How much Intensity is “Good Enough?”

By Susan Warren Warshow, LCSW

Published in “The Conejo Connection” a Quarterly Publication of the Conejo Valley Mental Health Professional's Organization, Volume 2, Issue 2 Summer, 2004

For the past three years, I’ve been a participant in an email forum in which therapists from around the world, practicing diverse styles of affect-focused therapies, engage in wide-ranging and richly substantive discussions. The exchange on “Intensity of Emotional Experience,” as it relates to successful and long-lasting therapeutic outcome, especially piqued my interest. My own training in ways to bring buried affect to the surface, adapted to each patient so as to enable the effective processing of emotions, has been immensely rewarding. I’d like to pass along some rich tidbits of information from this email exchange.

Patricia Coughlin Della Selva, Ph.D., international presenter and prominent author, writes that “accumulating data from studies on process and outcome [show] that depth of emotional intensity is a crucial variable [even in cognitive-behavioral therapy].” Her review finds that neither just talking about an area of disturbance nor just having a cathartic experience produces long term change. It is the combination of processing emotions on a visceral level and the gaining of psychological insight that is associated with lasting, positive outcome. She discovered that “High levels of nurturance and controlling responses (i.e. ‘You’re thinking about this in the wrong way’) quelled deep emotional experiencing.

Dr. Leigh McCullough, clinical assistant professor at Harvard Medical School, researcher and author of Changing Character, has commented on the element of emotional arousal present in successful CBT that has been observed by some researchers. Bridges (see below) stated that “Depth of emotional experiencing also has recently been shown to predict reduction of depressive symptoms in CBT (Castonguay, Goldfried, and Hayes. 1996).”

McCullough states that “We do not see behavior change if affect arousal is below 25 or so (scale of 100). Low moderate to moderate emotional experiencing is sufficient to cause behavior change in targeted problems. From 50-70 appears to be even better in promoting change. We also find that intense levels (above 70) sometimes are very promoting of change, but sometimes flood the system and are hard to integrate.” This only occurs, in my experience, without sufficient anxiety regulation or when inappropriate populations are involved (such as patients with active substance dependence, severe impulse disorders and psychosis).”

A study by Beutler, Clarkin and Bongar (2000), found that session emotional intensity was one of the strongest predictors of outcome, according to Michael Bridges, Ph.D., Associate Professor and Director of the Emotional Expression in Psychotherapy Research Center. He also states that “the effect of high session arousal on outcome is usually found to be mediated by the working alliance.” Iwakabe, Rogan and Stalikas (2000) came to the same conclusion. I interpret that there must be strong cooperation between patient and therapist to access and process emotions in a meaningful way so as to achieve specific goals.

Allan Abbass, M.D., an associate professor of psychiatry at the University of Dalhousie in Canada, and his team studied 89 consecutive patients treated with ISTDP, a highly focused dynamic therapy, involving intense emotional arousal, that has been the subject of 60 controlled trials. Most of the patients had already tried medication and other forms of treatment. 52% had personality disorders, 43% major depression, 37% somatoform disorder, 29% panic disorder. They found that there was a savings of $551, 954. in health care and disability insurance savings in the year that followed therapy. 80.6% returned to work and 69.0% stopped all medications during treatment.

Sue Johnson (empirically based Emotion Focused Couples Therapy) joins the chorus with this conclusion from her research with Les Greenberg: “We have found that to get new interactive responses that change the quality of the bond between partners in key change events you need a 4 or 5 ( highest ratings) on the Depth of Experiencing scale at key moments.”

Dr. Coughlin Della Selva references the fascinating work by James Pennebaker (l99l, l997) and his colleagues, who “have amassed a great deal of data suggesting [that] emotional experiencing is directly related to physical as well as emotional health. They have found that repressers get sick and those who have the opportunity to express their feelings about traumatic events receive a boost in immune functioning and are healthier 6 months later.” Disclosers showed a significant drop in blood pressure six weeks after participating in one of the experiments. Arthritic pain decreased as more negative affect was expressed.

One of Pennebaker’s studies, involving 200 employees, found that those with the most health problems had experienced at least one undisclosed childhood trauma (65 of the respondents). They were more likely to be diagnosed with cancer, high blood pressure, ulcers, flu, and headaches. It made no difference what the trauma had been, only that the trauma had not been talked about to others. Drs. Della Selva and Milan psychiatrist Ferruccio Osimo both believe that emotional experiencing which takes place between sessions, originating in the interpersonal relationship, can also have a powerful effect.