results are based are presented in Table 1.
There were no significant differences in demographic and clinical characteristics between the CC
and EFT responder groups who were compared across follow-up (all ps > .05). There were also
no significant differences in demographic and clinical characteristics between clients who started
the acute treatment phase and those who entered the follow-up phase, regardless of treatment
response (ps > .05). For comparative analyses on outcome indices after removing those lost due
to attrition and those who returned to treatment for depression, 56 treatment responders (29 CC
and 27 EFT) who had completed all self-report follow-up data were compared on 6- and 18month self-report measures.
Attrition Analyses
Analyses were conducted to investigate potentially significant differential rates of
attrition between treatments across the entire follow-up period. Clients declining participation or
lost due to attrition during the 18-month follow-up period were all treatment responders (5 EFT
and 4 CC). Chi-square comparisons of differential attrition rates within the two treatment groups
during the 18-month follow-up period revealed no significant difference in the number of clients
lost due to attrition during the follow-up period, 2 (1, N = 9) = 0.50, p = .48. In addition, there
were no significant differences between clients who were lost due to attrition and clients who

Experiential Therapies for Depression

15

were retained across follow-up on demographic characteristics, including sex, age, ethnicity,
education, and marital status (all ps > .05).
Combined sample pre- and posttest comparison on all self-report outcome measures
showed that there were no significant differences (all ps > .05) between those lost due to attrition
and those retrained across the entire follow-up period. In addition, within-group comparisons on
pre- and posttest comparisons showed that there were no significant differences (all ps > .05)
between those lost due to attrition and those retained across the entire follow-up period.
Treatment Response and Relapse Rates
Table 2 summarizes the rates of clients (a) entering treatment, (b) completing treatment,
and (c) responding to treatment according the LIFE-II criteria. Table 3 presents the percentage
of treatment responders in each condition who relapsed across the 6- and 18-month follow-up
periods. There was no significant difference in relapse between the two treatment groups across
6-month follow-up. During the 18-month follow-up period, there was a significant difference
between groups in the proportion of treatment responders who relapsed, 2 (1, 43) = 4.04, p = .
044. A significantly greater proportion of the EFT treatment group did not relapse during the
entire follow-up period in comparison with the CC treatment group. By the end of the 18-month
follow-up period, approximately 52% (11/21) of CC clients and 23% (5/22) of EFT clients had
experienced depressive relapse.
Well Weeks
Table 4 shows the mean cumulative number of well weeks (successive addition of weeks
where clients experienced no or minimal depressive symptoms) during each follow-up period by
treatment condition. Clients included in these analyses were treatment responders for whom
complete LIFE-II follow-up data had been attained.

Experiential Therapies for Depression

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There was no significant difference between the two treatment conditions in well weeks
on the LIFE-II across the 6-month follow-up period, F(1, 43) = 3.147 p = .083, although there
was a trend indicating that EFT clients, on average, experienced a longer period free from
depression in comparison with CC clients. In fact, no EFT clients reported any or more than
minimal depressive symptoms across the 6-month posttreatment period. There was a significant
difference between the two treatment conditions in well weeks on the LIFE-II across the entire
18-month follow-up period, F(1, 43) = 5.183 p = .024 with EFT clients, on average, experiencing
a longer period of time with minimal or no depressive symptoms in comparison with CC clients.
Survival Time to First Relapse
Survival analyses, a method of regression analysis used for analyzing longitudinal data
and the timing of events, were conducted to compare the mean survival time in terms of weeks
before first depressive relapse on the LIFE-II for the two treatment conditions. Clients included
in this analysis were those for whom complete follow-up data on the LIFE-II were obtained.
Clients lost due to attrition were excluded from this analysis due to violation of the independence
assumption and because when they were included in the analysis, the result was extreme rightcensoring where these clients erroneously pulled the survival functions to the right, leading to
overestimates of the benefits of each treatment condition cumulative function.
Figure 2 shows the survival functions of time to first depressive relapse for treatment
responders in each treatment condition. Median survival times for the CC and EFT treatment
groups were 66 and 72 weeks, respectively. Mean survival times for the CC and EFT treatment
groups were 53 and 68 weeks, respectively. A Log-Rank test using the Kaplan-Meier productlimit method comparing the survival distributions between the two treatment conditions was
significant, 2 (1, N = 43) = 4.18, p = .041, indicating that the probability of surviving, or not

Experiential Therapies for Depression

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experiencing depressive relapse during the 18-month follow-up period, was significantly greater
for clients in EFT than for those in the CC treatment.
Comparative Analyses on Outcome Indices
Longitudinal analyses were conducted for each self-report outcome measure. All clients
in the treated groups for whom complete self-report follow-up data had been obtained, regardless
of whether or not they responders during the acute treatment phase, were included in these
analyses (with the exception of those who had returned to treatment for depression).
In the repeated measures analyses of variance (ANOVA), there was a significant main
effect of time on all self-report measures (all p < .001). For the BDI, the main effect of time was
qualified by a significant time by group interaction, , F(2, 108) = 4.84, p = .015. For the SCL,
the main effect of time was qualified by a significant time by group interaction, SCL-90-R, F(2,
108) = 4.16, p = .018. For the RSE, the main effect of time was qualified by a significant time
by group interaction, F(2, 108) = 4.96, p = .009. For the IIP, the main effect of time was
qualified by a significant time by group interaction, F(2, 108) = 3.80, p = .025.
As each of the time by group interactions was statistically significant, a series of planned
comparisons were conducted with Bonferroni adjustments on post-hoc planned contrasts. Table
5 displays the means and standard deviations by treatment group at each time point for each selfreport measure. Repeated measure plots by instrument can be found in Figures 3, 4, 5, and 6.
For the BDI, planned comparisons revealed no significant difference between the groups at 6month follow-up, F(1, 54) < 1, and a significant difference in favour of EFT at 18-month followup, F(1, 54) = 6.76, p = .010. For the SCL-90-R, planned comparisons revealed no significant
difference between the groups at 6-month follow-up, F(1, 54) < 1, and there was a trend in
favour of EFT at 18-month follow-up, F(1, 54) = 4.80, p = .027. For the RSE, there was again

Experiential Therapies for Depression

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no significant difference between the groups at 6-month follow-up, F(1, 54) = 1.56, p < .05, and
there was a significant difference in favour of EFT at 18-month follow-up, F(1, 54) =5.89, p = .
012. Lastly, for the IIP, there was no significant difference between the groups at 6-month
follow-up, F(1, 54) < 1, and there was a trend in favour of EFT at 18-month follow-up, F(1, 54)
= 4.39, p = .035.
Discussion
This study provides the first evidence of differential long-term effects in CC and EFT
treatments. Overall, there was support for the hypothesis that the addition of emotion-focused
interventions of EFT to the relational conditions of CC during the acute treatment phase would
lead to increased maintenance of gains across follow-up. While the two treatment groups were
not significantly differentiated during 6-month follow-up in terms of depressive relapse, EFT
were significantly more likely to not experience depressive relapse in comparison with clients in
the CC treatment when the entire follow-up period was taken into account. In addition, while the
treatment groups did not differ significantly across 6-month follow-up on average number of
weeks with minimal or no depressive symptoms, EFT clients maintained treatment gains of
minimal or no depressive symptoms for a significantly longer period of time across the entire
follow-up period compared to CC clients.
On self-reported symptomatology, CC and EFT clients did not differ significantly at 6month follow-up evaluation where both treatment groups appeared to maintain gains to a similar
degree. By the 18-month follow-up evaluation, clients in the EFT treatment showed, on average,
more improvement on self-report measures of depressive symptomatology and self-esteem.
Trends were found in favour of EFT over CC at 18-month follow-up in general symptom distress
and interpersonal problems.

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The overall pattern of convergence of the treatment conditions on many criteria at 6month follow-up and the divergence at 18-month follow-up may be due to a number of factors.
Before 6-month follow-up, CC clients may have been benefiting from the prior relational support
and from an ability to self-mobilize as a benefit of a less directive form of therapy that aims to
mobilize the clients growth-oriented or actualizing tendency. Self-mobilization is
conceptualized by CC theorists as taking place during treatment and operating and potentially
developing after treatment (Rogers, 1961). However, the mobilization of the clients growth
tendency, while beneficial in terms of sustained improvement to 6 months posttreatment, may
not have endured nor served CC clients as well as the deeper emotional processing and
emotional transformation acquired by EFT clients (Watson & Greenberg 1996).
From clients self-reports EFT appears to have led to more active and effective ways of
dealing with emotional distress in the follow-up period. In follow-up interviews, EFT clients
talked about exercising emotional processing skills that they had learned in therapy to help deal
with distressing life events. These emotion processing skills may have increased awareness of
and the ability to deal with potential depressogenic emotional events that emerged during the
follow-up period. Clients may have become better able to recognize vulnerable periods,
approach emotions, and self-initiate tools that acted as protective factors against the emergence
of a new depressive episode. This study suggests that the addition of EFT interventions at
appropriate markers to the core relational conditions in CC and promotes greater depressive
relapse prevention for periods greater than 6 months posttreatment.
A limitation of the present study was the absence of a control group. Although the
absence of change in untreated depressed clients has been reported (for example, see Nietzel,
Russel, Hemmings, & Greeter, 1987), a control group would have provided a useful comparison.

Experiential Therapies for Depression

20

In addition, as with many outcome and follow-up studies, the generalizability of the findings is
limited by the overrepresentation in the sample of European clients. A common problem in
follow-up studies of differential sieve among treatment conditions and across follow-up (Klein,
1996) is also noteworthy. Also, clients were extensively screened, and the present sample may
not be representative of the population seeking treatment for depression given the stringent
exclusion criteria used, thereby limiting the generalizability of the present findings to potentially
more troubled and difficult-to-treat patients (Westen & Morrison, 2001, p. 880). Lastly,
specific factors (e.g., number of previous MDD episodes) beyond treatment control that could
have accounted for sustained remission and/or relapse rates across follow-up were not identified
and/or controlled.
While the present study provides evidence of the generally superior effects of EFT in
comparison with CC in terms of long-term maintenance of gains, it does not allow for
identification of the nature of change processes that occurred within each treatment that led to
this effect. Intensive process analyses of both acute treatment and follow-up periods are needed
to identify change processes that contribute to maintenance of gains and relapse following
treatment. In addition, comparing treatment groups on the frequency of discrete depressive
episodes (beyond first recurrence) across follow-up, and the duration of relapse episodes, are
important directions for future study.
Lastly, replication of this study by other researchers is important given that, as with most
outcome and long-term efficacy studies, the current study involved only one site where
investigators and therapists, although claiming allegiance to both approaches, may be argued to
have shown greater allegiance to EFT over CC. Accordingly, further investigation at various
sites with investigators from differing theoretical orientations promises to be revealing.

Experiential Therapies for Depression

21

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Experiential Therapies for Depression

27

Author Note
Jennifer A. Ellison, Leslie S. Greenberg, Rhonda N. Goldman, and Lynne Angus,
Department of Psychology, York University, Ontario, Canada.
Rhonda N. Goldman is now at Department of Psychology, Illinois School of Professional
Psychology at Argosy University, Schaumburg, Illinois.
This research was supported in part by grants from the National Institute of Mental
Health and from the Ontario Mental Health Foundation, both granted to the second author.
Correspondence concerning this article should be addressed to Jennifer A. Ellison,
Department of Psychology, York University, Toronto, Ontario, Canada. E-mail:
jennifer@alumni.yorku.ca

Experiential Therapies for Depression

28

Table 1
Demographic and Clinical Characteristics For Treatment Responders
Treatment Condition
CC
EFT

Total

Variable
Female, n (%)

(n= 21)

(n = 22)

(N = 43)

13 (61.9)

12 (54.5)

25 (58.1)

European, n (%)

17 (81.0)

16 (72.7)

33 (76.7)

38.76 (11.62)

37.64 (7.27)

38.19 (9.54)

22-58

22-49

Single

9 (42.9)

7 (31.8)

16 (37.2)

Married

5 (23.8)

9 (40.9)

14 (32.6)

Divorced/Separated/Widowed

7 (33.3)

6 (27.3)

13 (30.2)

Axis II Diagnosisa, n (and %)

7 (33.3)

6 (27.3)

13 (30.2)

BDI Pretreatment, M (and SD)

25.10 (7.34)

27.32 (6.64)

26.23 (7.00)

BDI Postreatment, M (and SD)

6.19 (3.79)

5.23 (4.85)

5.70 (4.34)

Age
M (and SD)
Range (n)
Marital Status, n (and %)

Note. CC = client-centered; EFT = emotion-focused therapy. BDI = Beck Depression Inventory.

a

Axis II diagnosis at pretreatment.

Experiential Therapies for Depression

30

Table 2
Intent-To-Treat, Completed Treatment, and Treatment Responder Rates
Treatment Condition
Variable
CC
EFT
Total
Intent-to-treat, n
41
42
83
Completed, n
36
36
72
Responders, n
25
27
52
a
%
60.9
64.3
62.7
%b
69.4
75.0
72.2
Note. Intent-to-treat included those participants who where randomized to a treatment condition.
Completed included those participants who completed at least 11 treatment sessions. Responders
included those participants who reported minimal or no depressive symptoms (Psychiatric Status
Rating of 1 or 2) for at least 8 consecutive weeks posttreatment on the LIFE-II interview. CC =
client-centered; EFT = emotion-focused therapy.
b

Percent of all clients completing treatment.

Percent of all clients entering treatment;

Experiential Therapy for Depression

30

Table 3
Rates of Relapse Among Treatment Responders During Follow-Up
Treatment condition
CC
EFT

Variable
2
6-month follow-up
Responders, n
21
22
No Relapse, n (%)
18 (85.7)
22 (100.0)
2 (1, N = 43) = 3.38, p = 108.
Relapse, n (%)
3 (14.3)
0 (0)
18-month follow-up
Responders, n
21
22
No Relapse, n (%)
10 (47.6)
17 (77.3)
2 (1, N = 43) = 4.04, p = .044*
Relapse, n (%)
11 (52.4)
5 (22.7)
Note. Responders included those participants who reported minimal or no depressive symptoms
(Psychiatric Status Rating of 1 or 2) for at least 8 consecutive weeks posttreatment on the LIFEII interview. CC = client-centered; EFT = emotion-focused therapy. *p < .05.

Experiential Therapy for Depression

31

Table 4
Mean Number of Well Weeks Among Treatment Responders During Follow-up
Treatment Condition
CC
EFT
Well Week
M
SD
M
SD
F
Responders, n
21
22
6 months
23.05
2.52
24.0
0
F(1, 43) = 3.15, p = .083
18 months
47.43 20.97 60.18 15.47 F(1, 53) = 5.18, p = .024*
Note. Responders included those participants who reported minimal or no depressive symptoms
(Psychiatric Status Rating of 1 or 2) for at least 8 consecutive weeks posttreatment on the LIFEII interview. CC = client-centered; EFT = emotion-focused therapy. *p < .05.

Experiential Therapy for Depression

32

Table 5
Means and Standard Deviations of BDI, SCL-90-R GSI, RSE, and IIP by Treatment Group at
Each Follow-Up Period For All Acute Phase Treatment Completers
Treatment Condition
CC
(n = 29)

EFT
(n = 27)

M
SD
M
SD
Follow-up period
BDI
Pretreatment
24.62
6.80
26.30
6.96
6 months
8.72
7.01
7.58
5.41
18 months
11.76
8.32
6.74*
5.81
SCL-90-R GSI
Pretreatment
1.26
0.47
1.38
0.45
6 months
0.57
0.50
0.50
0.36
18 months
0.75
0.60
0.45
0.33
RSE
Pretreatment
21.76
6.46
20.43
6.17
6 months
27.97
5.50
29.87
5.91
18 months
27.10
5.97
31.00*
6.04
IIP
Pretreatment
1.49
0.58
1.54
0.40
6 months
0.99
0.54
0.97
0.53
18 months
1.23
0.61
0.91
0.49
Note. CC = client-centered; EFT = emotion-focused therapy; BDI = Beck Depression Inventory;
SCL-90-R GSI = Symptom Checklist-90-Revised Global Severity Index; RSE = Rosenberg SelfEsteem; IIP = Inventory of Interpersonal Problems. * p < .0125 (adj. for multiple comparisons).

Experiential Therapy for Depression

33

Figure Captions
Figure 1. CONSORT flow chart. CC = client-centered therapy; EFT = emotion-focused therapy.
Figure 2. Survival curves for time to first relapse among treatment responders across follow-up
(N = 43). CC = client-centered therapy; EFT = emotion-focused therapy.
Figure 3. BDI by Treatment Group Across Follow-up (N = 56). CC = client-centered therapy;
EFT = emotion-focused therapy. Pre = pretreatment; 6-Month = 6-month follow-up; 18-Month =
18-month follow-up.
Figure 4. SCL-90-R by Treatment Group Across Follow-up (N = 56). CC = client-centered
therapy; EFT = emotion-focused therapy. Pre = pretreatment; 6-Month = 6-month follow-up; 18Month = 18-month follow-up.
Figure 5. RSE by Treatment Group Across Follow-up(N = 56). CC = client-centered
therapy; EFT = emotion-focused therapy. Pre = pretreatment; 6-Month = 6-month follow-up; 18Month = 18-month follow-up.
Figure 6. IIP by Treatment Group Across Follow-up (N = 56). CC = client-centered
therapy; EFT = emotion-focused therapy. Pre = pretreatment; 6-Month = 6-month follow-up; 18Month = 18-month follow-up.

Experiential Therapy for Depression

34

Randomized (N = 83)

Allocated to client-centered therapy (CC; n

= 41)
Completed treatment (n = 36)
Did not complete treatment (n = 5)
Therapist nonadherent;
transferred to EFT at client
request following session 3 (n = 1)
Began other psychotherapeutic
treatment (n = 1)
Client-initiated treatment
termination before session 11 and
not followed (n = 2)
Unable to contact (n = 1)
Treatment responders according to the
LIFE-II at posttreatment (n = 25)

Follow-up analyses
LIFE-II for treatment responders
(n = 21)
Unable to contact (n = 3)
Client declined participation in
follow-up period (n = 1)
Self-report for treatment completers
(n = 29)
Unable to contact (n = 4)
Declined participation in follow-up
period (n = 1)
Return to treatment excluded
(n = 2)

Allocated to emotion-focused therapy (EFT;

n = 42)
Completed treatment (n = 36)
Did not complete treatment (n = 7)
Serious medical illness (n = 1)
Sudden move (n = 1)
Began other psychotherapeutic
treatment (n = 2)
Client-initiated treatment
termination before session 11 and not
followed (n = 1)
Unable to contact (n = 2)

Treatment responders according to the

LIFE-II at posttreatment (n = 27)

Follow-up analyses
LIFE-II for treatment responders
(n = 22)
Unable to contact (n = 4)
Client declined participation in
follow-up period (n = 1)
Self-report for treatment completers
(n = 27)
Unable to contact (n = 5)
Declined participation in follow-up
period (n = 1)
Return to treatment excluded
(n = 3)

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Experiential Therapy for Depression

35

CC
EFT
CC
Experiential Therapy for Depression

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EFT
CC
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EFT
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Experiential Therapy for Depression

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