Exploring poor outcome cases in emotion-focused therapy—a mixed-method study

OBJECTIVE: Poor outcome cases in psychotherapy are prevalent, costly, and understudied. In this study, we wanted to contribute to a better understanding of poor outcome cases in Emotion-Focused Therapy by doing an in-depth exploratory analysis of therapist and client contributions. METHODS: Six cases drawn from a randomized clinical study on depression were selected and analyzed using both quantitative process measures, self-report measures, and qualitative investigations. We investigated the working alliance, clients' emotional processing qualities, therapist adherence in applying the model, as well as a qualitative clinical assessment of possible contributions to poor outcome. RESULTS: The results suggest that in five out of six cases, there were unaddressed challenges in the alliance, when it came to defining a clear goal and agreement on tasks. Also, adherence measures suggest that the therapists had difficulties with developing meaningful case formulations and helping clients deepen emotional processes. In the same five out of six cases, clients showed difficulties with emotional processing. CONCLUSION: It seems like difficulties with establishing an idiosyncratic, meaningful therapeutic project hindered sufficient emotional engagement and processing, contributing to poor outcome. Possible reasons for these challenges, as well as suggestions for what might have mitigated them, are discussed.