Week 5: Humanistic-Experiential Psychotherapies 11 Under these, categories included smoother and healthier emotional experiencing, self-acceptance of vulnerability, mastery and resilience, feeling supported, healthier interpersonal functioning, self-insight and self-awareness, and changed view of others. One study found minimal differences in what clients with quantitatively successful versus unsuccessful outcomes reported as changes, with the only notable difference being that clients with poorer outcomes reported increased awareness of their own problematic functioning rather than positive change. Another study comparing individual EFT to attachment-based family therapy found that EFT clients reported more emotional processing and individuation, while family therapy clients reported more relational improvement with the target parent. Negative outcomes identified included therapy increasing anger, worsening relationships, positive changes not lasting, continuing symptoms and emotional restriction. Qualitative Process and Case Study Research on HEPs Helpful and Difficult Aspects of HEPs: Qualitative studies consistently identified several helpful factors: feeling understood, listened to, supported and validated by the therapist; client agency and motivation; co-construction of new awareness and meaning between client and therapist; in-session emotional experiences of attending to own needs, feeling free or empowered; expressing vulnerability; opening up to the therapist; and processing painful emotional experiences. Experiential techniques such as empty-chair dialogues were described by clients as meaningful, allowing access to powerful adaptive emotional experiences including self-compassion and feeling cared for. However these tasks were also described as demanding and difficult, pushing clients outside their comfort zone and bringing up chronically painful emotions. The therapist's facilitative style and awareness of client fragility must therefore remain important. Other Qualitative Studies Other qualitative work included studies of therapist experiences, mixed-methods task analysis studies and theory-guided qualitative studies. One study using EFT theory found that clients with GAD were preoccupied with anxieties rooted in underlying painful feelings of loneliness, shame and terror. A study on EFT groups for eating disorders found that clients struggled with their inner critic but could recognize both its destructive and protective functions, and reported the importance of self-assertion in the face of self-criticism. Qualitative Case Studies Hermeneutic single case studies demonstrated the efficacy of person-centered therapy and EFT for health anxiety and social anxiety, with processing of painful emotions and relational validation playing central roles. Several studies examined the theory of sequential emotional processing in EFT, finding that in successful cases clients move from undifferentiated global distress through core painful feelings of shame, fear and loneliness, to unmet needs, and finally to self-compassion and healthy assertion as a response to those unmet needs. Please Note! Unhelpful Aspects of HEPs: Unhelpful aspects included experiential work being too overwhelming or exposing, misunderstandings in the therapeutic relationship, therapy being too short, continuing symptoms and clients holding back or not putting in enough work. Please Note! This model has become a central framework for understanding change in EFT. Week 5: Humanistic-Experiential Psychotherapies 12 Quantitative Process Research on Humanistic-Experiential Psychotherapy Process research in HEPs has historically focused on Rogers' therapeutic relationship conditions and client experiencing, and has evolved toward a more differentiated focus on specific therapist interventions and client change processes. Process-Outcome Research on the Therapeutic Relationship The three core Rogerian conditions — empathy, positive regard and congruence/genuineness — have all been shown to be robust predictors of client outcome. The most recent meta-analyses found weighted mean correlations of r = 0.28 for empathy, r = 0.18 for positive regard and r = 0.23 for congruence. Empathy has shown the most consistent and slightly larger effect than the other two conditions. These effects hold across different therapeutic approaches, not only HEPs. Client progress was better when both clients and therapists rated the relationship as improving over the course of therapy. Empathy, positive regard and congruence are so deeply interwoven that it may be a mistake to treat them as distinct and study them independently. Several methodological limitations have been identified, including small sample sizes, different rating perspectives, restricted range of measurement, possible nonlinear effects and third variable or reverse causation problems. Relationship Variable Mediator and Moderator Research Research has started to investigate what mediates the relationship between therapist relational conditions and outcome. One study found that therapist empathy predicted outcome both directly and indirectly, through improvements in clients' attachment insecurity and reductions in negative self-treatment including self-criticism and self-silencing. Another study found that therapist empathy in the first session predicted outcome indirectly through working alliance scores after session one and clients' emotional processing in the mid-phase of therapy. Research on alliance formation found that clients who were more socially inhibited had lower alliance scores after the first session, while greater self-disclosure predicted higher alliance scores. Therapist loving and approaching behaviors were more common in high-alliance dyads, highlighting the importance of client pretreatment characteristics and initial mode of engagement for the alliance. Research on Specific Therapeutic Tasks Two-Chair Dialogue for Conflict Splits: Two-chair dialogue is used in EFT and gestalt therapy to work with self-critical processes. This intervention was associated with significantly increased self-compassion, reductions in self-criticism and symptom improvements maintained at six-month follow-up. Another study found that adding EFT chair work to a person-centered baseline produced greater reductions in anxiety and depression for self-critical clients. Empty Chair Work for Unfinished Business: Earlier research found empty chair work more effective than empathy alone for resolving unfinished business, with resolvers showing greater improvement in symptom distress, interpersonal problems and degree of unfinished business. A comparison of two forms of EFT for trauma found that clients using empty chair work showed more pre-post change but also had a higher dropout rate (20% vs. 7%), suggesting that not all clients respond positively to this highly evocative task and should not be forced to use it. Interpersonal Forgiveness in Couples: Task analytic research identified a sequential model of forgiveness in EFT for couples involving six steps: the injured party expresses hurt and the impact of the injury; the injurer offers non-defensive acceptance of responsibility; the injurer expresses shame, remorse or empathic distress; the injurer offers a heartfelt apology; the injured partner shifts their view and expresses forgiveness; and the injurer accepts the forgiveness with relief or contrition. Research found that expressed shame accounted for 33% of outcome variance in posttherapy forgiveness, with acceptance and in-session forgiveness explaining additional variance, with the full model accounting for 50% of outcome variance. Week 5: Humanistic-Experiential Psychotherapies 13 Research on Client Processes Research on client processes in HEPs focuses on depth of experiential self-exploration as a central pillar of therapy process and client change, measured most commonly using the Client Experiencing Scale. Depth of Experiencing and Emotion Processing Client Experiencing Ratings of clients' depth of experiencing have consistently shown a positive relationship with outcome, the higher the experiencing level, the better the therapy outcome. A meta-analysis found experiencing to be a small to medium predictor of outcome. However the relationship is not large, suggesting other factors also play a role. It is also overly simplistic to assume a purely linear relationship between experiencing level and outcome, as all narrative modalities across the full range of the experiencing scale serve useful functions for clients. Rogers predicted that experiencing levels would increase throughout successful therapy, but this has not been consistently confirmed in research. However studies have found significant differences in how good and poor outcome clients refer to their emotional experience during sessions, suggesting that processing and deepening bodily felt experience may be important for change across therapeutic approaches. Depth of Experiencing, Emotional Expression, and Outcome EFT research found that higher emotional arousal at mid-treatment, coupled with reflection on the aroused emotion and deeper emotional processing late in therapy, predicted good outcomes. EFT appears to work by helping clients first experience, then accept, and finally make sense of their emotions. Client experiencing during the working phase predicted reductions in depressive and general symptoms and gains in self-esteem, even after controlling for alliance and early emotional processing. Moderate frequency of heightened emotional arousal predicted the best outcomes, while both too little and too much emotional arousal were associated with poorer outcomes. Specifically, a rate of approximately 25% for moderate-to-high emotional expression predicted the best outcomes. Emotional expression that does not reach a heightened level of arousal, or that reflects interruption of arousal, appears undesirable rather than simply a lesser goal. This presents a challenge for therapists in managing arousal levels and selecting clients for EFT. Research also found that client initial level of affect regulation predicted emotional processing during early and working phases of therapy, and that the quality of emotional processing during sessions mediated the relationship between initial affect regulation and final outcome, independently of the working alliance. Modeling Client Emotional Processing Using a model of emotional processing that tracks clients' movement through various emotional states, research found that effective emotional processing was associated with steady improvement and increased emotional range, occurring in a two-steps-forward, one-step-backward pattern, with increasingly shorter emotional collapses in helpful in-session events compared to unhelpful ones. Research on self-criticism found that clients who resolved self-criticism showed drops in secondary emotions and increases in primary adaptive emotions both within and across therapy phases. A good outcome case analysis over 15 sessions showing the important role of accessing adaptive primary emotions and expressing self-compassion and assertive anger in positive EFT outcomes. Research using the Client Emotional Productivity measure found that quality of emotional processing during the working phase was the sole predictor of improvement in depression in experiential therapy, over and above early phase processing, working alliance and emotional arousal. Week 5: Humanistic-Experiential Psychotherapies 14 Further research confirmed that lower frequency of secondary emotion and higher frequency of primary adaptive emotion in the working phase predicted outcome, and that clients' movement from primary maladaptive to primary adaptive emotions during the working phase was significantly related to successful change. Narrative Processes and Assimilation Research on narrative processes in HEPs has used several different scales including narrative processing markers, innovative moments and narrative shifts. Studies of client narrative sequences in EFT found that there was a significant increase in the specificity of autobiographical memories from early to late therapy sessions, and that outcome was predicted by a combination of high narrative specificity plus expressed arousal in late phase sessions. Neither expressed emotional arousal nor narrative specificity alone was sufficient for recovery. Research on narrative flexibility found that the probability that client narratives would shift among different narrative markers remained constant for clients who recovered but declined for those who did not, suggesting narrative flexibility is an important indicator of good outcome. Research by Gonçalves and colleagues identified five kinds of innovative moments in therapy: action, reflection, protest, reconceptualization and performing change. Good outcome cases showed more innovative moments overall, and therapists' use of exploration and insight skills more often preceded client innovative moments in good outcome cases. In the final phase of therapy, these skills more often preceded reconceptualization and performing change moments specifically. Task analysis of the consolidation phase in EFT identified nine steps in resolution. Research found that the overall category of reconceptualization was a better predictor of outcome than either of its two subtypes separately. Research using Stiles' assimilation of problematic experiences model found that setbacks in poor outcome cases typically occurred when the therapist worked ahead of the client's zone of proximal development, while setbacks in good outcome cases were part of a productive process of broadening or deepening therapeutic work. Research confirmed that therapists who used a balance of supportive and challenging interventions within the client's zone of proximal development produced better outcomes than those who used primarily supportive interventions. Higher levels of assimilation late in therapy were associated with a distanced, reflective perspective on difficult experiences, pointing to increased capacity to make meaning out of emotional experience. Please Note! These include recognition of differences between past and present views of self, developing a meta-perspective, amplifying the contrast, expressing appreciation of change, experiencing empowerment, identifying ongoing difficulties, recognizing the problem is no longer central, seeing change as ongoing and gradual, and referring to new projects and plans. Week 5: Humanistic-Experiential Psychotherapies 15 Conclusions Humanistic-Experiential Psychotherapies as Evidence-Based Treatments HEP outcome research has grown rapidly, with a 50% increase in studies over the past 10 years. Those are the important conclusions: • HEPs are associated with large pre-post client change that is maintained over the early post-therapy period • In controlled studies clients in HEPs show large gains relative to no-therapy clients, supporting the causal inference that HEPs produce client change • In comparative studies HEPs are statistically and clinically equivalent to other therapies, especially non-CBT therapies • CBT appears to have a small advantage over HEPs in the current dataset, but this is largely attributable to non-bona fide supportive-nondirective treatments delivered under negative researcher allegiance conditions → when these are removed or researcher allegiance is controlled for, HEPs are equivalent to CBT • Among HEP subtypes, EFT continues to show the best results, person-centered therapy falls in the middle, and supportive-nondirective therapy consistently performs most poorly against CBT Key Change Processes in Humanistic-Experiential Psychotherapies Process research has moved beyond global relational conditions like empathy and positive regard toward more specific within-session client change processes. Six key questions and answers summarize current understanding. 1) Most productive sequence of narrative exploration: External event description leads to initial self-reflection, leads to access to internal experiences, leads to self-reflection on broader meaning. 2) How new narratives emerge: Through a spiraling movement between action and reflection, from attempts to change the problem, to reflection on the old narrative, to active protest, to reconceptualization of self, to carrying out change in life. 3) How problematic experiences get assimilated: Via a sequence from warded-off or painful awareness, through problem clarification and insight, to working through and mastery. 4) When emotional expression leads to good outcome: When grounded in specific autobiographical memories, accompanied by deeper experiencing, and becomes more regulated and differentiated as explored. 5) How stuck emotions get transformed: By helping clients move from undifferentiated global or secondary distress through core painful feelings to unmet needs and finally to self-compassion or assertive anger. Please Note! For specific client populations: HEPs show large pre-post and medium controlled effects for depression, though comparative effects were equivocally negative in this dataset due to overwhelming negative researcher allegiance. For relationship and interpersonal problems, HEPs clearly meet criteria as efficacious. For chronic medical conditions, HEPs show large pre-post effects, superiority to no-treatment and equivalence to other treatments including CBT. For self-damaging activities including eating difficulties, process-guiding HEPs are possibly efficacious. For anxiety, evidence is mixed but sufficient for a verdict of possibly efficacious, with CBT showing superiority mainly over supportive-nondirective approaches. For psychosis, promising pre-post and comparative effects directly contradict NICE guidelines contraindicating HEPs for this population, and HEPs may in some cases be more effective than comparison therapies. Tip! For the exam, remember those main conclusions. Week 5: Humanistic-Experiential Psychotherapies 16 6) How therapists can best facilitate these processes: By responding within the client's zone of proximal development, and by balancing supportive following responses that provide safety with challenging process-guiding responses that offer opportunities to move forward. Recommendations for Research, Practice, and Training More research is needed across all client populations and on well-studied problems like depression to keep pace with evolving research standards. National guidelines such as NICE need to be updated to reflect the available evidence, and HEPs should be offered and funded in national health service contexts. Supportive-nondirective therapies are not recommended for routine practice, if the choice is between supportive-nondirective HEP and CBT, clients should generally receive CBT. HEP researchers should conduct their own RCTs on bona fide versions of their therapies and collaborate with other orientations on balanced allegiance studies. Guideline development committees must contain balanced representation of theoretical allegiances. Finally, HEPs should be included in postgraduate training programs as an evidence-based alternative to CBT across a wide range of presenting problems. Chapter 6: Brief Humanistic and Existential Therapies Introduction Humanistic and existential therapies focus on the client’s personal experience, self-awareness, and ability to make meaningful choices. Rather than concentrating only on symptoms, these therapies explore deeper emotional and existential struggles such as fear, isolation, shame, and lack of purpose. Both approaches are important in substance abuse treatment because they help clients develop insight, responsibility, hope, and healthier ways of living. Humanistic vs. Existential Perspectives Humanistic therapy believes that people naturally move toward growth and healing when they are accepted and understood. Existential therapy focuses more on anxiety, freedom, responsibility, and the search for meaning in life. Despite these differences, both approaches emphasize self-awareness and authentic living. Relevance to Substance Abuse Treatment These therapies are valuable in addiction treatment because they address emotional emptiness, hopelessness, guilt, and lack of meaning that often contribute to substance abuse. They encourage clients to take responsibility for recovery and develop healthier, more meaningful lives. Tip! Humanistic therapy is built on the belief that people naturally move toward healing and growth when they experience empathy, acceptance, and understanding. Instead of focusing only on symptoms or mistakes, therapists try to help clients reconnect with their strengths, values, and potential. Tip! One of the easiest ways to distinguish the two approaches is to remember that humanistic therapy highlights growth and self-acceptance, while existential therapy highlights responsibility and the search for meaning in life. Week 5: Humanistic-Experiential Psychotherapies 17 Using Humanistic and Existential Therapies These therapies emphasize empathy, reflective listening, emotional honesty, and authentic relationships. Therapists help clients understand how their thoughts and experiences shape the meaning they give to life events and encourage them to make healthier choices. Essential Skills The therapist’s personal qualities are extremely important in these approaches. Therapists must be genuine, empathetic, emotionally present, and able to build trusting relationships with clients. When To Use Brief Humanistic and Existential Therapies Different approaches are useful for different situations. Client-centered therapy helps build trust, existential therapy addresses fear and responsibility, narrative therapy helps clients rewrite destructive life stories, Gestalt therapy increases present-moment awareness, and transpersonal therapy focuses on spirituality and personal transformation. Duration of Therapy and Frequency of Sessions These therapies work well in brief treatment because they quickly strengthen the therapeutic relationship and encourage clients to take responsibility for change. Growth is expected to continue between therapy sessions as clients apply insights to daily life. Initial Session The first therapy session focuses on building trust, encouraging hope, and helping clients recognize that entering treatment is an important personal choice. Therapists also help clients clarify goals and expectations for recovery. Compatibility With 12-Step Programs Humanistic and existential therapies share several important similarities with 12-Step programs such as Alcoholics Anonymous. Both approaches encourage honesty, self-examination, acceptance of limitations, and ongoing personal growth. The Serenity Prayer, for example, reflects existential ideas about accepting what cannot be changed while courageously changing what can be changed. At the same time, some existential therapists question the idea of defining people primarily through a “disease identity” or emphasizing powerlessness. Existential therapy values free will and personal responsibility. However, surrender within a 12-Step program can still be understood as a conscious and meaningful personal choice. Tip! Many humanistic and existential therapists believe that substance abuse is not only a behavioral problem but also a sign of deeper emotional pain, hopelessness, or spiritual emptiness. Recovery therefore involves creating a more meaningful and emotionally fulfilling life. Tip! The concept of “apperception” is important because it explains that people do not simply experience events objectively. Instead, they interpret events through their emotions, memories, beliefs, and expectations, which shapes how they respond to life. Week 5: Humanistic-Experiential Psychotherapies 18 Research Orientation Humanistic and existential therapists often prefer qualitative research methods because they focus on personal meaning and subjective experience rather than only measurable behavior. Carl Rogers helped pioneer research on the therapeutic relationship. The Humanistic Approach to Therapy Humanistic psychology emphasizes personal growth, self-actualization, and human potential. Important figures include Abraham Maslow, Carl Rogers, and Fritz Perls. The approach views people holistically and values empathy, authenticity, and collaboration in therapy. Client-Centered Therapy Client-centered therapy, developed by Carl Rogers, is based on empathy, acceptance, and unconditional positive regard. Rogers believed that people naturally move toward growth when they feel understood and emotionally safe. This approach is especially useful in addiction treatment because it reduces shame and increases motivation for change. Narrative Therapy Narrative therapy helps clients understand how life stories shape identity and behavior. Therapists encourage clients to separate themselves from addiction, identify strengths, and develop more hopeful and empowering personal narratives. Transpersonal Therapy Transpersonal therapy combines psychology with spirituality and focuses on expanded awareness, mindfulness, and personal transformation. It views addiction as partly connected to spiritual emptiness and encourages clients to find meaning, connection, and inner peace. Tip! Although existential therapy values freedom and personal choice, many existential therapists still appreciate the role of surrender in recovery programs if surrender is understood as a conscious and meaningful decision. Tip! Humanistic psychology is often called the “third force” because it developed as an alternative to both behaviorism and psychoanalysis. It emphasizes hope, personal meaning, creativity, and the positive potential of human beings. Tip! Transpersonal therapy explores experiences that go beyond ordinary awareness, including spirituality, meditation, intuition, and feelings of deep connection with others and the world. Week 5: Humanistic-Experiential Psychotherapies 19 Gestalt Therapy Gestalt therapy focuses on present-moment awareness and direct emotional experience. It helps clients resolve “unfinished business,” become more aware of feelings, and reconnect with themselves and others. The Existential Approach to Therapy Existential therapy explores freedom, responsibility, anxiety, meaning, isolation, and death. Therapists help clients face difficult realities honestly and create meaningful lives instead of escaping through substance abuse. Time and Existential Therapy Existential therapy emphasizes that life and time are limited. Awareness of mortality can motivate clients to make meaningful choices and become more engaged in recovery. Overall Conclusion Humanistic and existential therapies help clients develop self-awareness, responsibility, authenticity, and meaning in life. In addiction treatment, these approaches support emotional healing, strengthen motivation for recovery, and encourage clients to build healthier and more meaningful lives.
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