Person-Centered & Experiential Psychotherapies

ISSN: 1477-9757 (Print) 1752-9182 (Online) Journal homepage: http://www.tandfonline.com/loi/rpcp20

How does client expressed emotional arousal

relate to outcome in experiential therapy for
depression?

A. E. Pos, D. A. Paolone, C. E. Smith & S. H. Warwar

To cite this article: A. E. Pos, D. A. Paolone, C. E. Smith & S. H. Warwar (2017): How does client
expressed emotional arousal relate to outcome in experiential therapy for depression?, Person-
Centered & Experiential Psychotherapies, DOI: 10.1080/14779757.2017.1323666

To link to this article: http://dx.doi.org/10.1080/14779757.2017.1323666

Published online: 25 May 2017.

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PERSON-CENTERED & EXPERIENTIAL PSYCHOTHERAPIES, 2017
https://doi.org/10.1080/14779757.2017.1323666

How does client expressed emotional arousal relate to

outcome in experiential therapy for depression?
A. E. Posa, D. A. Paolonea, C. E. Smitha and S. H. Warwarb
a
Department of Psychology, York University, Toronto, Canada; bPrivate Practice, Toronto, Canada

ABSTRACT ARTICLE HISTORY

Experiential empirically supported treatments for depression Received 11 July 2016
assume that both arousal and experiencing of emotion are neces- Accepted 31 January 2017
sary for good treatment outcomes. The current study examined
the importance of emotional arousal and experiencing to outcome KEYWORDS
Experiential; emotion;
during 32 experiential therapies for major depression. Experiential arousal; experiencing
theory assumes that arousal is important to outcome because it
facilitates further emotional processing. The relative contribution
of emotional arousal and experiencing was examined within
phases of therapy. Two main hypotheses were explored. (1) We
hypothesized that arousal would indirectly predict outcome
mediated by experiencing and (2) we hypothesized that experi-
ential therapy would increase emotional arousal across therapy.
Both hypotheses were supported. The present findings therefore
support experiential theory concerning the importance of both
emotional arousal and experiencing to good outcome in experi-
ential treatment of depression.

Comment l’éveil émotionnel exprimé par le

client entre en corrélation avec l’issue d’une
thérapie expérientielle appliquée à la
dépression.
Les traitements de la dépression effectués sur base empirique
supposent que l’éveil et l’experiencing de l’émotion sont
nécessaires pour une bonne issue du traitement. L’étude
présentée examine, au cours de 32 thérapies expérientielles
menées dans des cas de dépression majeure, l’importance de
l’éveil émotionnel exprimé et de l’experiencing sur l’issue de la
thérapie. La théorie expérientielle suppose que l’éveil est impor-
tant quant à l’issue parce qu’il facilite la poursuite d’autres
développements émotionnels. Les contributions respectives de
l’éveil émotionnel et de l’experiencing ont été étudiées au sein
des phases de la thérapie. Deux théories principales ont été
explorées. 1) Le noyau de l’hypothèse était que l’éveil indiquerait
l’issue de manière indirecte par l’entremise de l’experiencing; et 2)
que la thérapie expérientielle augmenterait l’éveil émotionnel tout
au long du parcours thérapeutique. Les deux hypothèses se sont
vérifiées. Les conclusions présentes confortent donc la théorie
expérientielle concernant l’importance de l’éveil émotionnel
et de l’experiencing l’un et l’autre pour une issue favorable lors
du traitement expérientiel d’une dépression.

CONTACT A. E. Pos aepos@yorku.ca York University

© 2017 World Association for Person-Centered & Experiential Psychotherapy & Counseling
2 A. E. POS ET AL.

Wie verhält sich von Klienten ausgedrückte

emotionale Erregung zum Outcome in
Experienzieller Therapie für Depression?
Experienzielle empirisch abgestützte Behandlungen bei Depression
gehen davon aus, dass sowohl das Wachrufen als auch das Erleben
von Emotion für gute Behandlungsergebnisse notwendig sind. Die
vorliegende Studie untersuchte die Wichtigkeit von sowohl
ausgedrückter emotionaler Erregung als auch dem Erleben auf den
Outcome während 32 Experienzieller Therapien von Major Depression.
Experienzielle Theorie nimmt an, dass das Wachrufen von Emotionen
wichtig für den Outcome ist, weil es weiteres emotionales Prozessieren
fördert. Der relative Beitrag von emotionalem Wachrufen und dann
dem Erleben wurde innerhalb von Therapiephasen untersucht. Zwei
Haupt-Hypothesen wurden untersucht. 1. Die Kern-Hypothese war,
dass das Wachrufen indirekt den Outcome vorhersagen würde, ver-
mittelt durch das Erleben, und dass 2. Experienzielle Therapie die
emotionalen Reaktionen über die Therapie hinweg erhöhen würde.
Beide Hypothesen wurden gestützt. Die gegenwärtigen Befunde
unterstützen daher die experienzielle Theorie, was die Wichtigkeit
von sowohl emotionalem Wachrufen als auch dem Erleben als wesen-
tlichen Faktoren für ein gutes Resultat in der experienziellen
Behandlung von Depressionen angeht.
¿Cómo se relaciona la excitación emocional
expresada por el cliente con el resultado en la
terapia experiencial para la depresión?
Los tratamientos experienciados para la depresión apoyados
empíricamente asumen que tanto la excitación como la experien-
cia de la emoción son necesarias para buenos resultados del
tratamiento. El presente estudio examinó la importancia de expre-
sar la excitación emocional y experienciar el resultado durante
treinta y dos terapias experienciales para la depresión mayor. La
teoría experiencial asume que la excitación es importante para el
resultado porque facilita el procesamiento emocional adicional. Se
examinaron la contribución relativa de la excitación emocional y el
experienciar, dentro de las fases de la terapia. Se exploraron dos
hipótesis principales. 1) La hipótesis central era que la excitación
indirectamente predeciría resultado mediado por el experienciar;
Y 2) la terapia experiencial aumentaría la excitación emocional a
través de la terapia. Ambas hipótesis fueron apoyadas. Por lo
tanto, los presentes hallazgos apoyan la teoría experiencial sobre
la importancia de la excitación emocional y la experiencia de un
buen resultado en el tratamiento experiencial de la depresión.

De que forma a ativação emocional manifestada

pelo cliente se relaciona com o resultado da
terapia experiencial da depressão?
Alguns tratamentos experienciais apoiados empiricamente assumem
a necessidade de ativar e experienciar emoções, com vista a bons
resultados terapêuticos. O presente estudo analisou a importância da
ativação e da experienciação de emoções, manifestadas pelo cliente,
no resultado de trinta e duas terapias de depressão major. A teoria
experiencial admite que a ativação emocional é importante porque
facilita o subsequente processamento das emoções. A contribuição
 PERSON-CENTERED & EXPERIENTIAL PSYCHOTHERAPIES 3

relativa da ativação e da experienciação emocional foi analisada em

várias fases da terapia. Foram exploradas duas hipóteses principais. 1)
A hipótese central é a de que a ativação prediz de forma indireta o
resultado mediado pela experienciação. 2) A terapia experiencial faz
aumentar a ativação emocional no seu curso. Ambas as hipóteses
foram confirmadas. Os resultados aqui expressos apoiam assim uma
terapia experiencial, no que diz respeito à importância da ativação e
emocional para o bom resultado do tratamento experiencial da
depressão.

Major depressive disorder (MDD) is the current leading health burden in western economies,
and is projected to become the leading cause of disability worldwide by 2030 (WHO, 2012).
A number of empirically supported treatments for MDD exist, but Westen and Morrison
(2001) argue that their effects are moderate and not long lasting. As such, treatments for
depression should be improved. To do so requires that we empirically establish how
treatments for MDD work by demonstrating that processes assumed to occur in treatments
for depression, in fact, do occur and lead to client improvement (Wampold, 2001). This study
examines two emotional processes, arousal and experiencing, both assumed to be core
contributing components of the core change process that is assumed to be at the heart of
experiential treatment for depression – emotional processing. In this investigation, we
examine how these two emotional processing components contribute to predicting out-
come during experiential treatment for depression – emotional processing.
Humanistic experiential therapies (HEPs) are empirically supported treatments for
depression (Goldman, Greenberg, & Angus, 2006; Greenberg & Watson, 1998; Watson,
Gordon, Stermac, Steckley & Kalogerakos, 2003). From the HEP perspective, depression is
viewed as resulting from incomplete processing of emotional experience (Greenberg, Elliott,
& Foerster, 1990; Greenberg & Paivio, 1997). For this reason, emotional processing (attending
to, regulating, reflecting on, making meaning of, and transforming emotions) is both an
important therapeutic task and change process in experiential treatment (Pos & Greenberg,
2007). As such, experiential treatments do not seek to help clients eliminate emotional
experience, but rather, to help clients process their emotions more effectively (Pos,
Greenberg, & Elliott, 2008). In particular, according to emotion-focused theory (Greenberg
& Watson, 2006), the ‘brass ring’ of emotional processing is emotional transformation of
clients’ emotional vulnerability to depression. This is assumed to occur if clients stop
experiencing secondary protective or maladaptive depressogenic emotion, such as self-
critical anger or feelings of worthlessness, and, instead, access, experience and express
adaptive emotions such as assertive anger or grief that can support needs for limit setting
or letting go. As such, experience of adaptive emotion is thought to resolve clients’ emo-
tional vulnerability to depression (Greenberg & Watson, 2006). The concept ‘emotional
transformation’ was not directly measured in the present study. What were directly mea-
sured were two emotional processes assumed to contribute to ‘emotional processing and
transformation’, emotional arousal, and emotional experiencing.
In order for clients to accomplish processing emotional experiences in awareness and to
transform their depressogenic emotion schemes, a core experiential theory assumption is
that emotion must first be activated or aroused in therapy. Alternatively stated, productive
4 A. E. POS ET AL.

emotional processing requires that clients’ emotions are felt, are ‘up and running’, or ‘on-
line’ in a live way in the session. Following their aroused activation, emotions can then be
further processed by attending to and reflecting on them in awareness. That is, they can be
‘experienced’. As such, through emotional arousal in therapy, automatically functioning
(likely depressogenic) emotion schemes are thought to become salient and therefore
more ‘consciously available’ to clients’ awareness and further processing. Therefore,
when emotions are aroused in session, this is viewed as adaptively contributing to
increasing the emotional ‘signal’ and to the likelihood that clients will attend to and
further process their emotions through experiencing them in awareness and talking
about them with the therapist. This assumption leads to a hypothesis: emotional arousal
will indirectly contribute to optimal outcomes by facilitating emotional experiencing. This
was the main hypothesis in this study.
While the importance to outcome in experiential therapy of both emotional experiencing
and expressed emotional arousal has been examined (Carryer & Greenberg, 2010;
Greenberg, Auszra, & Herrmanns, 2007; Missirlian, Toukmanian, Warwar, & Greenberg,
2005; Pos, Greenberg, Goldman, & Korman, 2003; Pos, Greenberg, & Warwar, 2009), their
concurrent contribution to outcome has not yet been adequately investigated. Emotional
experiencing during ‘emotion episodes’ (EEs) (see procedure section for a full explanation of
EEs) has been demonstrated to be a robust predictor of outcome, even after controlling for
the alliance (Goldman, Greenberg & Pos, 2005; Pos et al., 2003, 2009). Using a measure of
expressed emotional arousal, optimal mid-levels of expressed emotional arousal that predict
good outcome have also been identified (Carryer & Greenberg, 2010). Using a newly
developed complex measure of several dimensions of arousal, ‘productive’ levels of arousal
have now also been described and quantitatively linked to good outcomes (Auszra,
Greenberg, & Herrmann, 2013; Greenberg et al., 2007).
Only one previous dissertation has concurrently examined expressed arousal and experi-
encing on outcome during experiential therapy (Warwar, 2003). Using hierarchical regres-
sion, Warwar regressed process ratings of both expressed emotional arousal (measured
using the Client Emotional Arousal Scale (CEAS-III-R:Warwar & Greenberg, 1999) and emo-
tional experiencing (measured using the Experiencing Scale during emotion narratives or
episodes; EXP; Klein, Mathieu-Coughlan, & Kiesler, 1969) on outcome. Both measures were
applied to the same EEs from early, middle, and late sessions of therapy. Warwar’s hypoth-
esis was that expressed arousal in the middle of therapy would lead to higher experiencing
late in therapy and that both would predict outcome directly. However, Warwar (2003)
found that expressed emotional arousal often did not directly predict outcome.
One cannot conclude, however, that because expressed emotional arousal often dropped
out of Warwar’s (2003) models as an independent predictor of outcome, that arousal was not
important to the experiential therapeutic process. Arousal may still positively and indirectly
impact outcome by facilitating the experiencing process within sessions. Since Warwar used
hierarchical regression, only direct independent predictors to outcome were tested, so any
indirect impact of arousal on experiencing was never examined. The potential indirect effect
of emotional arousal on outcome via experiencing, therefore, remains to be investigated.
The primary goal of this study was to provide a strong test of this assumed relation-
ship between arousal and experiencing in experiential theory. By using a path analytic
strategy (using the R statistical package) both direct and indirect effects of expressed
emotional arousal and experiencing on therapeutic outcome for depression could be
 PERSON-CENTERED & EXPERIENTIAL PSYCHOTHERAPIES 5

tested. Further, we tested this relationship within phases of therapy, as opposed to

across phases of therapy as in Warwar (2003), as we wished to examine the assumed
impact of arousal on experiencing expected within therapy sessions.
A second interesting concern resulting from Warwar (2003) is that, in that study, arousal
and experiencing were found to be highly linearly correlated. However, the relationship
between arousal and performance on tasks has been previously described as curvilinear by
the Yerkes–Dobson law (Broadhurst, 1957). This law suggests that both low and high
arousal relate to poorer performance on tasks. It is middle level of arousal that has been
shown to be optimal for performances. Carryer and Greenberg (2010) did find this for 38
depressed clients for whom mid-levels of average arousal from the first 5 min of three
therapy sessions exhibiting high arousal best predicted outcomes (experiencing, however,
was not measured). If one considers emotional experiencing as a therapy performance
task, and that the Yerkes–Dodson law concerning arousal is true, a curvilinear relationship
between expressed arousal and experiencing would also be expected. However, since
Warwar found a linear relationship between emotional arousal and experiencing in her
sample of 32 depressed clients, it begs the question of whether a restricted range of
arousal scores was obtained in Warwar (2003), perhaps due to selection criteria for the
study, or the nature of the depressed population (Greenberg & Watson, 1998). To explore
this concern, we reanalyzed Warwar’s (2003) arousal scores in preparation for R path
analyses, to confirm that the data satisfied assumptions requiring linear relationship
existing between expressed arousal and experiencing scores.
Finally, since experiential therapies intentionally arouse emotion in order to facilitate
emotional exploration, clients’ emotional arousal across experiential therapies should
increase. This, too, has not been fully examined. An additional goal was, therefore, to
investigate whether experiential therapy results in significant increases in emotional
arousal across therapy. All of these research questions were examined through a second-
ary analysis of the archival arousal and experiencing data obtained from Warwar (2003).

Summary of study hypotheses

Hypothesis One ‘a’ and ‘b’: 1a. Expressed emotional arousal and experiencing scores in
the current data will be linearly related. 1b. As assumed by experiential theory, within
phases of therapy expressed arousal will significantly, albeit indirectly, predict outcome
by being mediated by experiencing.

Hypothesis Two: As assumed by experiential theory, expressed arousal will significantly

increase across experiential therapy for depression.

Method
Participants
Participants were 32 clients who participated in the York I Depression Study (Greenberg &
Watson, 1998) which compared the effects of client-centered (CC) versus process-experiential
treatment (more currently called Emotion-focused therapy; EFT) for MDD. All participants met
6 A. E. POS ET AL.

criteria for MDD on the Structured Clinical Interview for the DSM-III-R (SCID; Spitzer, Williams,
Gibbon, & First, 1989) and had Beck Depression Inventory (BDI; Beck, Steer, & Garbin, 1988)
scores equal to or higher than 16. Exclusion criteria, assessed using the SCID and a clinical
interview, were a Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American
Psychiatric Association, 1987). Global Assessment and Functioning Scale score lower than 50,
current drug or alcohol abuse, current eating disorder, antisocial or borderline personality
disorder, bipolar or psychotic disorder, a past history of incest, recent suicide attempts, loss of
a significant other in the past year, or involvement in an ongoing violent relationship. The
sample included 21 females, 11 males, and age ranged from 27 to 63 years (M = 37, SD = 8.9).
For further demographic information, see Warwar (2003).

Treatments
Two brief (16–20 sessions) experiential therapies were used: CC therapy and process experi-
ential therapy (PET)/EFT. Although CCT is less directive than EFT after session 3, the change
theory in both treatments is the same that emotional processing is essential to promote
change. Since the two treatments share this goal of deepening emotional processing, testing
the relationship between these two emotional processing components and outcome in the
collapsed sample of clients across both these experiential therapies was valid.

Client-centered therapy
Originally developed by Carl Rogers (Rogers, 1957, 1961), Rogers’ CC therapy involves
providing conditions of congruence, unconditional positive regard, and empathic under-
standing, which are necessary facilitative relationship conditions provided by the thera-
pist. These core therapeutic elements are essential in order for the client to feel safe to
approach their experience and express themselves in therapy.

Emotion-focused therapy (EFT)

(Greenberg, Rice, & Elliott, 1993; Greenberg & Watson, 2006). EFT is a humanistic treatment
that also views emotions as essential in the experience of self, in adaptive and maladaptive
functioning, and therapeutic change. EFT is an integration of CC and gestalt treatment
principles that uses both a CC relationship style and marker-driven intervention. Markers of
emotional processing difficulties signal therapists to address clients’ difficulties with
specific interventions designed to resolve the difficulty. For example, self-criticism is
processed using two-chair work. Focusing and unfinished business interventions are also
employed. For more information on the EFT see Greenberg and Watson (2006).

Process measures
Client Emotional Arousal Scale III (Revised)
CEAS-III-R; Warwar and Greeenberg (1999). The CEAS-III-R is a 7-point, observer-rated
ordinal measure of clients’ expressed arousal. Average CEAS-III-R has been shown to
predict outcome (Greenberg et al., 2007; Missirlian et al., 2005; Warwar, 2003).
Observers rate expressed emotion by using vocal speech pattern markers (Rice &
Kerr, 1986) detected by attending to vocal accentuation patterns and vocal regularity
of pace, expressive terminal contours, as well as by disruptions in speech patterns
 PERSON-CENTERED & EXPERIENTIAL PSYCHOTHERAPIES 7

that occur under high arousal. An ‘emotional voice’ is indicated by irregular patterns
of accentuation and unexpected terminal contours with uneven regularity of pace, all
of which suggest aroused feelings. High CEAS-III-R levels indicate higher arousal
intensities. Lower levels (i.e. 1 and 2) indicate restricted emotion, e.g. Level 1: Client
does not express emotions. Voice or gestures do not disclose any emotional arousal.
Level 4: Arousal is moderate in voice and body. Emotional voice is present; ordinary
speech patterns are moderately disrupted by emotional overflow as represented by
changes in accentuation patterns, unevenness of pace, changes in pitch. Level 7:
Arousal is extremely intense and full in voice and body. Usual speech patterns are
completely disrupted by emotional overflow (there is a falling apart quality).
Trained raters make more reliable ratings from live observation or from videotape but
ratings can also be made using audiotape. Raters rate both the modal (most frequent)
and peak (highest) levels of intensity of the client’s expressed emotional arousal.
Previous studies have reported inter-rater reliability scores ranging from .75 to .81
(Carryer & Greenberg, 2010), which are considered excellent beyond chance (Fleiss,
1981).

Client Experiencing Scale

(EXP; Klein et al., 1969). The Client Experiencing Scale is also a 7-point ordinal measure
that captures the degree to which clients orient to, symbolize, and use their internal felt
experience as information while solving their problems. Rogers (1961) considered opti-
mal experiencing as ‘ideal’ in therapy behavior and he defined a ‘fully functioning
person’ as one who could dynamically integrate affective and rational aspects of
experience and use this experiential complex as an ‘online’ source of information to
inform present behavior. Limited experiencing was assumed to contribute to pathology
(Kiesler, 1973; Klein, Mathieu-Coughlan, & Kiesler, 1986) because limited experiencers
avoid experiencing ongoing internal events (feelings and conflicts), express experience
impersonally, and abstractly, and relate to their environment using ideas of self, rather
than in-the-moment experience. EXP scale Level 1 expresses external and intellectual
processing, and Level 4 EXP represents more internal ‘contact’ with experience as it is
processed (Perls, Hefferline, & Goodman, 1951). The highest Level 7 EXP expresses fluid
processing of presently occurring internal experiential referents. EXP is a robust pre-
dictor of outcomes (see Hendricks for a review, 2002). Raters use grammatical, expres-
sive, paralinguistic, and content distinctions to rate EXP. Both modal (most frequent) and
peak (highest level) ratings are made (Klein et al., 1969). Previous studies have shown
EXP to have excellent reliability and validity (see Klein et al., 1986; for a review; Pascual-
Leone & Yeryomenko, 2016; Pos et al., 2003; 2009).

Outcome measure
Beck Depression Inventory
(BDI; Beck, A. T., Ward, C. H., Mendelsohn, M., Mock, J., & Erbaugh, J., 1961). The BDI is a
21-item self-reported scale designed to measure the severity of depression (Beck, 1972).
The higher the score (possible range 0–63) is, the greater the severity of the depression.
A 10-year review of research reported the BDI Scale to have validity coefficients ranging
8 A. E. POS ET AL.

from .66 to .86 and internal consistency coefficients ranging from .73 to .93 (Beck, Steer
& Garbin, 1988). Here, outcome was measured using BDI residual gain scores that parse
out the impact of pretreatment scores and average therapy effects to provide a more
stringent measure of outcome (Linn, 1981).

Procedures
Emotion episodes
(EEs; Greenberg and Korman, 1993) EEs were the primary units within which emotional
processing ratings were made in this study. An EE is a segment of psychotherapy
narrative in which clients speak about having experienced emotion in response to a
situation. A complete protocol for an EE contains five components: the situation (i.e. loss
of loved one), an emotional response (i.e. sadness), a tendency toward behavior asso-
ciated with emotion (i.e. crying), an appraisal of self or situation (i.e. ‘I’m alone’/‘she’s
gone forever’), and a related concern/need (i.e. attachment). To identify an EE, only the
emotional response and reported situation are required. All EEs were sampled for six
sessions, two sessions each from each client’s early, middle, and late phase sessions of
therapy.

Session selection
The second and third sessions were used as early indices of clients’ baseline levels of
emotional process. Session 1 was excluded because this initial session typically
involves client–therapist interaction that focuses less on process and more on orient-
ing the client to the details of treatment. The middle phase of therapy was defined as
sessions between the fourth and fourth last session judged by raters as exhibiting high
arousal. Therefore, a client’s middle session if they completed 16 total sessions could
have been any two sessions between session 4 and 13 that had exhibited the highest
arousal for that client. The rational of choosing highest aroused sessions in the middle
of therapy was twofold. First it ensured that the highest expressed arousal scores
across therapy for each client would be captured. Assuming that the early sessions
would exhibit lower expressed arousal scores for clients beginning therapy, this
allowed investigating the fullest range of arousal scores exhibited by depressed clients
in experiential therapy. Second and more important, it allowed a strong test of the
relationships between arousal and experiencing at the highest levels of arousal
obtained. The second and third last sessions represented clients’ emotional process
late in therapy.

Process rating procedure

All EEs from every client’s sessions were rated for modal and peak CEAS-III-R (Warwar &
Greeenberg, 1999) and EXP (Klein et al., 1969). Modal ratings represented the average
level while peak ratings the highest process level evidenced in each EE.
For the Experiencing Scale, two independent raters blind to outcome rated the EE
segments on EXP from transcripts of therapy sessions. Both raters were graduate
 PERSON-CENTERED & EXPERIENTIAL PSYCHOTHERAPIES 9

students who had previously completed 60 hours of training, and had previously
participated as EXP raters in past research studies in which they had attained good
reliability.
For the CEAS-III-R ratings, two independent raters, blind to outcome, rated the
expressed emotional arousal of EEs by watching videotapes of the therapy sessions,
aided by session transcripts. Raters were two senior undergraduate students with
supervised therapy experience by registered psychologists who also participated in
40 hours of arousal rating training and were established as reliable arousal raters by
an established expert arousal rater.
For both CEAS-III-R and EXP ratings, each rater rated EEs from every client, and from
each client’s early, middle, and late sessions. For both coding systems, any discrepancies
between the ratings provided by the two raters were discussed and consensual ratings
used in the analyses. Independent ratings were used to establish reliability.

Final scoring of emotional processes

For each client, the ratings for individual EEs within a session were averaged. Averaged
ratings for sessions within phases of therapy were again averaged to provide a mean
modal and mean peak rating for each emotion measure for each phase of therapy. (For
more information on rating procedures see Pos et al., 2005; Warwar, 2003).

Results
Reliability
Inter-rater reliabilities for process ratings reported are archival from both Pos et al. (2009)
and Warwar (2003). These were calculated using Cohen’s Kappa. Cohen’s kappas for
modal and peak EXP ratings were k = .76 and k = .78, respectively, and for the modal and
peak CEAS-III-R ratings, k = .75 and k = .78, respectively. These are considered excellent
reliability by Fleiss (1981).

Descriptive statistics for emotional process measures

Means, standard errors, and ranges for both CEAS-III-R (expressed arousal) and EXP
(experiencing) modal and peak ratings across therapy are presented in Table 1.
Related to CEAS-III scores across therapy, the potential range of CEAS-II-R scores = 6 (7
max – 1 min).

Result Hypothesis 1a.: A restricted range in CEAS-III-R arousal scores and linear
relationships among CEAS-III-R and EXP and outcome were found.

Table 1 indicates that the mean obtained range of arousal scores across therapy
phases was only 1.83, which was only 31% of the possible range of arousal scores
capable of capture by CEAS-III-R (no average CEAS-III scores either modal or peak were
below 1.85 or above 4.83). That is, no arousal scores of 5, 6, or 7 were obtained. Before
proceeding with linear regression and mediation analyses, we examined the impact of
this obtained range of arousal scores on their relationships with experiencing and
10 A. E. POS ET AL.

Table 1. Descriptive statistics for experiencing and expressed arousal scores.

Therapy phase and process variable Mean SD Min Max Range
Early modal experiencing 2.79 .40 2.00 3.86 1.86
Early modal expressed arousal 2.78 0.40 1.97 3.66 1.69
Early peak experiencing 3.34 .29 2.83 4.00 1.17
Early peak expressed arousal 3.39 0.42 2.83 4.43 1.60
Middle modal experiencing 2.84 .36 2.18 3.89 1.71
Middle modal expressed arousal 2.96 0.51 2.17 4.24 2.07
Middle peak experiencing 4.24 .29 2.95 4.24 1.29
Middle peak expressed arousal 3.48 0.50 2.72 4.83 2.11
Late modal experiencing 2.96 .39 2.33 3.85 1.52
Late modal expressed arousal 2.98 0.40 1.85 3.67 1.82
Late peak experiencing 4.32 .35 3.01 4.32 1.31
Late peak expressed arousal 3.62 0.41 2.63 4.33 1.70
Expressed arousal measured as Client Expressed Arousal Scale, Version 3, revised (CEAS-III-R; Warwar & Greeenberg,
1999) and experiencing measured using the Experiencing Scales (EXP: Klein et al., 1969) both rated during Emotion
Episodes (EEs: Greenberg & Korman, 1993); Early = sessions 2 and 3; Middle = two sessions between session 4 and
the fourth last session that were rated as highly aroused by independent raters; Late = the second and third last
sessions.
Expressed arousal measured as Client Expressed Arousal Scale, Version 3, revised (CEAS-III-R; Warwar & Greeenberg,
1999) and experiencing measured using the Experiencing Scales (EXP: Klein et al., 1969) both rated during Emotion
Episodes (EEs: Greenberg & Korman, 1993); Early = sessions 2 and 3; Middle = two sessions between session 4 and
the fourth last session that were rated as highly aroused by independent raters; Late = the second and third last
session.

outcome. We did this using SPSS curve estimation analyses that examined linear versus
curvilinear relationships among these variables in both the middle and late phase of
therapy. In both phases of therapy, very small but significant curvilinear (as expected by
Yerkes–Dodson law) relationships were indicated among arousal and experiencing and
emotional arousal and reductions in depression. However, these curvilinear relationships
contributed .002–2% explanations of variance in either experiencing or outcome.
Alternatively, the linear relationships among arousal and experiencing and outcome
contributed 16–52% of the variance explained in these variables. Therefore, the limited
range of obtained expressed arousal scores resulted in substantial linear relationship
being found among variables, permitting the use of linear regression in further analyses.
These linear correlations between expressed arousal and experiencing and outcome on
the BDI that met mediation analyses assumptions can be found in Table 2.

Results Core Hypothesis 1b: Emotional experiencing mediated the effect of arousal on
outcome

Four path analyses using R (Venables & Smith, 2016) statistical package examined
whether experiencing mediated the impact of expressed arousal on outcome for
depression. Separate models were performed for modal and peak processes as
predictors.
Mediation analyses are presented in Figures 1(middle phase) and 2 (late phase) for
emotional processes predicting outcome. In each figure, the simple relationship
between expressed arousal and outcome without experiencing in the model is
pictured above as Path ‘c’. Path ‘a’ is the effect of expressed arousal on experiencing,
Path ‘b’ is the effect between experiencing on reductions in the BDI, and Path ‘c´’ is
any remaining direct effect between expressed arousal and reductions in depression
 PERSON-CENTERED & EXPERIENTIAL PSYCHOTHERAPIES 11

Table 2. Pearson R correlations among BDI scores, expressed arousal, and experiencing ratings.
BDI Early Middle Late Early Middle
RG scores CEAS CEAS CEAS EXP EXP
Correlations with peak expressed arousal and experiencing
Early CEAS-III-R −0.18
Middle CEAS-III-R −0.46** 0.59***
Late CEAS-III-R −0.42* 0.61*** 0.42*
Early EXP −0.42* 0.79*** 0.70*** 0.48**
Middle EXP −0.60*** 0.44* 0.72*** 0.48** 0.62***
Late EXP −0.57*** 0.29 0.64*** 0.41* 0.64*** 0.59***
Correlations with modal expressed arousal and experiencing
Early CEAS-III-R −0.27
Middle CEAS-III-R −0.46** 0.60***
Late CEAS-III-R −0.43* 0.60*** 0.49**
Early EXP −0.48** 0.70*** 0.66*** 0.63***
Middle EXP −0.64*** 0.57*** 0.74*** 0.66*** 0.77***
Late EXP −0.64*** 0.34 0.64*** 0.45** 0.56*** 0.76***
***p < .001; **p < .01; *p < 0.05; BDI RG Scores = Beck Depression Inventory residual gain scores; early, middle, and
late = therapy phases; EXP = Experiencing Scale; CEAS = CEAS-III-R = Client Expressed Arousal Scale III-revised;
correlations not corrected for family wise error; N = 32 for all correlations.

Middle Modal Arousal and Experiencing Models Middle Peak Arousal and Experiencing Models

Figure 1. Predicting final outcome from modal and peak emotional processes during the middle
phase of therapy.
Significant codes; ***p < .001, **p < .01, *p < .05; Simple regressions found above, mediated model
regressions below.
Betas are all standardized to allow comparison; BDI = Beck Depression Inventory residual gains;
Emotional arousal = Expressed arousal measured as CEAS-III-R (Warwar & Greeenberg, 1999) and
emotional experiencing measured as EXP (Klein et al., 1969) Middle = two sessions between session
4 and the fourth last session that were rated as highly aroused by independent raters.

with experiencing co-considered in the model. All effects reported are standardized
betas.

Middle phase arousal and experiencing predicting reduction in depression

Middle modal emotional processess
A simple regression of mid-therapy modal arousal on final reductions in the BDI was
significant (see Figure 1, left figure; Path c: β = −0.458, SE = 0.165, p = .008). About 20.9%
12 A. E. POS ET AL.

of the variation in final reductions of BDI scores can be explained by modal expressed
arousal alone in the middle of therapy.
In the mediation analysis of modal emotional processes (also found in Figure 1, left
figure), middle phase modal expressed arousal significantly predicted experiencing (Path
a: β = .739, SE = 0.119, p = .001) which was the sole significant direct predictor of BDI
outcome (Path b: β = −.661, SE = 0.202, p = .001). The significant direct effect of middle
phase modal arousal on outcome found in the simple regression was no longer sig-
nificant when experiencing was included as a predictor. The Sobel test of the indirect
effect of arousal on outcome was significant (Sobel test: β = −0.489, SE = 0.169, p = .004).
Preacher and Kelley (2011) recommend using the ratio of the relative magnitudes of the
indirect to total effects (PM = ab/ab+ c´) to represent the magnitude of a mediated
effect. Using this relative ratio modal, middle phase experiencing mediated virtually
100% of the total effect of modal middle phase arousal on final reductions in BDI scores.

Middle peak emotional processes

The standardized beta obtained from a simple regression of peak middle phase
expressed that arousal on outcome was significant (see Figure 1, right figure, Path c:
β = −0.457, SE = 0.162, p = 0.008) and 20.9% of the variation in final reductions in
depressive symptoms could be explained by peak expressed arousal alone in the middle
of therapy.
In the mediation analysis including peak EXP (also Figure 1, right figure), peak middle
phase expressed arousal significantly predicted experiencing (Path a: β = 0.723,
SE = 0.112, p < .001) which again was the sole significant direct predictor of outcome
(Path b: β = −.573, SE = 0.204, p = .005). The significant direct effect of expressed arousal
on outcome indicated by the pervious simple relationship was no longer significant
when experiencing was included as a predictor. The Sobel test of the indirect effect of
peak middle arousal on outcome was significant (Sobel test: β = −0.414, SE = 0.163,
p = 0.01). Preacher & Kelley’s (2011) ratio of the relative magnitudes of the indirect to
total effects (PM = ab/ab+ c´) indicated that middle peak experiencing mediated 91% of
the effect of peak middle arousal on final reductions in BDI scores.

Late phase arousal and experiencing predicting reduction in depression

Late modal emotional process
The simple standardized beta from the simple regression of modal expressed arousal
late in therapy on final reductions in the BDI was significant (Figure 2, left figure; Path c:
β = −0.431, SE = 0.165, p = 0.014). In this simple model relating expressed arousal and
outcome, about 18.6% of the variation in depression is explained by late modal arousal
alone.
In the mediation analysis of late phase modal emotional processes predicting reduc-
tions in depression (also Figure 2, left figure,) late phase modal expressed arousal
significantly predicted experiencing (Path a: β = .454, SE = 0.158, p = .004), experiencing
being the sole significant direct predictor of outcome (Path b: β = −.556, SE = 0.149,
p = < .001). Any remaining direct effect of the late phase modal expressed arousal on
outcome indicated by the simple regression between arousal and outcome was no
longer significant when experiencing is included as a predictor. The indirect effect of
 PERSON-CENTERED & EXPERIENTIAL PSYCHOTHERAPIES 13

Late Modal Arousal and Experiencing Models Late Peak Arousal and Experiencing Models

Figure 2. Predicting final outcome from modal and peak emotional processes during the late phase
of therapy.
Significant codes; ***p < .001, **p < .01, *p < .05; Simple regressions found above, mediated model
regressions below.
Betas are all standardized to allow comparison; BDI = Beck Depression Inventory residual
gains; Emotional arousal = Expressed arousal measured as CEAS-III-R (Warwar & Greeenberg,
1999) and emotional experiencing measured as EXP (Klein et al., 1969) Middle = two sessions
between session 4 and the fourth last session that were rated as highly aroused by independent
raters.

late modal arousal on outcome was significant (Sobel’s test: β = −0.252, SE = 0.111,
p = 0.023). The Preacher & Kelly’s ratio of the relative magnitudes of the indirect
to total effects (PM = ab/ab+ c´) indicated that late in therapy late modal experien-
cing mediated 59% of the effect of arousal on final reported reductions in
depression.

Late peak emotional process

The standardized beta from the simple regression of peak late phase expressed arousal
on outcome was significant (see Figure 2, right figure; Path c: β = −0.417, SE = 0.166,
p = 0.02). About 17.4% of the variation in final reported reductions of depressive
symptoms was explained by peak expressed arousal late in therapy.
In the mediation analysis (Figure 2, right figure), late peak expressed arousal
significantly predicted experiencing (Path a: β = .407, SE = 0.161, p = .012) which
again was the sole significant direct predictor of outcome (Path b: β = −0.484,
SE = 0.154, p = .002). Any significant direct effect of expressed arousal on outcome
indicated by the simple relationship between expressed arousal and outcome was
again no longer significant when experiencing is included as a predictor. The Sobel
test of the indirect effect of expressed arousal on outcome was again significant
(Sobel’s test: β = −0.197, SE = 0.100, p = .05). The ratio of the relative magnitudes
of the indirect to total effects for this model indicates that late therapy peak experi-
encing mediated 47% of the effect of late peak arousal on final reductions in
depression.
14 A. E. POS ET AL.

Results Hypothesis 2: Emotional arousal increases across phases of therapy.

Two repeated measures ANOVAs tested whether significant increases in expressed

arousal across therapy occurred. A significant increase in modal expressed arousal scores
across phases of therapy, F (2,62) = 4.330, p = .017 was found. No violations of sphericity
were indicated (Mauchly’s test, χ2 (2) = 3.233, p = .20). Post hoc Bonferroni correction
pairwise comparisons indicated a trend to increased modal expressed arousal between
early and middle phases of therapy (M = 2.783 versus M = 2.957, p = .08) and a
significant increase in modal expressed arousal between middle and late phases of
therapy (M = 2.957 versus M = 2.983, p = .009).
An increase in peak expressed arousal across phases of therapy was also found, F
(2,62) = 4.819, p = .011. Again, Mauchly’s test indicated no violations of sphericity. Post
hoc Bonferroni-corrected comparisons revealed no significant increase between early
and middle peak expressed arousal (M = 3.386, versus M = 3.484, p = .61), but a
significant increase in peak expressed arousal between early and late phases of therapy
(M = 3.386, versus M = 3.622, p = .003). Therefore, expressed arousal during EEs does
increase during experiential therapy for depression.

Discussion
This study investigated the importance of clients’ expressed emotional arousal and
experiencing to outcomes during experiential treatment of depression testing the
experiential assumption that arousal is important to outcome because it facilitates the
emotional meaning-making or experiencing process. The validity of the experiential
assumption that experiential therapy increases clients’ emotional arousal during therapy
was also tested (Pos et al., 2009).
Relating to the first aim, in preparation for mediation analyses, we examined the
relationship between expressed arousal and experiencing scores as well as the obtained
range of expressed arousal scores. A restriction of range in expressed arousal scores was
indeed indicated. No high extreme expressed arousal scores were obtained. The limited
range of obtained expressed arousal scores likely informed significant linear relation-
ships found among expressed arousal, experiencing, and outcome in this study, results
that made it ‘legal’ to employ linear modeling analysis in both Warwar (2003) and the
present study.
A number of variables can explain this potential ‘limited range’ of obtained expressed
arousal scores in this depressed sample. First, exclusion criteria for the trial (no bipolar
disorder, no borderline personality disorder, no current and active suicidality, and no
current substance abuse) eliminated clients most prone to problematically high arousal.
The lack of very low arousal scores, on the other hand, can be explained by the fact that
clients in the trial were seeking treatment for depressed mood, the arousal of which they
were aware. Treatment seeking to change mood (depression) may have therefore
precluded clients who were either incapable of, or highly unlikely to express any
emotional arousal at all. The obtained early expressed arousal scores suggest that the
clients represented by this sample expressed neither extreme distressed nor restricted
emotion.
 PERSON-CENTERED & EXPERIENTIAL PSYCHOTHERAPIES 15

The assumption within experiential therapies is that through increased arousal

emotions become more salient to awareness. This therefore allows emotions to be
approached and made sense of through a process of experiencing. We successfully
validated this assumption. In all four mediation models, expressed arousal signifi-
cantly indirectly predicted positive outcomes by positively impacting on the experi-
encing process. This mediation was particularly complete in the middle of therapy.
Depending on the stage of therapy experiencing during EEs mediated 47–100% of
the effect of expressed arousal on outcomes. What this appears to suggest is that the
role of expressed arousal in predicting experiencing varies depending on the stage of
therapy, and that it is in the middle phase of therapy that the relationship between
these two variables is the ‘tightest’. We would argue therefore that during the middle
phase of therapy, experiencing is, in fact, an implicit measure of optimal expressed
arousal, and that explicitly measuring expressed arousal is not as important as
measuring the process of experiencing. Late in therapy, however, expressed arousal
appears to not have had as strong impact on experiencing as in the middle phase. In
the late phase of therapy, it is possible that expressed arousal still positively impacts
on outcome by playing another role on outcome than facilitating experiencing. Not
captured by the present analyses, perhaps emotional arousal could directly impact on
outcome in a manner not measured here. This will require future research to fully
explain.
Relating to our second aim, expressed arousal scores did increase significantly
across therapy, congruent with the tasks of experiential therapy. However, while
expressed arousal increased, it remained contained within a productive range that
promoted experiencing. How this optimal range of arousal was achieved remains a
clinical question worthy of future study. One could argue that the experiential
therapy relationship provides empathic safety and unconditional regard, and that,
since empathy can both regulate and evoke emotion as well as provide regulating
safety (Geller & Porges, 2014) and space within which clients can safely experience
and express what they are feeling (Malin & Pos, 2015), the importance of a moderat-
ing impact of the therapy relationship between productive expressed arousal and
enhanced emotion experiencing is suggested (Pos et al., 2008). This also should be
further investigated.

Limitations
All studies have limitations and the present study is no exception. First the sample size
was relatively small. While effects were detected and experiential theory validated, a
bigger sample would allow more variables to be examined. It would be useful for future
psychotherapy research on arousal to include a larger sample of aroused clients expres-
sing a full range of arousal scores which may yield the expected curvilinear relationship
between arousal and experiencing that the well-known Yerkes-Dodson law would
predict.
Another possible study limitation is that since the Client Expressed Arousal Scale III-R
is a measure of explicit arousal, physiological measures of clients’ implicit arousal might
also contribute to a more full understanding of the emotional arousal process and how
it impacts on cognitive processes such as experiencing.
16 A. E. POS ET AL.

Also, little has been explored here concerning therapist effects. Experiential therapy
can be evocative (Rice, 1974) but the experiential therapist also helps clients regulate
their emotions in therapy. This too must be investigated.
Finally, specific levels of arousal may be best for activating optimal experiencing.
No exploration of this issue was presently pursued. Exploring expressed arousal
within other models of therapy such as behavioral and psychodynamic would also
help us understand the relationship between arousal of emotion in good therapy
outcomes. It may be that emotional arousal is a common factor in all effective
treatments for depression.

Disclosure statement
No potential conflict of interest was reported by the authors.

Notes on contributors
A. E. Pos is an associate professor in Clinical Psychology, international trainer in IS_EFT, is an expert
in the application of EFT to personality disorders and has been a process research in emotional
processes in experiential therapy for over 15 years. She is the investigator who collected the
current EXP data. She has presented her data at several conferences and meeting and has
reviewed years ago for this journal (on the editorial board). She was a graduate student of Dr. L.
S. Greenberg.

D. A. Paolone is a researcher in a number of trials for DBT for borderline personality disorder. Was
an honours thesis student of Dr. Alberta Pos and pursued the current study under her supervision.
She has presented an earlier version of this study at the North American meeting of the Society for
Psychotherapy Research in Memphis TN, in 2013.

C. E. Smith Carrie is an expert in R statistical package.

S. H. Warwar Serine is in private practice in Toronto and uses EFT as her primary model. She is
original investigator who collected the current arousal data. She was a process researcher, and
student of L. S. Greenberg. She is also a trainer in EFT as indicated by the IS_EFT.

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