Journal of Counseling Psychology 2002, Vol. 49, No.

3, 376 380

Copyright 2002 by the American Psychological Association, Inc. 0022-0167/02/$5.00 DOI: 10.1037//0022-0167.49.3.376

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Patterns of Client Emotion in Helpful Sessions of CognitiveBehavioral and PsychodynamicInterpersonal Therapy

Hannah C. Mackay and Michael Barkham
University of Leeds

William B. Stiles
Miami University

Marvin R. Goldfried
State University of New York at Stony Brook

Whereas cognitive behavioral (CB) therapy sessions aim to be instructive and encouraging, psychodynamicinterpersonal (PI) sessions aim to be exploratory and may be emotionally painful. Raters rated degree of pleasure and arousal in each sentence of client speech in CB and PI sessions (N 18) that therapists had identified as particularly helpful. Client emotion in PI sessions was less pleasant, on average, than client emotion in CB sessions; emotion was most negative in the middle of the PI sessions. Within sessions, arousal tended to follow a U-shaped course for CB clients but an inverted U-shaped course for PI clients. The results support suggestions that these two therapeutic approaches operate by different emotional mechanisms.

Virtually all theories of psychotherapy give central importance to dealing with clients emotions. However, the role of emotion is conceptualized differently across approaches. These conceptual differences have not led to differential effectiveness; alternative bona fide therapies appear to be more or less equivalently effective (Wampold, 2001). This equivalence paradox (equivalent outcomes despite grossly nonequivalent processes; Stiles, Shapiro, & Elliott, 1986) heightens the potential interest and value of understanding the pathways or mechanisms of change within alternative approaches. In this study, we measured clients emotions, as they changed within sessions, to directly assess two contrasting approaches to dealing with emotion in psychotherapy. We studied client emotion in sessions of cognitive behavioral (CB) and psychodynamicinterpersonal (PI) psychotherapy selected from the Second Sheffield Psychotherapy Project, which was a comparative clinical trial of time-limited CB and PI treat-

Hannah C. Mackay and Michael Barkham, Psychological Therapies Research Centre, University of Leeds, Leeds, United Kingdom; William B. Stiles, Department of Psychology, Miami University; Marvin R. Goldfried, Department of Psychology, State University of New York at Stony Brook. Hannah C. Mackay was supported by a Medical Research Council studentship. The original work was done as her postdoctoral thesis at the University of Leeds. Transcription was supported by National Institute of Mental Health Grant MH-40196. Correspondence concerning this article should be addressed to Hannah C. Mackay, who is now at the Health Care Practice Research and Development Unit, Statham Building, Statham Street, University of Salford, Salford M5 4WT, United Kingdom, or to William B. Stiles, Department of Psychology, Miami University, Oxford, Ohio 45056. E-mail: hannahmackay@hotmail.com or stileswb@muohio.edu 376

ments for depression, both of which were found to be effective (Shapiro et al., 1994). Following recommendations to study sessions in which the processes of interest are most likely to be evident (Elliott & Anderson, 1994; Greenberg, 1994), we focused on those clients who were most severely depressed at the beginning of treatment and studied sessions that the therapists rated as particularly helpful, which seemed likely to exemplify processes considered important theoretically. Cognitive and behavioral approaches often focus on the control or elimination of anxiety and other unwanted emotions. Greenberg and Safran (1989) described behavioral therapy as focusing on the clinical problem of modifying undesirable affective states and cognitive therapy as focusing on the elimination of emotional responses to faulty cognitions (p. 20). Emotions are considered to be responses to the clients beliefs about the world and ways of behaving; they may be dealt with by changing beliefs and behaviors. Though not avoided or suppressed, negative thoughts and feelings are likely to be challenged. At times, CB therapy can be conducted in a businesslike manner, with little experienced emotion, for example, when the client is learning new skills. A focus on the completion of achievable tasks (e.g., homework) and the use of humor may lead clients to experience relatively positive emotion. With the exception of exposure and response prevention techniques, which were not used with the depressed clients seen in the Sheffield project, in-session work concentrates on overcoming rather than experiencing negative emotions such as sadness or anxiety (Shapiro & Firth, 1985). Thus, although a range of emotion could be expected, a good CB session should be marked by reduced, rather than heightened, painful emotion. In contrast, psychodynamic, interpersonal, and experiential approaches often implicate the avoidance of painful emotion in the

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etiology and maintenance of psychological disorders, such as depression, anxiety, or interpersonal problems. Confronting intense, painful emotions within sessions is often seen as a vehicle of change, a step on the way to understanding the problems historical, interpersonal, or experiential roots. Therapists often encourage clients to experience and explore their emotions deeply, particularly in the context of the relationship with the therapist. In their PI manual, Shapiro and Firth (1985) said, Rather than promoting strategies for coping with or dispelling distress, the exploratory mode entails an attempt to stay with the experience of a particular feeling as it arises in the actual session (p. 2). Furthermore, there is an optimal anxiety level during the session, which must be high enough to promote exploration, but by the end must be low enough to permit the client to cope with the thoughts and feelings prompted by the session until the next meeting (p. 12). Clients in good PI sessions should therefore experience more intense negative emotion, particularly in the middle of sessions, than clients in good CB sessions. Previous empirical comparisons of CB and PI therapy found indirect evidence supporting these distinct theoretical pictures. For example, therapists described their intentions as more directed toward promoting awareness of feelings in PI than in CB sessions (Stiles et al., 1996), and therapists were rated by observers as focusing more on emotion in PI than in CB sessions (Goldfried et al., 1997). Portions of sessions identified as clinically significant by CB therapists were characterized by decreases in emotional experiencing, whereas those identified by PI therapists were characterized by increases in emotional experiencing (Wiser & Goldfried, 1993). Early in treatment, clients felt more positively after CB sessions than after PI sessions (Reynolds et al., 1996), and client emotion was more intense in experiential than in cognitive therapies (Burgoon et al., 1993; Mahrer et al., 1990). These contrasting emotional patterns may be associated with different change mechanisms. In intensive case studies, significant insight events tended to be associated with strong negative emotion in PI but not in CB sessions (Elliott et al., 1994). In this study, we took a more direct look at patterns of emotion in CB and PI sessions. We sought an approach that was equally applicable to different orientations and chose to measure pleasure displeasure and arousal, which are widely understood as fundamental dimensions of emotional states across many contexts (Diener, Smith, & Fujita, 1995; Reisenzein, 1994). Although people have many sorts of distinctive emotions, much of the variation among them can be understood as reflecting their position on these two basic dimensions. Emotional states associated with pleasure include contentment and elation; emotional states associated with displeasure include anger, terror, and gloom. Other emotional states, such as surprise, would be near the midpoint of the pleasure displeasure dimension. Emotional states associated with high arousal include anger, terror, surprise, and elation; states associated with low arousal include gloom and contentment. Emotional processes during psychotherapy sessions are likely to be complex and varied (Greenberg & Safran, 1989). To track changes in clients emotional experience during the targeted sessions, we rated each sentence with respect to pleasure displeasure and arousal. We then compared patterns and sequences of ratings across CB and PI approaches. Following Barkham, Stiles, and Shapiro (1993), we characterized emotion within each session on each dimension using six quantitative parameters: initial

level, mean level, rate of change, degree of variability across time, degree of curve, and direction of curve (U-shaped or inverted-U-shaped). We hypothesized that clients emotional experience would differ systematically in mean level and time course between PI and CB sessions that were selected as particularly helpful by their therapists. We expected the mean level of pleasure to be lower and the mean level of arousal to be higher during the PI sessions, particularly in the middle of the sessions, than during the CB sessions.

Method
We studied one tape-recorded session from each of 18 clients, who presented with relatively severe depression and were seen for 16 sessions of either CB or PI therapy. The clients thus represented two cells of the factorial design of the Sheffield project in which clients were stratified into 3 levels of severity (high, medium, low) and randomly assigned to 1 of 2 treatments (CB, PI) and 1 of 2 treatment lengths (16 sessions, 8 sessions). Both treatments were found generally and approximately equally effective for these clients (see Shapiro et al., 1994).

Clients and Therapists

The clients (5 men, 13 women) were professional, managerial, or other white-collar workers who met criteria for major depressive episode in the Diagnostic and Statistical Manual for Mental Disorders (3rd ed.; American Psychiatric Association, 1980). All had scores of 27 or above on the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) at prescreening and were therefore in the high-severity group. Each received 16 weekly sessions of CB (n 9) or PI (n 9) therapy. (One additional high-severity client was excluded from the present analysis because of confidentiality constraints.) Sessions were audiotape recorded routinely. Each client consented to the use of the tape recordings and other materials for research before starting treatment and signed a release after therapy was completed. Clients had the opportunity to discuss confidentiality issues with an assessor, to refuse to allow their tapes to be released, or to attach provisos. Four therapists (2 male and 2 female) conducted the sessions described in this article. Recruitment to the project required evenhanded allegiance to the two treatments being offered, as each therapist treated clients in both CB and PI modes (see Shapiro et al., 1994, for details). Because all therapists participated in both treatments, differences in emotion patterns would not be attributable to confounding with therapist differences.

Treatments
Both of the treatments used in the Sheffield project were presented in manuals to ensure standard delivery (Firth & Shapiro, 1985; Shapiro & Firth, 1985). The PI therapy was based on Hobsons (1985) conversational model. It uses psychodynamic, interpersonal, and experiential concepts and focuses on the therapist client relationship as a vehicle for revealing and resolving interpersonal difficulties viewed as primary in the origins of depression. The method emphasizes negotiation . . . a language of mutuality, the use of statements rather than questions, and the offering of hypotheses about the clients experiences and their interconnections. (Shapiro et al., 1994, p. 525) The CB therapy emphasizes the provision by the therapist of cognitive and behavioral strategies for application by the client. A wide range of techniques is available to the therapist, including anxiety-control training, self-

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BRIEF REPORTS management procedures, cognitive restructuring and a job strain package. (Shapiro et al., 1994, p. 525) Therapist and client evaluations of sessions are often not highly correlated (e.g., Dill-Standiford, Stiles, & Rorer, 1988; Stiles et al., 1988); using client evaluations would probably have led to selecting different sessions. We return to this point later. In the Sheffield study, clients global helpfulness ratings showed little differentiation between sessions (Goldfried et al., 1997).

Adherence ratings demonstrated that both treatments were delivered as intended (Startup & Shapiro, 1993).

Measures of Session Processes

Session helpfulness. The helpfulness of each session to the client, from the therapists perspective, was assessed by asking the therapist to please rate how helpful or hindering to you this session was overall on a fully anchored 9-point scale that ranged from 1 (extremely hindering) through 5 (neither helpful nor hindering; neutral ) to 9 (extremely helpful ). Session Evaluation Questionnaire (SEQ; Stiles et al., 1994). The SEQ is a self-report measure consisting of a series of 7-point bipolar adjective scales used by clients or therapists to describe their session and postsession mood. We used three items drawn from the therapists SEQ Depth scale (internal consistency, .84; Stiles, Shapiro, & Firth-Cozens, 1988) in selecting sessions for analysis (see Session Selection section). Pleasure and arousal ratings. Clients emotional tone in each sentence of each target session was rated using a protocol described previously (Mackay, Barkham & Stiles, 1998). Raters could use all information available from the audiotape and transcript in making their judgements, including verbal (the words used) and nonverbal information (e.g., tone of voice, crying). Based on theoretical accounts of emotion (Oatley & Johnson-Laird, 1987; Reisenzein, 1994), the protocol included ratings on dimensions of pleasure displeasure and arousal. Raters assess client level of pleasure in each sentence by responding to the question, How positive or negative is the clients emotion in this sentence? on a 9-point rating scale with anchor points of 4 (very negative) and 4 (very positive). Raters assess client level of arousal in each sentence by responding to the question, What is the level of activation of the clients emotion in this sentence? on a 9-point scale with anchor points of 4 (very low activation) and 4 (very high activation). Training on these items was based on descriptions of the dimensions made by Diener, Smith, and Fujita (1995). As discussed during training, the terms positive emotion and negative emotion were used to mean pleasure and displeasure respectively. The term activation was used to mean emotional arousal, where, for example, terror was scored high and gloom was scored low.

Procedure for Measuring Moment-By-Moment Emotion

Each of the 18 sessions was transcribed and then checked for accuracy independently by two researchers (Hannah C. Mackay and an experienced assessor). Names, identifying characteristics, and certain passages were deleted to preserve anonymity. Client speech was divided into sentence units (range of ns 327749) following criteria described by Auld and White (1956). The emotion measurement protocol was applied to each session independently by three paid raters out of a pool of 14 undergraduates or recent graduates (11 women and 3 men; aged 18 26) who had completed 6 15 hr of training on the protocol. Sessions were randomly allocated to raters, with the restrictions that approximately equal numbers of PI and CB sessions were completed by each rater and that no session was the first to be completed by more than one rater. Raters based their judgments on both the session audiotape and the transcript. We used the mean of the three ratings of each unit in our analyses. Interrater reliability, measured by the intraclass correlation (Shrout & Fleiss, 1979), was .76 for pleasure and .75 for arousal.

Parameters of Change in Pleasure and Arousal During Sessions

Extending suggestions by Barkham et al. (1993), we used six parameters to characterize the temporal pattern of emotion in each session, based on regression equations predicting speech unit number (client sentences numbered consecutively) from each emotion variable (i.e., pleasure and arousal): 1. Initial level, measured as the intercept of the linear regression line for that emotion variable in that session 2. Mean level of each emotion variable over the session 3. Rate of change, measured as the slope of the linear regression line (the unstandardized B coefficient in the linear regression equation) multiplied by the number of speech units in the session. This index corrected for variation in the number of speech units and yielded an estimate of linear change across the whole session on each 9-point (4 to 4) emotion scale. 4. Variability, measured as the root-mean-square error (RMSE; the square root of the residual variance)in effect, the standard deviation around the linear regression line 5. Degree of curve, measured as the reduction of RMSE obtained by adding a quadratic component to the regression equation, indicating the improvement in fit to the data obtained by using a quadratic curve rather than a linear regression line. As noted elsewhere (Barkham et al., 1993), this parameter reflected the degree of curve apparent to observers more closely than did alternative indexes. 6. Curve direction, measured as 1 (U-shaped) or 0 (inverted U-shaped), depending on the sign of the quadratic coefficient.

Session Selection
The 18 sessions we studied were a subset of a 114-session sample, described previously (see Goldfried et al., 1997), for which verbatim transcripts were available. This larger set included 1 high-helpfulness session and 1 low-helpfulness session (as rated by the therapist) from each of the 57 clients in the Sheffield project who were seen for 16 sessions. We chose the high-helpfulness session from 18 of these clients in the highseverity group (i.e., those with an intake BDI of 27 or higher). Helpfulness and SEQ ratings were made immediately after each session. As described by Goldfried et al. (1997), for each client the high-helpfulness session was selected as the session with the highest helpfulness rating from among Sessions 4 13. Sessions 13 and Sessions 14 16 were excluded from consideration because these sessions would be likely to focus on the formation of the therapeutic alliance and termination issues, respectively, rather than on the main tasks of therapy. If there were ties or only 1-point gaps between highest and lowest ratings on helpfulness (a minority of cases), the raw therapist scores on the SEQ items worthlessvaluable, ordinaryspecial, and emptyfull were used to make a finer discrimination. The CB sessions selected ranged from Session 4 to Session 11 (M 7.33), and the PI sessions also ranged from Session 4 to Session 11 (M 7.89). These means were not significantly different from each other (t 0.50, p .10), making it unlikely that any differences between treatments would be attributable to confounding with which sessions were selected.

Results
Consistent with expectations for different mean levels of pleasure, clients in these therapist-rated helpful PI sessions averaged significantly more negative emotion (lower mean pleasure levels) than did clients in the helpful CB sessions. Means and t tests for this and subsequent comparisons are reported in Table 1. A slightly (nonsignificantly) lower initial level of pleasure ratings in PI and

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Table 1 Pleasure and Arousal Indices in CognitiveBehavioral and PsychodynamicInterpersonal Sessions

Pleasure Mean Parameter Initial value Mean Slope Variability Degree of curve Curve directiona
a

Arousal Mean

PI 0.918 0.944 0.059 0.752 0.023 0.44

CB 0.584 0.364 0.436 0.807 0.005 0.67

t(16) 1.07 3.37** 1.07 0.72 2.32* 0.90

PI 0.170 0.020 0.298 0.976 0.018 0.00

CB 0.178 0.242 0.152 0.981 0.012 0.78

t(16) 1.46 1.07 1.90 0.09 0.63 11.45***

Note. N 18 sessions (9 CB, 9 PI). CB cognitive behavioral; PI psychodynamicinterpersonal. Curve direction means are proportions of positive (U-shaped) curves, compared using chi-square. For pleasure, 2 0.90; for arousal, 2 11.45 ( p .001). p .08. * p .05. ** p .005. *** p .001.

a slight increase across sessions in CB contributed to the difference in means. Consistent with expectations for different time courses, the degree of curve in the pleasure profiles was significantly greater in the PI sessions than in the CB sessions. Examination of the individual scores for degree of curve suggested that this difference mainly reflected three PI sessions that had degree-of-curve parameters greater than .03. All three of these sessions had the theoretically expected U-shaped curve direction, representing a decrease in positive emotion in the middle of the session followed by a return to initial levels. The pleasure ratings of the remaining 6 PI sessions and the 9 CB sessions appeared to have little or no quadratic curve (parameter values were between 0 and .02). Contrary to expectation, PI and CB sessions did not differ significantly in initial or mean levels of arousal or in their degree of variability or curvilinearity of arousal across sessions. However, as Table 1 shows, the direction of the arousal curve differed across treatments. In the CB sessions, clients arousal tended to follow a U-shaped pattern (declining at first, then rising again), whereas in PI sessions tended to follow an inverted-U-shaped pattern (increasing at first, decreasing later). The PICB difference in slope also approached significance; arousal tended (marginally) to decrease during PI sessions and increase during CB sessions.

Discussion
We found support for our expectation that clients would experience more intense negative emotion in helpful PI sessions than in helpful CB sessions. The negative emotional tone was most intense in the middle of the PI sessions. The CB clients mean pleasure level was also in the negative range, however, suggesting that they too tended to experience unpleasant emotions, even in these therapist-judged helpful sessions. Contrary to our expectation, the clients did not average higher arousal in the PI sessions than in the CB sessions. However, the time course of arousal tended to be U-shaped in the CB sessions and inverted-U-shaped in the PI sessions, so that the PICB difference was in the expected direction during the middle of the sessions. The absence of significant differences in the initial levels of pleasure and arousal suggests

that the different emotional patterns reflected in-session processes rather than differences in how the clients felt when they arrived. Although the course of pleasure ratings was significantly more curved in PI than in CB sessions (Table 1), this effect reflected strongly U-shaped patterns in only 3 of the 9 PI sessions. Reading the transcripts suggested that, consistent with PIs exploratory goals, these PI clients confronted difficult and emotionally charged issues but did not leave the session in excessive distress, reflecting successful management of intense negative emotion. For example, Client 14 (PI) had been raped many years before and wanted to lay it down. Early in her helpful session, she said that despite a previous joint decision to address this, she was frightened to talk about it and had been too upset to attend the previous scheduled session. The therapist, while acknowledging her reluctance, suggested that she would have to pick the issue up again in order to lay it down. The client then described the events of the rape in detail and, with the therapist, explored her distressing feelings and the lack of support she experienced from friends and family. Later in the session, she linked this experience with her tendency to avoid emotional commitment, so as not to be let down again. In all 9 of the helpful PI sessions, there were periods of therapist-encouraged exploration of painful, inexplicable, or frightening emotions, although the periods were not always well centered within the session. For example, Client 15 (PI) began her session in great distress but felt less negative by the end of the session, producing a positive linear slope (see Mackay et al., 1998, for a detailed discussion of this case). The course of arousal tended to be curved in different directions in PI and CB sessions (see Table 1). Whereas arousal in PI tended to follow an inverted-U pattern, consistent with a midsession focus on emotionally intense material, arousal in CB tended to follow a U-shaped pattern consistent with therapists seeking to control or reduce strong arousal during sessions (e.g., promoting relaxation to reduce anxiety). To illustrate, Client 13 (PI) spent most of his helpful session discussing his discomfort with his changed role at work and was facilitated by his therapist. Client 8 (CB), in contrast, having begun by describing feelings of panic over a difficult class he had had to teach, and his car overheating and making

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BRIEF REPORTS Goldfried, M. R., Castonguay, L. G., Hayes, A. M., Drozd, J. F., & Shapiro, D. A. (1997). A comparative analysis of the therapeutic focus in cognitive behavioral and psychodynamicinterpersonal sessions. Journal of Consulting and Clinical Psychology, 65, 740 748. Greenberg, L. S. (1994). The investigation of change, its measurement and explanation. In R. L. Russell (Ed.), Reassessing psychotherapy research (pp. 114 143). New York: Guilford Press. Greenberg, L. S., & Safran, J. D. (1989). Emotion in psychotherapy. American Psychologist, 44, 19 29. Hobson, R. F. (1985). Forms of feeling: The heart of psychotherapy. London: Tavistock. Mackay, H. C., Barkham, M., & Stiles, W. B. (1998). Staying with the feeling: An anger event in psychodynamicinterpersonal therapy. Journal of Counseling Psychology, 45, 279 289. Mahrer, A. R., Lawson, K. C., Stakilas, A., & Schachter, H. M. (1990). Relationships between strength of feeling, type of therapy and occurrence of in-session good moments. Psychotherapy, 27, 531541. Oatley, K., & Johnson-Laird, P. N. (1987). Towards a cognitive theory of emotions. Cognition and Emotion, 1, 29 50. Reisenzein, R. (1994). Pleasure-arousal theory and the intensity of emotions. Journal of Personality and Social Psychology, 67, 525539. Reynolds, S., Stiles, W. B., Barkham, M., Shapiro, D. A., Hardy, G. E., & Rees, A. (1996). Acceleration of changes in session impact during contrasting time-limited psychotherapies. Journal of Consulting and Clinical Psychology, 64, 577586. Shapiro, D. A., Barkham, M., Rees, A., Hardy, G. E., Reynolds, S., & Startup, M. (1994). Effects of treatment duration and severity of depression on the effectiveness of cognitive behavioral and psychodynamic interpersonal psychotherapy. Journal of Consulting and Clinical Psychology, 62, 522534. Shapiro, D. A., & Firth, J. A. (1985). Exploratory therapy manual for the Sheffield Psychotherapy Project. Memo 057. (Available from the Psychological Therapies Research Centre, University of Leeds, Leeds LS2 9JT, United Kingdom) Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: Uses in assessing rater reliability. Psychological Bulletin, 86, 420 428. Startup, M., & Shapiro, D. A. (1993). Therapist treatment fidelity in prescriptive vs. exploratory psychotherapy. British Journal of Clinical Psychology, 32, 443 456. Stiles, W. B. (1983). Normality, diversity, and psychotherapy. Psychotherapy: Theory, Research, and Practice, 20, 183189. Stiles, W. B., Reynolds, S., Hardy, G. E., Rees, A., Barkham, M., & Shapiro, D. A. (1994). Evaluation and description of psychotherapy sessions by clients using the Session Evaluation Questionnaire and the Session Impacts Scale. Journal of Counseling Psychology, 41, 175185. Stiles, W. B., Shapiro, D. A., & Elliott, R. (1986). Are all psychotherapies equivalent? American Psychologist, 41, 165180. Stiles, W. B., Shapiro, D. A., & Firth-Cozens, J. A. (1988). Do sessions of different treatments have different impacts? Journal of Counseling Psychology, 35, 391396. Stiles, W. B., Startup, M., Hardy, G. E., Barkham, M., Rees, A., Shapiro, D. A., & Reynolds, S. (1996). Therapist session intentions in cognitive behavioral and psychodynamicinterpersonal psychotherapy. Journal of Counseling Psychology, 43, 402 414. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Hillsdale, NJ: Erlbaum. Wiser, S., & Goldfried, M. R. (1993). Comparative study of emotional experiencing in psychodynamicinterpersonal and cognitive behavioral therapies. Journal of Consulting and Clinical Psychology, 61, 892 895.

worrying noises on the motorway, was encouraged by his therapist to try out the relaxation exercises that he had learned (which he did). Limitations of this study included its small sample one helpful session from each of 18 clientsand therefore its relatively low statistical power. Our strategy of selecting single sessions did not allow us to detect changes that occurred gradually over a number of sessions. Therapists and clients do not agree closely about the value of sessions (Dill-Standiford et al., 1988; Stiles et al., 1988), and it remains to be seen whether the patterns we found would also characterize CB and PI sessions judged as helpful by clients or selected randomly. Sessions judged as helpful by therapists seemed likely to manifest the processes considered theoretically to be effective within each treatment. On the other hand, the selection could also reflect a therapist tendency to assume that conformity with theory implies effectiveness. It is possible, for example, that therapists perceptions of helpfulness were colored by assumptions that exploring negative emotions would be helpful in PI but not in CB. The convergence of these direct observations of emotion patterns with previous indirect evidence of differences between CB and PI sessions (Burgoon et al., 1993; Goldfried et al., 1997; Mahrer et al., 1990; Reynolds et al., 1996; Stiles et al., 1996; Wiser & Goldfried, 1993) supports the suggestion that the treatments work by differential emotional mechanisms. In the context of the approximately equivalent effectiveness of CB and PI treatments, the evidence of different emotional mechanisms is consistent with a view that there are multiple paths to overcoming psychological disorder (Stiles, 1983).

References
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. Auld, F., Jr., & White, A. M. (1956). Rules for dividing interviews into sentences. Journal of Psychology, 42, 273281. Barkham, M., Stiles, W. B., & Shapiro, D. A. (1993). The shape of change in psychotherapy: Longitudinal assessment of personal problems. Journal of Consulting and Clinical Psychology, 61, 667 677. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561571. Burgoon, J. K., Beutler, L. E., Le Poire, B. A., Engle, D., Bergan, J., Salvio, M.-A., & Mohr, D. C. (1993). Nonverbal indices of arousal in group psychotherapy. Psychotherapy, 30, 635 645. Diener, E., Smith, H., & Fujita, F. (1995). The personality structure of affect. Journal of Personality and Social Psychology, 69, 130 141. Dill-Standiford, T. J., Stiles, W. B., & Rorer, L. G. (1988). Counselor client agreement on session impact. Journal of Counseling Psychology, 35, 4755. Elliott, R., & Anderson, C. (1994). Simplicity and complexity in psychotherapy research. In R. L. Russell (Ed.), Reassessing psychotherapy research (pp. 65113). New York: Guilford Press. Elliott, R., Shapiro, D. A., Firth-Cozens, J., Stiles, W. B., Hardy, G. E., Llewelyn, S. P., & Margison, F. R. (1994). Comprehensive process analysis of insight events in cognitive behavioral and psychodynamic interpersonal psychotherapies. Journal of Counseling Psychology, 41, 449 463. Firth, J., & Shapiro, D. A. (1985). Prescriptive therapy manual for the Sheffield Psychotherapy Project. Memo No. 058. (Available from the Psychological Therapies Research Centre, University of Leeds, Leeds LS2 9JT, United Kingdom)

Received June 3, 1999 Revision received July 11, 2001 Accepted September 12, 2001