Psychotherapy

© 2021 American Psychological Association 2022, Vol. 59, No. 1, 63– 73

ISSN: 0033-3204 https://doi.org/10.1037/pst0000369

EVIDENCE-BASED CASE STUDY

Connecting In-Session Corrective Emotional Experiences With Postsession

Therapeutic Changes: A Systematic Case Study

Kaori Nakamura1, Shigeru Iwakabe2, and Nikolas Heim3

1
Graduate School of Humanities and Sciences, Ochanomizu University
2
Human Science Division, Faculty of Core Research, Ochanomizu University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

3
Tavistock and Portman NHS Foundation Trust, London, United Kingdom
This document is copyrighted by the American Psychological Association or one of its allied publishers.

This systematic case study investigated the nature of corrective emotional experiences (CEEs) that occurred
over the course of psychotherapy in a single case and how those in-session CEEs were related to changes in
the client’s life. Client’s e-mails on her experience of therapy sessions and postsession changes sent to the
therapist, as well as outcome and postsession measures, were analyzed. The client was a Japanese woman
who sought help for a variety of psychological symptoms including depression, anxiety, and emotional dys-
regulation. A long-term therapy of 67 sessions was conducted by a Japanese male psychotherapist who fol-
lowed an integrative affect-focused approach. The quantitative analysis showed that the client achieved
clinically significant change in depression, anxiety, self-compassion, interpersonal functioning, and self-
esteem over the course of therapy. A grounded-theory analysis of client e-mails to the therapist showed that
she experienced a deep connection with the therapist, gained a sense of relief through experiencing her dis-
avowed feelings, and developed a positive sense of self in the course of her sessions. The client felt she had
gained strength, had deepened her understanding of her feelings and behaviors, and that she was beginning
to develop new relationships with others. The understanding of the theory of CEEs through this case, cul-
tural issues, and the limitations and future directions of this study are discussed.

Clinical Impact Statement

Question: What was the nature of corrective emotional experiences (CEEs) that occurred over the
course of therapy and how were they related to changes in the client’s daily life? Findings: In this
case conducted in Japan, central to in-session CEEs were positive relational experiences with the
therapist characterized by feeling seen and understood by the therapist who was fully present and
working through past emotional pain. As a result, the client felt encouraged and empowered, extend-
ing the therapeutic work and initiating new actions in her daily life. Meaning: A deep connection
with the therapist as well as the experience of a sense of relief and positivity through working with
past emotional conflicts were both keys to therapeutic change in this integrative affect-focused ther-
apy. Next Steps: More systematic case studies are needed to examine in-session CEEs and postses-
sion changes and their relationship, validating the findings cross-culturally.

Keywords: corrective emotional experiences, systematic case study, emotion, therapeutic relationship,
intersession processes

This article was published Online First July 22, 2021.
Kaori Nakamura https://orcid.org/0000-0002-3980-0107
Shigeru Iwakabe https://orcid.org/0000-0001-7005-8978
Nikolas Heim https://orcid.org/0000-0002-2820-4051
This work was supported by Japan Society for the Promotion of Science
KAKENHI Grants JP25380919 and JP16K04347 given to Shigeru Iwakabe.
We have no conflicts of interest to disclose.
Kaori Nakamura served as lead for data curation, formal analysis,
investigation, and project administration; contributed equally to methodology,
conceptualization, resources, software, visualization and writing (original draft,
review, and editing); and served in a supporting role for validation. Shigeru
Iwakabe served as lead for funding acquisition, supervision, and validation;
contributed equally to conceptualization, methodology, project administration,
resources, visualization, and writing (original draft, review, and editing); and
served in a supporting role for data curation, formal analysis, investigation, and
software. Nikolas Heim contributed equally to methodology, supervision,
validation, and writing (original draft) and served in a supporting role for
writing (review and editing).
Finally, we would like to express our gratitude to the client for her
openness and generosity to contribute her work to our research study.
Correspondence concerning this article should be addressed to Kaori
Nakamura, Graduate School of Humanities and Sciences, Ochanomizu
University, 2-1-1 Otsuka, Bunkyo-ku, Tokyo, 112-8610, Japan. Email:
k_nakason@yahoo.co.jp

63
 64 NAKAMURA, IWAKABE, AND HEIM
Despite the vast amount of psychotherapy research, the question
of how psychotherapy facilitates change remains unanswered
(Goldfried, 2019). In particular, an understanding of how clients’
in-session change is associated with changes in their daily life
could elucidate the question of mechanisms of change in psycho-
therapy. Corrective emotional experiences (CEEs) are thought to
be central to the psychotherapeutic process of change by trans-
forming pathological and maladaptive interpersonal patterns in the
here and now with the therapist (Alexander & French, 1946) and
by generalizing these new experiences to relationships with signif-
icant others (Sharpless & Barber, 2012). Nevertheless, the nature
of CEEs remains largely unclear, and the link between the process
in which in-session CEEs lead to new postsession changes has not
been empirically examined.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Corrective experiences (CEs), lessening the emphasis of emo-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
tions, have been defined in a consensus across different therapeutic
orientations as “experiences in which a person comes to under-
stand or experience affectively an event or relationship in a differ-
ent and unexpected way” (Castonguay & Hill, 2012, p. 5). Two
types of CEs are distinguished. Type I CEs lead to behavioral
change through actively doing something different. Type II CEs
encompass new thoughts, emotions, and behaviors resulting from
encountering events that challenged the client’s frame of refer-
ence. These two definitions show that the emphasis on emotions
was dropped to satisfy different approaches and that corrective
(emotional) experiences is an inclusive concept. Empirical studies
confirm the breadth of the concept by distinguishing intrapersonal
and interpersonal change processes as subtypes of CEEs (Naka-
mura & Iwakabe, 2018). To further complicate matters, it is
thought that CEs could both occur as a result of awareness and
insight as well as without any explicit knowledge (Castonguay &
Hill, 2012). Thus, CEs could be defined as memorable poignant
events that some clients explicitly recall (Huang et al., 2016) as
well as processes on an implicit and unconscious level such as
microaffective interpersonal regulation (Krause & Merten, 1999).
In the present study, the original term corrective emotional ex-
perience is used to account for the central role of emotions in psy-
chotherapeutic change (Greenberg, 2002). Across therapeutic
orientations, the focus on facilitating client emotional processing
is associated with positive outcome (Greenberg & Pascual-Leone,
2006). Moreover, this is confirmed by neuroscientific research on
the importance of emotional arousal for memory reconsolidation
and therapeutic change (Lane et al., 2015). Furthermore, both
improved cognitive insight and improved affective awareness
were associated with long-term change (Høglend & Hagtvet,
2019). As the therapeutic alliance is strongly associated with out-
come (Flückiger et al., 2018) as well as other relationship varia-
bles (Norcross & Wampold, 2019), we believe that CEEs could
constitute a synergetic effect of combining the two powerful thera-
peutic factors (i.e., therapeutic relationship and emotions), rather
than by studying each of them separately.
So far, most studies on CEEs used a retrospective, qualitative
design by asking clients to recall specific experiences. For exam-
ple, Constantino et al. (2017) conducted extensive interviews with
former clients. This qualitative analysis using consensual qualita-
tive research method showed that the CEs that these clients identi-
fied were positive changes in cognition, interpersonal problems,
self-esteem, and symptoms. The clients believed that these in-ses-
sion gains might have led to adaptive interpersonal behavior
outside of sessions such as being more assertive and more open to
others. These clients also identified therapist’s actions associated
with CEs. These varied from direct feedback to affirmation and
self-disclosure. Another study using the same interview protocol
in Argentina replicated these findings (Roussos et al., 2017). How-
ever, aggregating CEs across different clients with their individual
problems obscures how specific CEs can be related to the client’s
individual issues. Additionally, these studies were based on the cli-
ent’s retrospective recollections of their experience after termina-
tion. Clients may not be able to recall the details of the experience,
which may be one of the reasons that clients’ descriptions of CEs
tend to be rather general (e.g., achieving new understanding) than
differentiated reports of specific processes of change.
Nakamura and Iwakabe (2018) conducted a task analysis of
CEEs in cases with good therapeutic outcome. The analysis
showed that CEEs consisted of both intrapersonal and interperso-
nal components. Intrapersonal components described the process
of the client allowing the experience of painful emotions associ-
ated with past interpersonal injuries. The interpersonal compo-
nents included the client taking in the therapist’s acceptance and
affirmation, which resulted in an enhanced sense of comfort and
closeness. The study also identified two types of interventions that
therapists used to facilitate CEEs. The first one was experiential
interventions that focused the client on their immediate physical
emotions, which then guided the client experience, ultimately con-
veying empathic understanding. The second one was relational im-
mediacy interventions, which made the client aware of the here
and now of the therapeutic relationship and facilitated the disclo-
sure of immediate feelings toward each other. At the end of CEE
events, clients made statements that suggested they developed a
positive self-understanding and articulated the newness of their
relational experiences with the therapist.
Friedlander et al. (2018) conducted a systematic case study on
CEs applying a multimethod analysis. CEs were identified in both
client’s and therapist’s verbal statements. In addition, moment by
moment narrative-emotion markers, therapeutic immediacy, and
contributions to the working alliance were observer-rated.
Through consistent attention to the alliance and increasingly
deeper immediacy, the therapist enabled the client to experience
painful, avoided emotions, and thus a new CE, which was reflected
in changes in the client’s identity narrative and the creation of new
experiences with peers. An earlier systematic case study (Fried-
lander et al., 2012) demonstrated how acceptance and the confron-
tation of defenses within the affirming and validating relationship
with the therapist allowed the client to experience anger and sad-
ness more deeply. This led to new realizations about herself, her
relationship with her parents, and other current interpersonal
relationships.
Existing studies show that CEEs involve the client’s intensive
emotional experience within a positive relationship with the thera-
pist, which in turn provide new CEEs that are transferred to
changes outside of therapy. Although those studies demonstrate
that in-session CEEs lead to postsession changes, only in-session
data were systematically analyzed. Thus, a systematic investiga-
tion of the relationship of how in-session CEEs lead to postsession
change as well as a quantitative investigation on the nature of
CEEs is outstanding.
Nonetheless, there have been innovative attempts to bridge in-
session and postsession episodes, although not specifically in
 CORRECTIVE EXPERIENCES AND POSTSESSION CHANGES
regard to CEEs. Yalom and Elkin (1974) published a book called
Everyday Gets a Little Closer in which his patient and he as a ther-
apist both wrote a diary entry about their experience of each ses-
sion, contrasting the therapist’s experience with that of the client
within and outside of sessions. This process revealed their unex-
pressed thoughts and feelings in addition to how each can have
varying views of the same session even when both agreed that a
particular session was helpful. Similarly, Mackrill (2007) devel-
oped a practical diary method. He invited clients to keep a log
about their experience of sessions as well as in everyday life and
to note possible connections between the two. He gave concrete
instructions so that clients’ written responses provided sufficient
details to allow a valid qualitative analysis. The qualitative analy-
sis generated an overarching category representing a mode of cli-
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ent involvement called triangulation, in which the client compared
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advice received from the therapist, friends, and other helping pro-
fessionals to confirm the validity to arrive at his own view and
decision.
Finally, there are studies that used a questionnaire to gather in-
formation about intersession activities. Geller and Farber (1993)
used the Therapist Representation Inventory that taps into clients’
internal representations of their therapists and the therapeutic rela-
tionship. They found that clients recalled the therapist and the ther-
apeutic relationship to continue to work on their issues in their
daily lives. They had a felt presence of their therapists when seek-
ing comfort from negative emotions and when working on every-
day problems previously discussed in therapy. It was concluded
that clients do not simply “remember” their therapists but actively
brought forth their representation to regulate painful affects and
facilitate problem-solving and conflict resolution. There are more
recent studies that examined the relationship between in-session
processes and between-session activities. Owen et al. (2012) dem-
onstrated that a better alliance led to clients’ increased engagement
in therapeutic activities between sessions. In addition, Quirk et al.
(2018) found that when clients had good alliances with therapists
and also with people in their everyday lives, they tend to engage in
more actions associated with what they addressed in therapy. Fur-
thermore, when clients saw that their therapy was progressing,
they tended to continue to think about their issues, and initiate new
actions. This also led to a better alliance with the therapist and
with those around them. These studies show that clients are more
likely to engage in intersession therapeutic activities to extend
their therapeutic gains when they have a good relationship with
their therapist and when they have a sense of progress. When cli-
ents have in-session CEEs, it is anticipated that a synergetic effect
is created between in-session and postsession improvements that
make an increase in meaningful activities and thoughts more
likely.
The Present Study
A particularly favorable situation for studying the relationship
between in-session CEEs and postsession changes arises when a
client voluntarily provides information on their in-session CEEs
and their influence on postsession life. In the present case study
with a female adult client who was treated in Japan as part of a
larger research project on emotional change process, the client
started sending e-mails about her experiences in therapy sessions
and how they affected her in her daily life to the therapist. The
65
therapist responded with a brief message thanking her for her e-
mail and acknowledging the importance of the events that she
reported. He did not discourage her from writing e-mails to him,
as he considered it more beneficial than detrimental, as they were
able to pick up topics that she brought up in her e-mails. Although
her e-mail reports did not follow a controlled data-gathering
schedule, accounts were written almost after each session. The
fact that she wanted to communicate with the therapist supports
that these events had personal significance to her. Most impor-
tantly, in these e-mails, she also made connections in a concrete
and detailed manner between in-session events and postsession
changes in the following days. We took this unique circumstance
as a special opportunity to study the nature of CEEs as well as the
relationship of in-session CEEs and postsession changes by ana-
lyzing the client’s e-mail reports by using a systematic case study
design.
Method
Aims
This systematic case study aimed to understand the nature of
both in-session CEEs and postsession changes and the link
between them in a single case of psychotherapy. We combined
quantitative and qualitative methods to develop a comprehensive
understanding of CEEs. First, we tested whether the outcome of
this case in which in-session CEEs occurred was positive and if
those measures that were expected to be associated with in-session
CEEs significantly improved, such as depression, anxiety, emo-
tional regulation, interpersonal relationship, and self-esteem. Sec-
ond, to understand the nature of in-session CEEs and resulting
changes following these sessions from the client perspective, we
qualitatively analyzed e-mails sent by the client and developed a
category system of both in-session CEEs and postsession changes.
We also examined how the client linked in-session change to post-
session changes based on the qualitative analysis of her e-mails.
Study Design
The design of this study followed that of a systematic case study
method, particularly the theory-building case study method (Stiles,
2007). According to Stiles, theory-building case studies are based
on (a) familiarity with the theory and research, (b) selection of a
case that includes something new, interesting, or theoretically rele-
vant, (c) collection of data from as many sources as possible such
as audio/video recordings, session-by-session assessments, out-
come assessments, posttreatment interviews, and other personal
documents, (d) familiarity with the data, deciding the focus of the
study, and understanding what happened theoretically, and (e) the
use of the results to revise and improve the theory. We attempt to
extend the understanding of CEEs based on this single case by
combining quantitative measures with the qualitative analysis of
client e-mails. This is a novel approach to investigate the connec-
tions of client's in-session experiences with postsession changes.
The Researchers and Reflexivity
Three researchers were involved in this research project. The
first author is a Japanese female doctoral student in clinical
 66 NAKAMURA, IWAKABE, AND HEIM
psychology with 6 years of experience in psychotherapy process
research. She conducted both quantitative and qualitative analyses.
For the qualitative part of the study, she took a primary role in
coding the data, generating categories, and confirming them
against session recordings. The second author is a Japanese male
professor in clinical psychology, who specializes in psychotherapy
process research from an integrative perspective. He was also the
therapist of the case used in this study. He played a secondary role
in the data analysis mainly by examining the fit between the data
and emerging categories and supplementing the contextual infor-
mation about sessions in which CEEs occurred. The third author
had a master’s degree in clinical psychology and worked as a psy-
chotherapy research assistant in the United Kingdom. He joined
this research during his study in Japan. He examined the validity
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of the interpretation of the results.
In qualitative research, the researchers’ preexisting intentions,
worldviews, assumptions, and theoretical orientations influence
the whole process of the study from the research design to the
interpretation of the data. The two researchers who conducted the
qualitative analysis wrote down their expectations before the study
and discussed how those might impact their decisions and interpre-
tations. Based on a previous study on task analysis of six CEE
events (Nakamura & Iwakabe, 2018), the first author expected that
new relational experiences with the therapist are central to CEEs.
The second author expected that working through painful emo-
tions, which stem from past interpersonal injuries, require an
affirming relationship to be transformed into CEEs. Both assumed
that CEEs lead to therapeutic change by generalizing positive
experiences with the therapist to relationships with significant
others outside therapy and practicing new behavior. The third
author was brought in to counteract potential interpretation bias
due to the specific theoretical background of the first two research-
ers who both took an emotion-focused approach. He acted as an
auditor, examining the fit of the data to categories. He suggested
alternative interpretations of the data to the first author so that she
can thoroughly examine her assumptions in interpreting the data.
His suggestions were relatively minor, and a few phrasing of cate-
gories were slightly modified.
Because the second author is the research supervisor of the first
author, the power imbalance was monitored throughout. In their
analytic meetings, the first author explained the development of
her analysis and the second author gave feedback in the form of
suggestions. The first author’s analyses were mostly reflected in
the final results. The second author had several suggestions to
organize lower categories to reflect the meaning of the client e-
mail data. More specifically he made two major suggestions. One
was separating drawing parallels from gaining emotional aware-
ness because the former is about interpersonal relationships and
the latter is about internal emotional experiences. The distinction
was important as the two were interrelated but different compo-
nents of CEEs. The other was including asserting herself to the
therapist as one of the subcategories of gaining strength from the
therapy. The first author considered asserting herself to the thera-
pist as a distinct category on its own representing a potential rup-
ture. Later, the first author realized that this was one of the
therapeutic gains in which the client mastered a more assertive
attitude based on information about the context of therapy that the
second author provided.
The Case of Naomi
The personal details of the present case study were anonymized
while preserving the main themes of the client’s conflicts and the
therapeutic process. At the time when the psychotherapy started,
Naomi was a married Japanese woman in her late 30s who worked
as a high school teacher and lived with her husband and her one-
year-old child. She initially sought help because of depression,
anxiety, and emotional dysregulation. A doctor suspected a con-
genital health problem of her child at birth, which turned out to be
a false alarm. However, it shocked Naomi and she was emotion-
ally and physically drained. Naomi reported to the therapist during
an early session that she blamed herself for the baby’s health con-
dition and took it as a confirmation of her personal inadequacies.
At the time, Naomi’s husband was living in another city for work.
Naomi desperately sought help from her mother. After repeated
pleading, her mother reluctantly agreed to help her. However, she
constantly criticized Naomi’s parenting from breastfeeding to
cooking. Naomi felt increasingly more distressed and depressed.
Eventually, she followed a friend’s advice and sought a therapist.
Naomi was raised in an upper-middle-class family with two
highly achievement-oriented and career-driven parents. Her
parents were emotionally cold, distant, uninterested, and absent.
Naomi was left with her grandmother and aunt who were present
but controlling, dismissive, and critical of Naomi and her parents.
To protect herself, Naomi learned not to show her feelings in front
of others. For a long time, she did not tell anyone about her com-
plicated family situation. When she was 14 years old, she dis-
closed her life story to her most trusted teacher, who dismissed her
by saying she was ungrateful and making up a story. She was dev-
astated and felt betrayed by everyone. Despite her unfavorable
upbringing, Naomi studied on her own and was awarded with a
scholarship to study at a college in another city. When her mother
became seriously ill, Naomi frequently visited her in the hospital
and took care of her.
It is customary for women to spend their maternity under the
care of their own mother for an extended period of time in Japan.
However, her mother did not invite her to come and stay with her
or even call her to ask how she was doing, which was upsetting to
Naomi. Her husband was at a critical period of his career and was
not able to attend to her. Naomi was also hesitant to ask her hus-
band for his care and help because she considered it her duty as a
wife to not burden him with her concerns and interfere with his ca-
reer. When Naomi finally asked for her mother's help for the first
time in her life, Naomi felt that her mother not only came reluc-
tantly but also criticized her as a parent, which Naomi felt pushed
her off the edge. At this point, she felt emotionally distressed and
felt like she couldn’t cope. In sum, her main conflict comprises
issues of abandonment, betrayal, and constant criticism from her
caregivers as well as lack of emotional care. Based on the thera-
pist’s report and also from her statements in sessions, Naomi,
however, was not initially aware that her unresolved conflicts with
her mother contributed to her depression as well as concern with
her baby’s health. We did not consider Naomi as a case of postpar-
tum depression, as many stressors were involved and her distress
significantly worsened after her interaction with her mother,
although we acknowledge her experience of giving birth as one
factor contributing to her distress.
 CORRECTIVE EXPERIENCES AND POSTSESSION CHANGES
The Therapist
The therapist was a Japanese male clinical psychologist in his late-
40s with 20 years of clinical experience. He describes his therapeutic
approach as integrative affect-focused, centrally influenced by emo-
tion-focused therapy (EFT; Greenberg, 2002) and accelerated experi-
ential dynamic psychotherapy (AEDP; Fosha, 2000). EFT is a
humanistic treatment approach that has been shown to be effective
for depression, complex trauma, and anxiety (Greenberg & Goldman,
2018). It facilitates client’s effective emotional processing within an
empathic and collaborative relationship using emotional activating
interventions. AEDP, on the other hand, derives its foundation from
short-term dynamic therapies, experiential approaches, attachment
theory, affective neuroscience, and psychology of emotions (Fosha,
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2000). Both EFT and AEDP aim at experiencing and transforming
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emotions in the presence of an empathic and affirming psychothera-
pist. Moreover, AEDP adds an understanding of affective phenomena
from an attachment perspective and provides relational interventions
to work through interpersonal ruptures and provide CEEs.
Treatment
The therapy was open-ended and long-term, lasting a total of 67
sessions and five follow-up appointments. The treatment was di-
vided into two phases with the 34th session as the midpoint for the
following reasons. First, an interim outcome was measured at this
point. In the 33rd session, the therapist shared his observation that
the client had made significant improvements and was doing a lot
better, which the client confirmed. The therapist suggested that the
client take outcome measures to monitor her progress. Second, the
therapist observed a shift from a focus on the client’s childhood
experiences toward her current life around the 34th session. In the
first phase, the focus was mainly on the client’s difficulties with
her mother, postnatal life changes, and adverse childhood experi-
ences. The second phase focused on her teenage years, work-
related issues, and her new social life that she was developing as a
result of therapy.
Naomi’s therapist reported that he focused on three objectives
while reviewing session recordings with the first author: (a) mak-
ing connections between her current difficulties and past traumatic
events, (b) experiential psychoeducation in which the therapist
explained the role of emotions in physical and psychological
health as they occurred during the session, and (c) experiential
work to increase her emotional awareness and emotion regulation
capacity. After terminating the therapy at the 67th session follow-
ing improvements in functioning and symptom reduction, they
mutually agreed to follow-up sessions with a reduced frequency
until the client felt comfortable without therapy. In five follow-up
sessions that were spaced 8 weeks apart, the client maintained a
high level of functioning and well-being. The client reported dur-
ing those sessions that she developed satisfying new friendships,
but that her relationship with her mother remained tense. The fol-
low-up sessions were not included in the data set, as there were no
e-mails about her experience in these sessions.
Procedure
The client was treated at a university outpatient clinic as part of
a larger research project on emotional change process conducted
67
by the second author in Japan. Written consent for using session
recordings, questionnaires, and e-mail exchanges for research pur-
poses was obtained from the client, and all components of the
study were approved by the ethical committee of the first and sec-
ond authors’ institute. Naomi’s therapy was an open-ended long-
term treatment, which is the standard at the university outpatient
clinic she was seen. Therapy sessions were conducted weekly or
fortnightly free of charge, and all sessions were videotaped. Out-
come measures were given at the first session, midtreatment (after
the 34th session), and end of treatment (after the 67th session). Im-
mediately after each session, over the course of treatment, the cli-
ent filled out postsession measures. In addition, the client
voluntarily wrote about in- and postsession experiences in the
form of e-mails to the therapist after sessions.
Measures
Five outcome and two postsession measures were used in this
study. For the five outcome measures, Japanese versions with con-
firmed validity and reliability were used.
Outcome Measures
(a) Center for Epidemiologic Studies–Depression Scale (Radl-
off, 1977) is a 20-item depression screening measure. (b) State
Trait Anxiety Inventory (Spielberger et al., 1970) is a 40-item
measure assessing state and trait anxiety. (c) Inventory of Interper-
sonal Problems-64 (Horowitz et al., 2000) is a 64-item measure
assessing interpersonal problems. (d) Rosenberg Self-Esteem
Scale (Rosenberg, 1965) is a 10-item measure assessing self-
esteem. (e) Self-Compassion Scale (Neff, 2003) is a 26-item mea-
sure assessing the degree of self-compassion.
Postsession Measures
(f) Short Working Alliance Inventory (WAI; Tracey & Koko-
tovic, 1989) is a 12-item measure assessing the strength of the
therapeutic relationship between the client and the therapist. The
score is between 1 and 7. Cohen’s a for the total WAI score was
.98 in this study. (g) Corrective Emotional Experience Scale (CEE
scale; Nakamura & Iwakabe, 2020) is a 14-item measure assessing
four components of in-session CEEs and rated on a 7-point Likert
scale, from 1 (not at all) to 7 (very much): Positive Emotional Ex-
perience With the Therapist (e.g., “I felt the therapist’s empathy,
care, and warmth”), Emotional Transformation (e.g., “I was able
to express in words new feelings that emerged in the session”),
New Understanding (e.g., “The familiar way I saw myself and
others changed”), and Core Pain (e.g., “I touched emotional pain
that stems from past experiences”). Cohen’s a for each subscale
was over .72 (Nakamura & Iwakabe, 2020). In this study, the CEE
scale was added as a postsession measure from the 24th session
when the scale was developed.
E-Mail Reports
During the course of 67 sessions, the client sent a total of 72 e-
mails to the therapist. The average length of the e-mail was
1,213.08 characters (range from 207 to 2,826 characters). When
the therapist received her e-mails, he often started the next session
by recapitulating what stood out for him. For example, she wrote
in one e-mail that “When you asked about how I felt toward my
 68 NAKAMURA, IWAKABE, AND HEIM
mother then, I couldn’t respond well. I couldn’t tell you why I felt
that way, either. Can I write about them in this e-mail? It is some-
times hard to tell you in sessions.” She also used her e-mail to
give a heads-up on the topic of the next session: “I have something
I want to talk about in the next session, so please let me write it in
this e-mail so that I do not forget it.” Thus, e-mails helped Naomi
to talk about issues that were not necessarily easy to bring up.
Data Analysis
Selection of E-Mail Texts That Are Likely to Describe
Client CEE Experiences
To ensure that the client’s e-mails were not simply communica-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
tions of her everyday experiences, but also of therapeutic signifi-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
cance that could be considered CEEs, we selected those sessions
that were likely to contain CEEs based on the high CEE subscale
scores. We used scores of three subscales, Positive Emotional Ex-
perience With the Therapist, Emotional Transformation, and Core
Pain, because these subscales were essential components. New
Understanding, though an important component, was not included
in the selection of the sessions because the client often reported in
her e-mail that realizations came not during sessions but after ses-
sions when she had a chance to reflect back. Therefore, we
adopted a criterion for CEE session as those sessions with 5 or
higher rating on a 7-point Likert scale on all three CEE subscales
except New Understanding. As a result, 25 sessions met this crite-
rion. Among these 25 sessions, there were 21 sessions on which
the client wrote e-mails. There was a total of 30 e-mails corre-
sponding to these 21 sessions. These 30 e-mails were first ana-
lyzed to generate representative categories, as they were most
likely to have good examples of CEEs. The remaining 42 e-mails
were analyzed later by using the category for comparison.
Qualitative Analysis
Grounded theory approach (Glaser & Strauss, 1967) was
used to analyze the client’s e-mails. This is a qualitative method
that allows the generation of theoretical constructs from text
data in a systematic way. It is often used effectively to under-
stand the client’s subjective experience in psychotherapy
(McLeod, 2011). To start, the first author immersed herself in
the data to understand the overall context of therapy as well as
to contextualize the e-mail data with the actual session record-
ings, which is consistent with the theory-building case study
method (Stiles, 2007). She read the 30 e-mails repeatedly,
viewed all session videos, and made transcripts of sessions after
which e-mails were sent. She identified episodes of CEEs based
on the descriptions given in the client e-mails. Second, she gen-
erated codes for the e-mail data and discussed them with the
second author. Codes were assigned to relatively longer texts
such as a few lines or a paragraph to grasp more general themes
of the client’s experience. The second author, the research
supervisor and also the therapist of this case, shared his impres-
sions and interpretations of the sessions and the e-mails at this
stage. The therapist’s remarks helped the principal researcher
to triangulate her interpretations of what happened in the ses-
sion and to fill gaps between what could be observed from the
data and what the therapist experienced. Third, the first author
used MAXQDA software to conduct a line-byline analysis of
the e-mail data. She first coded each data segment as either in-
session or postsession event. Similar codes for each of these
two groups were aggregated together as a category. Fourth, the
first author presented the result to the second author so that they
could examine the fit between the categories and the data. The
second author suggested adding several codes and elaborating
names of codes that, he thought, reflected the nuance and
poignance of the client’s subjective experience more accu-
rately. They repeated this process several times until both felt
that the data, codes, and categories were well coordinated. The
second author (therapist) showed the main categories to the cli-
ent for feedback. She felt that her experience of therapy was
accurately captured by the analysis. These two steps composed
the credibility check of the analysis. Fifth, the first two authors
independently analyzed the remaining 42 e-mails using the cat-
egories generated in the analysis. Lastly, the client’s important
quotes from her e-mails as well as names of codes and catego-
ries were translated from Japanese to English by the second
author who is bilingual. Both versions were examined by a pro-
fessional translator for accuracy. The third author examined the
fit between the data and categories, and the interpretation of
results by the first two authors. He pointed out some ambigu-
ities in translated e-mails. The content of her e-mails was ano-
nymized to disguise her identity while maintaining the meaning
of her experience.
Results
The Quantitative Outcome and Process of the Case
The outcome scores obtained from three data points, reliable
change, and clinically significant change are presented in Table 1.
The client’s problems were initially in the clinical range exceeding
1 or 2 SD from the population means for trait anxiety, interperso-
nal problems, and self-compassion. From pretreatment to mid-
point, she demonstrated clinically significant change on three
outcome measures: interpersonal problems, self-esteem, and self-
compassion. From midpoint to posttreatment, she demonstrated
clinically significant changes in anxiety in addition to these three
measures. From pre- to posttreatment, she demonstrated clinically
significant changes in all outcome measures including depression.
The client filled out the WAI immediately after 55 sessions out
of a total of 67 sessions. The mean score of WAI was high (6.72)
with a small standard deviation (.44). It indicates that a good
working alliance was maintained throughout the treatment. She
filled out the CEE scale immediately after 39 sessions between the
24th and the 67th session. The means of the subscales were 5.85
(SD = .87) for Positive Emotional Experience With the Therapist,
5.08 (SD = 1.27) for Emotional Transformation, 5.18 (SD = 1.30)
for New Understanding, and 6.25 (SD = .79) for Core Pain.
The Qualitative Analysis of E-Mails: In-Session CEEs
and Postsession Changes
The qualitative analysis of the 30 e-mails corresponding to 21
sessions that were likely to contain CEEs based on the CEE scale
scores yielded six in-session CEE categories and three postsession
change categories.
 CORRECTIVE EXPERIENCES AND POSTSESSION CHANGES 69

Table 1
Outcome Scores, Reliable Change, and Clinically Significant Change
Score Change
Pre-Mid (#1 34) Mid-Post (#35 67) Pre-Post (#1 67)
Normal population
Measure a M (SD) Pre (#1) Mid (#34) Post (#67) RC MIFD CSC RC MIFD CSC RC MIFD CSC
CES-D .80 7.70 (7.10) 14.00 6.00 0.00 1.78 * 1.34 * 3.12* * *
STAI
State .89 36.60 (9.06) 45.00 42.00 26.00 0.71 * 3.77* * * 4.47* * *
Trait .90 39.10 (9.90) 54.00 47.00 33.00 1.58 * 3.16* * * 4.74* * *
IIP-64 .96 51.50 (34.30) 127.00 106.00 58.00 2.25* * * 5.14* * * 7.39* * *
RSES .85 29.46 (7.11) 33.00 42.00 50.00 2.31* * * 2.05* * * 4.37* * *
SCS .81 17.17 (3.29) 12.80 19.15 27.90 3.13* * * 4.31* * * 7.45* * *
Note. # = session number; CES-D = Center for Epidemiologic Studies–Depression Scale; STAI = State Trait Anxiety Inventory; IIP-64 = Inventory of
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Interpersonal Problems-64; RSES = Rosenberg Self-Esteem Scale; SCS = Self-Compassion Scale; RC = reliable change; MIFD = movement into a func-
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tional distribution, achieved the level of functioning that fell within the range of the normal population, where range was defined as beginning at 2 SDs
below the mean for the normal population; in other words, achieved cutoff point b according to Jacobson et al. (1999); CSC = clinically significant change,
achieved both RC and MIFD.
* Significant change.

Categories of In-Session CEEs
Six categories of CEEs were generated out of 121 initial codes.
(a) Encounter with the therapist represents in-session experiences
in which the client felt recognized for who she was by the therapist
without his own personal motivations or solely through a profes-
sional lens. Feeling seen in this way by the therapist also describes
a feeling of not being alone as there was a sense of emotional con-
nection with the therapist. Encounter with the therapist had two
subcategories: (a1) Listened to/affirmed/seen and (a2) Powerful
presence of the therapist. After the 39th session, the client wrote,
“in yesterday’s session I felt like I was hugged by you just a bit
when you understood, without judging me, how I felt when I was
a teenager.” (b) Experiencing previously disavowed feelings repre-
sents an experience in which the client experienced, expressed,
and/or explored her strong negative feelings that were previously
avoided, blocked, or warded off. (c) Relief from emotional pain
represents a sense of release and relief from emotional suffering
from the past. The client was not able to verbalize it during the
session at first because it felt new and unfamiliar. After the 48th
session, she wrote, “in yesterday’s session I felt just like I did
when I was a teenager and couldn’t leave my room. It felt like I
was confined in a cage. But after I allowed myself to cry a lot
while you were with me throughout (in the session), it felt like I
was finally set free from the cage” (Encounter with the therapist,
Experiencing previously disavowed feelings, and Relief from emo-
tional pain). (d) Emerging positivity/self-affirmation captures the
client’s somatic experience of comfort, pleasantness, and energy
when she noticed something positive about herself. After the 67th
session, she wrote, “I felt a physical sense of well-being and ac-
ceptance. I couldn’t have done this without you” (Encounter with
the therapist and Emerging positivity/self-affirmation). (e) Having
maladaptive beliefs disconfirmed describes the experience in
which the client had her negative self- and other-beliefs and her
pessimistic worldview disproven in the interaction with the thera-
pist. She wrote after the 60th session:
All adults around me taught me that I was the problem, which meant
that I had to change who I was. On the other hand, you were empathic
to my feelings and you said that I didn’t have to get rid of myself. That
was my first experience and really helped.
(f) Experiencing affection and compassion for others represents
in-session experiences in which the client felt affection, warmth,
care, and compassion for significant others. In the 56th session,
she vividly remembered the time when her abusive aunt was dying
in the hospital: “I felt affection for her after all that happened. I
wanted to take care of her.” Her compassion extended to even
those who emotionally neglected or injured her in the past.
Categories of Postsession Changes
The qualitative analysis generated 334 codes of postsession
changes, which were aggregated in 10 subcategories and then
finally into three main categories: Gaining strength from the ther-
apy, Applying emotional understanding, and Building new rela-
tionships with others. (g) Gaining strength from the therapy
represents the client’s experience of being encouraged, empow-
ered, and energized to actively address challenges and conflicts,
and consists of four subcategories: (g1) Getting motivated to con-
front difficulties, (g2) Keeping good feelings, (g3) Vividly experi-
encing therapeutic change in life, and (g4) Asserting herself to the
therapist. After the 54th session in which she felt conspicuously
peaceful, she wrote, “The more I think about it, the more signifi-
cant it feels to me . . ., then joy springs out in me.” Asserting her-
self to the therapist represented her experience of challenging the
therapist by asserting her own opinions and views. This was con-
sidered a positive change, as the client was not able to assert her-
self or confront others before starting her therapy. (h) Applying
emotional understanding relates to a variety of ways in which the
client confirmed and extended understanding about her emotional
experiences gained in session to events in her daily life, and con-
sists of three subcategories: (h1) Gaining emotional awareness,
(h2) Drawing parallels, and (h3) Gaining new understanding. Af-
ter the 29th session in which she explored her work-related con-
flicts and felt understood by the therapist, she left the session
feeling encouraged and empowered to improve her relationship
with her colleagues. She also found that the positive relational
experience with the therapist increased her sensitivity to
 70 NAKAMURA, IWAKABE, AND HEIM

interpersonal cues that represented the perpetual conflictual rela-
tionship with her mother: “I was irritated by my mother’s dismis-
sive tone. Then I realized that this was exactly how I felt in my
teenage days.” (i) Building new relationships with others describes
the experience of relating with significant others in different ways
and venturing out and building new friendships based on the new
sense of self she was developing in therapy. This category con-
sisted of three subcategories: (i1) Heightened affection and com-
passion for others, (i2) Joining new social groups, and (i3)
Practicing what was learned from the therapist. After the 29th ses-
sion, she wrote, “I feel like I understand my student’s feelings
much better now. I am sensing their suffering and becoming more
empathic and attuned.”
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for example, the client felt free from shame as she felt she can be
honest with her therapist. However, when she went to work the
next day: “I noticed how shameful my work environment is and
how shame is silencing people.” This sharp contrast helped her to
identify problematic relationships in her life that needed to
change.
The Frequency of Categories of CEEs in Two Phases of
Treatment
The frequency of categories throughout the therapy is shown in
Table 2. There were 18 e-mails corresponding to 14 sessions of
the first 23 sessions when the CEE scale was not yet implemented.
In this period, three in-session categories and three postsession

The Link Between In-Session CEEs and Postsession categories were observed but to a lesser extent, except applying
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emotional understanding. There were 15 e-mails corresponding to

Changes
Three categories representing postsession changes also reflected
how the client linked in-session CEEs to postsession changes.
Gaining strength from the therapy involved the client feeling
empowered by new and positive relational experiences with the
therapist, which became a driving force to initiate new behaviors,
extending to changes in interpersonal relationships. In the 29th
session, for example, the client was touched by the therapist’s em-
pathic validation. She stated that this experience helped her come
out of despair about her workplace atmosphere in which her opin-
ion was repeatedly ignored or dismissed: “I was on the verge of
giving up. But I feel so encouraged by you. I reflected on our ses-
sion which felt so healing and I was empowered.” She was gradu-
ally able to improve relationships with her colleagues: “I noticed
my relationships with colleagues have deepened and are better
since I started therapy” (after the 44th session).
Another link was the contrasting of two experiences in which
the client clearly understood and felt her issues by comparing posi-
tive emotional experience that she just had in the sessions with her
daily conflict-laden relationships. This was observed mostly
related to applying emotional understanding. In the 59th session,
10 sessions in the latter part of the first phase with the CEE scale
scores. All categories except emerging positivity/self-affirmation
were observed to the same extent as in the second phase. In the
second phase, 39 e-mails corresponding to a total of 29 sessions
were analyzed, and emerging positivity/self-affirmation was
observed for the first time.
Discussion
In-Session CEEs and Postsession Changes
In accordance with Stile’s theory-building case study method
(Stiles, 2007), this study combined multiple methods to understand
the nature of in-session CEEs and postsession changes. The client
showed clinically significant changes in outcome measures for all
scales covering depression, anxiety, self-compassion, interpersonal
functioning, and self-esteem. A qualitative analysis of e-mails that
the client sent to the therapist showed that in-session CEEs were
characterized by the positive relational experience with the thera-
pist in which previously disavowed feelings could be experienced.
The client also experienced a sense of relief from emotional pain, a

Table 2
Categories and Frequency of In-Session CEEs and Postsession Changes
The first phase The second phase
#1 23 #24 34 #35 67
Category N % N % N %
Number of sessions 23 11 33
Number of sessions the client sent e-mails after the session 14 10 29
Categories of in-session CEEs
a. Encounter with the therapist 5 35.7 8 80.0 20 69.0
b. Experiencing previously disavowed feelings 4 28.6 5 50.0 11 37.9
c. Relief from emotional pain 0 0.0 2 20.0 6 20.7
d. Emerging positivity/self-affirmation 0 0.0 0 0.0 8 27.6
e. Having maladaptive beliefs disconfirmed 0 0.0 1 10.0 4 13.8
f. Experiencing affection and compassion for others 1 7.1 1 10.0 2 6.9
Categories of postsession changes
g. Gaining strength from the therapy 5 35.7 8 80.0 26 89.7
h. Applying emotional understanding 9 64.3 8 80.0 21 72.4
i. Building new relationships with others 4 28.6 5 50.0 8 27.6
Note. CEEs = corrective emotional experiences; # = session number. The categories were developed by analyzing 30 e-mails corresponding 21 sessions
that were likely to contain CEEs based on the CEE scale scores. The frequency of the category is the percentage of the session after which the client sent
e-mails. The CEE scale was implemented from the 24th session. The midtreatment outcome was conducted after the 34th session.
 CORRECTIVE EXPERIENCES AND POSTSESSION CHANGES
positive sense of self as well as disconfirmation of negative beliefs,
and affection and compassion for others. When in-session CEEs
occurred, the client felt empowered and invigorated, extended her
emotional understanding, improved existing relationships, and ven-
tured into new interpersonal experiences in her daily life as shown
in three categories for postsession changes.
The qualitative analysis of the client’s e-mails indicated that en-
counter with the therapist, an experience of meeting the therapist as a
person, and a sense of deep connection, was central to the client’s ex-
perience of CEEs. CEEs are originally considered as the patient mas-
tering an unresolved conflict from childhood in the transference with
the therapist from a psychodynamic point of view (Alexander &
French, 1946). It appears that the mastering of unresolved conflicts is
made possible within the specific relational framework that was pres-
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ent in this case study: The therapist being empathetic, present, and
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authentic created a safe relational environment that allowed the client
to face and process past unresolved painful emotions. Such relational
qualities are considered essential in both, AEDP and EFT, and match
what Mearns and Cooper (2005) named relational depth, a state of
profound contact and engagement between two people who are able
to value and understand the other’s experience. They pointed out,
that a deep relational connection itself forms a CEE, as found in the
present study.
Another significant aspect of the experience of a deeply positive
relationship with the therapist is that it was associated with the
link between in-session CEEs and postsession changes. This is
captured in the postsession category, gaining strength from the
therapy, which describes an experience of increased energy and
morale as well as benefiting from positive emotional experience
with the therapist even after the session. Previous studies on inter-
session activity showed that clients recalled the therapist and the
therapeutic relationship to further work on problems in daily life,
to seek comfort from negative emotions, and facilitate problem
solving (Geller & Farber, 1993). Similarly, Owen et al. (2012) and
Quirk et al. (2018) found that good alliance facilitated clients’
engagement in more actions to address their issues in their daily
life. The present study demonstrated that in affect-focused thera-
pies such as AEDP and EFT, such carryover effects come from
positive emotions sprung out from the relational experience with
the therapist. The client took strength from her positive relational
experience with the therapist after the session, which in turn led to
new positive experiences in her life. This finding highlights the pri-
mary importance of optimal therapeutic relationship in affect-
focused therapies: The client’s new actions may be facilitated with-
out specific advice or homework, leaving the client feeling empow-
ered by the positive emotional experience with the therapist.
Naomi savored her positive relational experience with the therapist
and reflected on her achievements, maintaining positive emotions
that seem to have led to her making use of new understanding in
daily life and to venture new interpersonal behaviors. This positive
cycle of change seems to match the adaptive roles of positive emo-
tions. Fredrickson (2000) in her broaden-and-build theory of positive
emotions pointed out that the experience of positive emotions mo-
mentarily broadens one’s awareness and encourages novel thoughts
and actions, which will likely result in building new skills and psy-
chological resources. In addition, Fredrickson pointed out a recipro-
cal relationship between positive emotions and personal resources, in
which experiences of positive emotions facilitate building of personal
resources, which in turn brings more experience of positive emotions,
71
creating an upward spiral of positive emotion and coping. Naomi’s
e-mails often described this type of sequence of change in which she
reported her positive emotional experience with the therapist (en-
counter with the therapist) followed by a sense of increased energy
and self-efficacy (gaining strength from the therapy), deepening or
extending her understanding of self and others (applying emotional
understanding), and building interpersonal recourses (building new
relationships with others).
Naomi’s positive relational experience also helped her to under-
stand her problems as they unfolded in daily life as shown in
applying emotional understanding. The positive experience with
her therapist contrasted Naomi’s rather cold and criticizing rela-
tionships from the past with her caregivers and the current life sit-
uation. The client experienced the therapeutic relationship as
novel and different. This was not simply a cognitive, but an emo-
tional experience. The therapist in the current study took an inte-
grative affect-oriented approach and did not make an explicit
interpretation linking her past hurtful relationship to the therapeu-
tic relationship. However, the client made these conclusions her-
self and extended her understanding of current problems in her
life. This finding confirms Friedlander et al. (2018) who also
pointed out that the client experienced therapeutic relationship as
novel and different.
In-session CEEs and postsession changes were reported by the cli-
ent more often toward the later part of the first phase and very consis-
tently in the second phase. Some CEEs, such as positive sense of self
and changes in maladaptive beliefs, may take more time to occur.
This presents an important question about the treatment length and
the extent of benefits from CEEs. It will be interesting to test whether
CEEs in short-term therapies may be different from those achieved
in longer treatments. Indeed, the client was able to improve her rela-
tionship with her students, coworkers, and those with whom she met
after she started her therapy. However, her difficulties with her
mother still persisted, and her relationship with her husband fluctu-
ated: He was initially bewildered by her assertiveness and more frank
expression of negative emotions. In this case, improvements in inter-
personal relationships were more easily achieved in new relationships
in which she felt comfortable acting from her newly developing
sense of self. It appears that further therapeutic work was necessary
to work through her unresolved feelings toward her mother to
improve their present relationship. The “corrective” power of CEEs
may manifest unevenly depending on relationships. This suggests
that therapists need to prioritize particular relationships so that clients
are not discouraged by focusing on the improvement of a particular
relationship that is more difficult to change despite significant thera-
peutic achievements.
Finally, cultural issues associated with this case need attention.
The study was conducted in Japan where cultural and social prac-
tices surrounding parenting were associated with the client’s diffi-
culties. First, fathers are often not expected to contribute to
parenting, which often adds additional burden on mothers. Second,
due to the scarcity of childcare, grandparents, especially when
they live in the same city, often play significant roles in helping
parents. In addition, the Japanese traditional practice is that moth-
ers spent a few months around the birth of the child in their
parents’ house under the maternal care. These cultural and social
practices might be a part of the increasing stress around the cli-
ent’s transition into maternity and subsequently triggering past
emotional conflicts with her mother. Furthermore, Asian clients
 72 NAKAMURA, IWAKABE, AND HEIM
are often oriented toward a more formal therapeutic relationship in
which the therapist takes a directive stance. With the client’s diffi-
culty in expressing her feelings, one might suspect her sense of
shame might be triggered by therapeutic activities that encourage
her in-session emotional experience and expression. However, with
the therapist encouraging and affirming stance coupled with psy-
choeducation about the importance of emotion in psychological
functioning, the client was able to greatly benefit from emotional
processing tasks within an affirming and empathic relationship cen-
tral to both AEDP and EFT. Further studies are needed to replicate
these results in different cultural contexts.
Limitations and Future Directions
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This study analyzed and discussed in depth both in-session CEEs
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and postsession changes in a single case of psychotherapy, corroborat-
ing both process and outcome and quantitative and qualitative data.
However, these results cannot be directly transferred to other cases, as
this is based on an individual case, whose peculiarity and uniqueness
are inextricably linked with the results. This particular case was cho-
sen, as it represents a pure gold sample (Greenberg, 2007) in which
CEEs were expected to be present, based on viewing of session
recordings, scores on postsession measures, and the availability of the
client’s e-mails documenting her subjective experience of session and
postsession changes, which allowed us to look into her experience of
in-session CEEs as well as postsession changes and triangulate our
understanding of e-mail data against session recordings and their tran-
scripts. The e-mails from the client were not instructed by the thera-
pist but a spontaneous action. Some other clients in this project wrote
e-mails to the therapist but not as extensively or consistently as this
client. Writing e-mails itself might have had some therapeutic func-
tion for this client by allowing her to express herself more freely, sort-
ing her thoughts and reflections after session, and giving the therapist
a heads-up for important topics for the coming session. Further repli-
cation with other similar cases that are different in some aspects of
important clinical dimensions is necessary.
A second limitation concerns the fact that this is a research case.
Sessions were videotaped, and the client was asked to fill out ques-
tionnaires after each session. These research tasks as well as her
awareness that the case materials would be analyzed by a group of
researchers might have influenced the nature of therapy.
Third, the CEE scale was still under development when the ther-
apy started and was only able to add it to the current study from the
24th session. In addition, her e-mails did not follow a systematic data
gathering procedure. Future studies may use a diary method (Mack-
rill, 2007) that is more systematic in the data gathering schedule.
Keeping logs can be a daunting task for clients. With the use of mo-
bile technology, it is also possible to conduct a short interview regu-
larly so that changes in their everyday life can be monitored and
recorded. However, we would like to emphasize the advantages of
this naturally occurring e-mail condition as in the present case. The
client was free to choose when and how to communicate her feelings,
thoughts, and events of personal significance. If a client was asked to
write following specific instructions and a schedule, the content of
what one might write could be quite different. The client might have
felt some pressure and spontaneous feelings toward the therapist
might not have occurred or been reported. Nonetheless, it would be
important to experiment and develop methods to gather outside ses-
sion data in a controlled fashion through the use of questionnaires.
Fourth, biases due to the fact that the second author was the
therapist of the case and also the research supervisor of the first
author need to be taken into consideration in interpreting the
results. The power imbalance might have affected the decisions of
the first author more than she realized, especially because this
research was conducted in Japan where the hierarchical nature of
the teacher–student relationship is notable and might operate
beyond their awareness. However, we decided that there was more
advantage in including him as the second author because as a ther-
apist he had a special insight into the course of therapy. This
indeed helped in developing a comprehensive understanding of the
context of in-session CEEs. It is important to note that both
researchers are integrative and emotion-focused in their clinical
orientations and are very much interested in CEEs and emotional
change processes. We also included the third author who did not
share the same cultural background to balance our understanding.
Researchers from other orientations may arrive at somewhat dif-
ferent conclusions, emphasizing different aspects of client change
such as cognitive and behavioral changes. The power imbalance
might be also at play in the client’s acceptance of the researchers’
interpretation of the qualitative data when presented with the
result. Due to the hierarchical nature of interpersonal relationships
in Japan, the client’s deference to the therapist (Rennie, 1994)
might have inhibited her from voicing disagreements more freely.
Fifth, this case occurred in Japan with a Japanese male therapist
and a Japanese female client. Cultural, gender, and social factors
around psychotherapy limits generalizability. The social and cul-
tural practices in Japan surrounding parenting were intricately wo-
ven into the client’s issues. However, the study also gives cross-
cultural support for affect-oriented therapy, which is sometimes
regarded as unsuited for Asian clients who tend to be less emotion-
ally expressive and prefer a more structured relationship.
Finally, this study mainly focused on the experience of change
from the client’s perspective and did not examine the therapist’s
interventions or the actual dialogue associated with CEEs in detail.
Session recordings were used to contextualize and better under-
stand the client’s e-mails. To develop a more comprehensive
understanding of CEEs, it would be important to examine the
actual in-session process of CEEs.
More systematic case studies need to be conducted to further
explore the current study’s findings. Systematic case study meth-
ods such as case formulation research (Silberschatz et al., 1989)
should be used to systematically identify clients’ past relationship
conflicts and types of CEEs that are needed to change them. The
integration of clinical information and the rigor of systematic and
objective research perspectives is needed to enable clinically rele-
vant research on CEEs, which can contribute to building the bridge
between research and practice that we greatly need in the field of
psychotherapy, as well as an understanding of the common change
mechanism (Goldfried, 2019).
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Received October 2, 2020
Revision received February 14, 2021
Accepted February 19, 2021 n