Differential Effects of Emotion Focused Therapy and Psycho-education in Facilitating

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Differential Effects of Emotion Focused Therapy and Psycho
-
education in Facilitating
Forgiveness and Letting Go of Emotional Injuries






Leslie

S.

Greenberg, Serine
H.
Warwar
,

W
anda M.

Malcolm



York University
,

Toronto





















Correspondenc
e should be sent to the first author Leslie S. Greenberg, Dept. of Psychology
York
University
4700 Keele St. Toronto, ON, Canada M3J 1P3.
E
mail
:

lgrnberg@yorku.ca


This study was supported by a grant ID# CRF 5202 from the Campaign

for forgiveness research
to the first author.


2


Abstract


This study compared the effectiveness of Emotion
-
focused Therapy (EFT) involving
gestalt
empty
-
chair dialogue in the treatment of individuals who were emotionally injured by a
significant other with

a psycho
-
education group

designed to deal with these injuries. In addition,
this study examined
aspects of
the emotional process of forgiveness in resolving interpersonal
injuries and
investigated the relationship between letting go of distressing feelings and
forgiveness.
A to
tal of f
orty
-
six clients assessed as having unresolved, interpersonal, emotional
injuries were randomly assigned to an individual therapy treatment of EFT or a psycho
-
education
group. Clients were assessed pre
-
treatment, post
-
treatment, and at 3
-
month foll
ow
-
up on
measures of forgiveness, letting go, depression, global symptoms, and key target complaints.
Results indicated that clients in EFT

using empty chair dialogue

showed significantly more
improvement than the psycho
-
education treatment on all measure
s of forgiveness and letting go,
as well as global symptoms and key target complaints.



Key words


Interpersonal injuries, Forgiveness, Letting go, Emotion
-
focused therapy, Psycho
-
education








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Differential Effects of Emotion Focused Therapy and Psych
o
-
education in Facilitating


Forgiveness and Letting Go of Emotional Injuries

Forgiveness has recently been proposed as an important
aspect

of
emotional recovery
following an interpersonal injury

(
Enright

& Fitzgibbons, 2000;

Worthington,

1998,

200
1
)
.

Although the debate continues as to whether forgiveness should be granted to injurers when they
will not take responsibility for their actions, or when they continue to perpetuate harmful acts
(Worthington, 2005), forgiveness has been shown to have a
positive impact on physical,
relational, mental and spiritual health, whereas unforgiveness
can be
distressing and
may
leave
people ruminating about their injuries and feeling hostile towards those who injured them
(Witvliet, Ludwig, & Vander Laan, 2001).
The majority of studies

on the facilitation of
forgiveness

(Al
-
Mabuk, Enright & Cardis, 1995; Hebl & Enright, 1993; McCullough &
Worthington, 1995; Ripley

& Worthington, 2002; Worthington & Drinkard, 2000; Wade,
Worthington, & Meyer, 2005)
have involved
ps
ycho
-
educational
group prog
ram
s designed to
promote the benefits of forgiveness to self and others, and
these
provide the knowledge and
skills

associated with a particular model of
forgiveness
.
To date o
nly two studies have
been published
that report on an

investigat
ion of

the effectiveness of

individual therapy in facilitating unilateral
forgiveness (Coyle and Enright, 19
97; Freedman and Enright, 1996)
.

The present

study
examined the effect
iveness

of
Emotion
-
focused Therapy (EFT)
compar
ed

to
a psycho
-
educa
tional group in facilitating emotional resolution and forgiveness.

Numerous
investigators
have proposed that b
oth emotion work and empathy play
important roles in forgiveness (Davenport, 1991; Enright & Fitzgibbons, 2000; Fitzgibbons,
1986; Hope, 1987; Kar
en, 2001; Malcolm, Warwar, & Greenberg, 2005).
One of the
assumptions of EFT is that the blocking of primary biologically adaptive emotions subverts

4

healthy boundary setting, self
-
respectful anger and necessary grieving
,

and that

adequate

processing of unr
esolved emotion leads to
its
transformation

(Greenberg, 2002)
. Many clinicians
(Akhtar, 2002; Baures, 1996; Enright & Eastin, 1992) emphasize the value of facilitating in
-
session expressions of adaptive anger at violation, and suggest that facilitating fo
rgiveness
requires an acknowledgement of the legitimacy of emotions such as resentment and hatred
towards the offender. Baures (1996), Boss (1997), and Fincham (2000) consider resentment and
desires for revenge to be closely linked with self
-
respect, and
Greenberg and Paivio (1997)
suggest that there may be times when it is therapeutic to encourage clients to talk about their
revenge fantasies. From these perspectives, the desire to retaliate is normalized as a sign of how
damaged the injured person feels.

Encouraging such expressions

in therapy

is not the same thing
as promoting outer
-
directed blaming or hurling of insults. In encouraging
clients to speak

from
their

inner experience
s

of violation
, the therapist is promoting ownership of a client’s emotiona
l
experience and is empowering clients to appropriately assign responsibility for harm done.
Ownership of emotion

al
so helps clients focus on their
own
needs and
concerns rather than
get
ting

stuck in blaming the other or feeling victimized. The danger in s
hort
-
circuiting
expressions of anger

as might occur in some treatments
is that the client may end up condoning
or excusing the injurer’s hurtful behavior, or inappropriately take too much responsibility for the
unfolding of events
that surrounded

the injur
y.

T
herapists also need to facilitat
e

the process of grieving the loss of, or damage to
,

a
significant relationship, as well as the shattering of the client’s view of self and the world that
may have been caused by the injury. Akhtar (2002) addresses the
relationship between mourning
and forgiveness, and Greenberg and Paivio (1997) emphasize that work with betrayal and
abandonment
often involve
s

a process of facilitating normal grieving in which anger and sadness

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play central roles. Facilitating an imagina
ry dialogue with the injurer can help the client grieve
and say goodbye to what has been lost or irreparably damaged as a consequence of the injury
(Greenbe
rg Rice & Elliott 1993
;
Elliott,
Watson, Goldman &

Greenberg 2004).


Emotion
-
focused Therapy

(
Greenb
erg 2002)
,

which employs

empty
-
chair dialogue
for

the resolution o
f unfinished

business as
one of
its

m
ajor

methods
has been found to be
an
effective
intervention
in the treatment of depression
,

in
terpersonal problems
and trauma
(Greenberg

& Watson
,
1998,
2005,
Paivio & Greenberg, 1995
; Paivio & Niewenhaus, 2001
).

Paivio and Greenberg’s (1995) comparative study of

a

psycho
-
educational group intervention
versus
individual
EFT using
gestalt
empty
-
chair dialogue in the resolution of unfinished
business, supp
orted the efficacy of the empty
-
chair intervention. The results demonstrated a
significant reduction in symptomotology, target complaints, and interpersonal distress

and more
resol
ution of

unfinished business
.

The empty
-
chair
method as it is

employed in EF
T is also a
particularly effective tool in promoting empathy
felt toward
the
offender

(
Paivio, Hall,
Holowaty, Jellis, & Tran,

2001
;
Paivio

& Nie
u
wenhuis
2001
;

Paivio & Greenberg, 1995). In
imaginatively bringing the injurer and injury alive, the client mov
es from a cognitive discussion
with the therapist, to an imaginal confrontation and dialogue with the injurer. In so doing, the
client is helped to move reified inner representations of self and other
(injurer)
into a transitional
space in conscious awaren
ess where the representations can be re
-
examined, reworked, and
resolved.

Empirical evidence
also
is mounting in support of the importance of transforming
emotions by changing one emotion with another
emotion
(Frederickson,

1998;

Greenberg 2002,
2004), an
d thi
s suggests that a maladaptive emotion state
can be
effectively transformed by
undoing it with the presence of another more adaptive emotion.

More s
pecifically
Frederickson,

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Marcuso, Bra
n
igun & Tugade (2002)

have

shown that positive emotion
undoes the

cardiovascular after
-
effects of negative emotion.
Greenberg (2002) has suggested that t
he key to
transforming maladaptive emotions is to access alternate healthy adaptive emotions to act as
resources in the self
. Thus, in an emotion
-
focused treatment, fe
elings related to unforgiveness
such a
s

anger, contempt and pain are eventually
changed
by
accessing feelings of
sadness,
compassion, empathy and concern
.

McCullough and his colleagues have shown
that
empathy for the perpetrator
mediates
successful forgive
ness

(McCullough, Worthington, & Rachal, 1997; McCullough, Rachal,
Sandage, & Worthington, 1997)
. This proposition is consistent with clinical observation, theory,
and empirical evidence
concerning
forgiveness (Macaskill, Maltby, & Day, 2002; McCullough,
W
orthington, & Rachal, 1997; McCullough, Rachal, Sandage, & Worthington, 1997;
Worthington
&

Wade, 1999).
When accessed, empathy involves understanding another’s
feelings and is a complex cognitive/affective state that facilitates forgiveness of an interper
sonal
injury. As Rowe et al. (1989) have pointed out, empathy towards the injurer involves being able
to see the other person as acting in a quintessentially human manner, which flows out of the
context of his or her own self
-
focused needs and perceptions.

This
includes (but does not require)
the possibility of recognizing that what the injurer did was similar to something one has done, or
could do under the same circumstances. In addition to assisting in the revision of how one sees
the injurer, cognitive
perspective taking sometimes allows the injury itself to be recast within a
broader understanding of the context of the unfolding of events.
However, c
ognitive perspective
taking of this nature does not have to involve warm benevolent feelings associated w
ith
forgiveness. Something more is required for forgiveness and this appears to be compassion for
the
injurer
, or affective empathy.


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Affective empathy is best understood as a means of imaginative entry into the world of
the other, which generates a bodil
y felt sense of understanding what the other person may have
been feeling, without actually sharing the same experience (Greenberg & Rosenberg, 2003).
Berecz (2001) suggests that the task for the injured person is to imaginatively transpose himself
or hers
elf into the other person’s place in an attempt to understand the unfolding of events from
the injurer’s perspective.

Un
forgiveness
has been defined
as the combination of
a
complex
set of
negative feelings
towards an injurer, and

it
ha
s been

shown

that

pe
ople can decrease unforgiveness without
increasing forgiveness

(Worthington, Sandage & Berry, 2000
;

Worthington & Wade, 1999).
Unforgiveness is regarded as being stuck in negative emotions and a hyperaroused stress
response through rumination (Harris, & T
horesen, 2005). It is noteworthy that reducing
unforgiveness is not the same as promoting forgiveness. Forgiveness seems to include the
reduction of unforgiveness, or letting go, through decreasing negative feelings and thoughts in
relation to the injure
r. In addition to, and in contrast with letting go or reducing unforgiveness,
forgiveness is also comprised of the increase of positive emotions such as compassion, empathy
or understanding felt towards the injurer.

In our view, f
orgiveness
thus
appears

to involve two

important emotional processes:

resolving the hurt and anger involved in the injury
;

and the possible generation of positive
feelings of compassion, loving, kindness and empathic concern for the injurer.

People thus may
be able to resolve em
otional injuries, by reducing
or letting go of
their bad feelings,
or by letting
go
of bad feelings
and
increasing positive feelings
ie:
by forgiving
.


The
main
purpose of the present study was to evaluate the effectiveness of Emotion
-
f
o
cused Therapy (EFT)

(Greenberg et al.,

1993) involving empty
-
chair dialogue in the treatment

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of individuals who had been emotionally injured by a significant other. Empty
-
chair work was
used to facilitate emotional transformation by
:

both expressing and processing the anger
and
sadness to the off
ender;

facilitating empathy;
and
asking clients to play the role of the injurer
,

thereby having them imagine what the injurer might feel if he or she were capable of
comprehending the consequences and impact of his or her actions on t
he client.

The primary
hypothesis was that EFT, which used empty
-
chair dialogue to process unresolved emotion,
would produce better outcomes than a psycho
-
education group

(PG)

in the treatment of
interpersonal, emotional injuries on measures of forgivenes
s and letting go, and other indices of
outcome. It was assumed that an experiential treatment such as EFT that works by evoking,
processing and transforming emotion would address the emotional causes of
the injury

more
directly than a psycho
-
education gro
up that was less emotion
-
activating.

This study also examined the emotional process of forgiveness in resolving interpersonal
injur
y

and evaluated whether forgiveness was necessary to resolution of the injury. In the
present study, recovery from an emotio
nal injury therefore was conceptualized
as occurring
in

one of
the following two ways: 1)

forgiving

the

injurer
, which was defined as letting go of
unresolved
bad
feelings or reducing unforgiveness
plus

the development of empathy and
compassion for the oth
er
; or 2)
letting go

of the bad feelings which
involves
letting go of unmet
needs and negative feelings in relation to the injury or injurer and changing negative perceptions
of self in relation to the injury or injurer
,
without

the development of empathy
and compassion
for the other
.

The second hypothesis was that all people who forgave would let go of bad
feelings but that not all who let go would forgive.

The third hypothesis was that reported
emotional arousal would be higher in the

EFT, than in

PG


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Tre
atment focused on facilitating the resolution of specific
unresolved
interpersonal
,

emotional injuries that had occurred at least two years prior to the start of therapy and continued
to be distressing. The injuries that clients brought to treatment were
both emotional and
interpersonal; they were emotional
in that
they involved intense lingering unresolved feelings of
hurt or anger and betrayal, and they
were

interpersonal
in that
the injurer was a significant other
in the injured person’s life. Injuries

involved abandonment, betrayals or violations by significant
others, such a friends,

bosses,

family members, or intimate partners.

Method

Participants

The sample for the present study consisted of 46 clients who
had
an
unresolved
interpersonal,
emotional

injury with a significant other that had occurred at least two years prior
to commencing treatment.

The requirement that the injury not be more recent was to ensure that
the natural process of
recovering from hurts
had been given
time to

work and that the

injured
person was not in the midst of coping with the immediate aftermath of the injury.

Participants
were required to be 18 years of age or older. Exclusion criteria for the study
,

based on the
assumption
a brief treatment
program

would be unsuitable

for some people,
were as follows:
victims of incest; individuals who had attempted suicide or had lost a significant other in the past
year; those
currently
in physically violent relationships; individuals
currently
abusing drugs or
alcohol; individuals d
iagnosed with antisocial, borderline

or

narcissistic personality disorder,
post
-
traumatic stress disorder, or a psychotic disorder
.
I
ndividuals
who were already

in
psychotherapy

elsewhere
were
also
excluded
.


The average age for clients in the EFT treat
ment was
43 years
.
T
he average age
for the

PG treatment

was 46
.
The overall po
pulation thus had a mean age of

44.5 and S.D = 8.3
(
range

10

22
-

67).
There were
seven
males and 16 females in the
EFT

treatment

and 13 males and 10

females in the

PG treatment
.
In the EFT treatment,
eight
individuals had never been married, 13
were married, and
two
were separated or divorced. In the

PG treatment
,
five
had never been
married,
nine
were married, and
nine
were separated or divorced. In terms of their level of
edu
cation, in the EFT treatment
one
individual had completed high school,
three
had some
college or university training, 12 had graduated from college or university, and
seven
had
postgraduate experience. In the

PG treatment
,
five
individuals had completed h
igh school,
three
had some college or university training,
six
had graduated from college or university, and
nine
had postgraduate experience.
Ethnicity in both groups was predominantly Caucasian with 1
client of South Asian and one of East Asian origins i
n each treatment group.

In terms of pre
-
treatment diagnosis on
DSM
Axis I and II, there were
nine
clients (39%)
wi
th a least one Axis I diagnosis

in the EFT treatment
, and

seven
clients (30%) with at least one
Axis I diagnosis

in the

PG treatment
. In the E
FT treatment there were
six
clients with at least one
Axis II diagnosis, and in the
PG treatment
there were at least
four
clients with an Axis II
diagnosis. The mean Global Assessment of Functioning was 77 for each treatment, with the
range being 65
-
95 fo
r the EFT treatment and 60
-
90 for the

PG treatment
. There were no
statistically
significant differences between treatment conditions on any of these variables.

Emotional Injuries


The type
s

of
emotional injuries clients presented in this study
,

and the n
ature of the
relationship with the significant other are summarized in Table 1.

Each participant targetd one
injury.

Parents were the main
perpetrators

of the injuries.

In the EFT treatment, 18 (78%) of the
clients were dealing with an interpersonal injur
y in relation to at least one parent and
two
(8%)
with an ex
-
partner
,

while in the

PG treatment
, 13 (57%) of the participants were dealing with an

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injury regarding at least one parent and
five
(21%) with
an
ex
-
partner. The people in

the

“other”
cate
gory i
ncluded a boss, a neighbo
r
,

and
people in
non
-
parental
position
s

of power relative to
children
.

Therapists

There were
eight
therapists in the EFT condition,
two of whom were
male and
six
female.
Two of the therapists were registered psychologists, one had

a doctora
te

and
five
were advanced
doctoral students in clinical psychology. Prior to training for the treatment study, all therapists
were required to have at least one year of EFT therapy training
including
prior
empathy training,
and
one

year of
exper
ience as a
therap
ist
. Therapists in the EFT treatment received an additional
30 hours of specialized training based on a treatment manual for resolving emotional injuries
developed for this project (Greenberg, Malcolm & Warwar, 2002).
The group had two lea
ders.
O
ne of the

group leaders was
a registered psychologist who
had devised the
PG
treatment
and
conducted it
on a number of prior occasions. The co
-
leader was a doctoral student and was
trained by the first leader.
The therapists in both treatment condit
ions received weekly
supervision throughout the study to promote adherence to treatment manuals.

Treatments

Both interventions involved 12 hours of treatment distributed over approximately 12
weeks.

Emotion Focused Therapy


The treatment
manual
for this
study is based on the principles outlined for Emotion
-
f
ocused Therap
y (EFT) (Greenberg et al., 1993;

Greenberg
,

2002), also known as
P
rocess
-
experiential therapy. This therapy includes the implementation of
the
person
-
centered
relational
attitudes of empa
thy, positive regard, and congruence,
as well as

marker
-
guided, process

12

directive, experiential interventions. In EFT, the therapist uses
the following interventions:
gestalt
two
-
chair dialogues when clients present
in
-
session

self
-
evaluative conflicts;

c
lient
-
centered
systematic evocative unfolding for problematic reactions
over which clients are
puzzling;

and gestalt empty
-
chair dialogue for resolving currently felt unfinished business with a
significant other.
F
ocusing (Gendlin, 19
9
6) is
also
utilized
in this approach to assist clients in
attending to

their internal experience and to obtain a bodily felt sense of the issues they are
exploring and struggling with (Gendlin, 1996, Greenberg et al., 1993). The
emphasis in

EFT is
on accessing primary adapti
ve feelings and maladaptive emotion schemes in order to make them
amenable

to change (Greenberg, 1993, Greenberg & Paivio, 1997).

A specialized EFT treatment
manual

(Greenberg
, M
alcolm,
&
Warwar,
2002)

was
developed
for this project
to focus

on facilitat
ing the resolution of emotional interpersonal
injuries. The treatment protocol is summarized in the following four phases

which overlap rather
than being purely sequentially
.

Phase I: Creating an Alliance.

The first phase of treatment involves creating
a
therapeutic alliance with the client by empathic
al
ly

responding to and validating the client’s pain
and emotional experience of the interpersonal injury. This stage also entails helping clients to
identity the impact of the injury and
articulate and cla
rify the most problematic aspects of the
injury

for them
.

Phase II: Evocation and Exploration.

The second phase of treatment involves
acknowledging, experiencing, and expressing the anger, sadness, pain, and other
distressing
feelings associated with the

emotional injury. Empty chair work is utilized to help clients
process unresolved feelings towards the injurer.
Therapists were advised to begin work on
Evocation and Exploration as early as the second session if the injury was clear and safety and

13

the
bond seemed to be sufficiently strong no later than the 3
rd

session if the client appeared
ready, and to continue up until the pen ultimate session if needed.
Empty chair work however
was not to be done in every session but if suitable in at least half the

sessions in the evocation
phase. The next
two
phase
s

integrate within
and overlap with
phase 2.

Phase III: Self
-
Interruptive Work.

The third phase of therapy involves interventions
facilitated by therapists at client marker
s

of interruption such as emoti
onal constriction,
resignation, or hopelessness. These interventions are aimed at turning the passive
,

automatic
process of interruption into an active one
. This
phase aims to heighten

clients’ awareness of how
they interrupt themselves and
to promote
ch
ange

in

these interruptive processes so th
at emotions

preven
ting resolution

can be
accessed and
processed
.

Phase IV: Empowerment and Letting Go or Forgiving.

This final phase entails accessing
previously unexpressed emotions
,

and mobilizing and promoting t
he entitlement of unmet needs.
The therapist promotes
a
change in the
way the client
view
s

the
injurer,
facilitated by
emotional
arousal and accessing of past unmet needs. This phase also involves helping clients grieve and
let go of unmet needs. Elaborat
ing the world
-
view of the other aids empathy towards the injurer
and the therapist helps the client understand

or hold the other accountable.

Homework.
Clients were asked to complete homework throughout the course of
treatment.
At
the start, t
hey were as
ked to keep a diary of their feelings and thoughts in relation
to their injuries and to note how the therapy sessions played a role in their change processes. At
session
six
, clients were given a handout which instructed them to write a
n unmailed

letter t
o the
injurer accus
ing

the injurer of knowing the impact of his or her hurtful behavior. The second
part of this homework exercise instructed clients to write a letter in response to themselves
denying the accusation from the perspective of the person who

injured them.
This was done to

14

highlight that change was to come from the client
,

not the perpetrator
, as the perpetrator may
never change
.

At session
seven
, clients were given
s
o
me

definition
s

of forgiveness and asked to
think about their
understanding

of forgiveness and
to consider
whether forgiveness was
important to them personally with respect to their emotional injuries. At session
eight
, clients
were
given a handout which
asked
them
to reflect on the bond that still h
eld

them to the injurer,
and
to write down
their difficulties in letting go of the emotional injury and what
was sustaining
the painful feelings.

These were discussed in the session

Psychoeducation Group

The psycho
-
education

group manual

(PG)
was devised for this study (Malcolm
,
2001
)

and drew on various sources for content
(Bolger,
1999
;
Klassen, 2001; Paivio

& Greenberg,
1995
;
Smedes,
1984
;
Worthington and Drinkard, 2000)
. The six workshops were facilitated by
the
two

workshop leaders
.

T
he introductory session

provided an

overview
of all the sessions,
along with a rationale for participating in the study and an explanation of the differences between
PG
and group therapy.
S
ession
s

two through five
included
a
discussion of
the
previous session’s
homework
,

a
topic presentation by
the
facilitators
,
a coffee break with a personal reflection task

and then
group discussion
of the presentation and personal reflection
. Each session ended with
the
assignment of
a

homework
task
to be done between sessio
ns and

completion

of session
measures
.

The content presentations covered the following topics: the
nature and
structure of an
emotional injury; understanding unfinished business and how it disrupts adaptive functioning;
aspects of forgiveness, including what it is and is not
,

and why one would

be motivated to
forgive in the face of being hurt by another person; the role of pain and other strong emotions in
experiencing and recovering from interpersonal

emotional injuries
; the process of reconciliation
with the hurtful other and how it differs f
rom forgiveness; and

finally how to

reso
lve an injury
.


15

The content presentation
of the first session
was short and group discussion intentionally
structured

to create safety and
assure group members that their participation in the group
discussions was vol
untary and at their discretion.
The final session

review
ed

the material
presented in the first five sessions

and i
nstead of a homework assignment,
a bibliography
was
provided for those interested in
further reading on the topics covered in the workshops.

The
PG
group members received the
same homework
as those

in individual therapy
, in
the same order and at approximately the same time intervals.
They

also received additional
journaling and reflection exercises in order to provide homework assignments afte
r each of the
first five workshops
.
It was assumed that
any
change

experienced

in the

PG

group
would

be the
result of
discussion of and
reflection on the
information
provided
,
which would produce change
in attitude
(s)
. It was further assumed

that attitud
e change would in turn
change
the
feeling
s
participants had toward the injurer and injury.

Measures

A battery of self
-
report measures was administered before and after treatment to assess
changes in specific domains. All clients were assessed approximatel
y one week prior to
treatment and one week following treatment. Clients were also assessed at a three
-
month follow
-
up on
measures of
letting go, forgiveness, level of depression, global symptoms, and target
complaints.

Forgiveness Measures

The Enright For
giveness Inventory (Enright, Rique & Coyle, 2000).
The Enright
Forgiveness Inventory is a measure of the degree to which one person forgives another who has
hurt him or her deeply or unfairly. The first part of the inventory instructs individuals to visual
ize
the emotional injury, focus on the offending person, and imagine what happened. The

16

participant is asked to write a description of the injury in his or her own words. The second part
of the inventory is comprised of 60 items from three
20
-
item
subscal
es measuring affect,
behavior and cognition in relation to forgiveness. Participants are aske
d to rate each item on a 1
to six
-
point
Likert scale from Strongly Disagree to Strongly Agree. The authors report a stability
coefficient

in a
community
sample
f
or total EFI scores of .86 during a four week test
-
retest
reliability study. The subscale test
-
retest coefficients ranged from .67 to .91. With respect to
concurrent validity, the EFI has been positively associated with other measures of forgiveness.
Ther
e is also support for the EFI’s divergent validity (Enright et al., 2000).

The Cronbachs alpha
for the scale as a whole
in this sample
was .81
.

Forgiveness Measure
(Enright
et al.
, 2000). Th
is single
item
scale for assessing degree
of forgiveness
derives
from the EFI and directly asks clients to what extent they have forgiven
the person who injured them. Responses are indicated on a
five
-
point Likert scale

(
1

=
not at all
,

3
=
in progress
,

5

= completely
). The authors
of the EFI
did not use the term “forgi
veness” in
any other item of the
EFI
measure to avoid creating conceptual biases. For th
is

reason the EFI is
referred to as the Attitude Scale during its administration.

The forgiveness measure is thus used
to directly assess degree of forgiveness.
In cla
ssifying peoples degree of forgiveness a score of 4
or above
,

i
.
e
.
:

rating that they had forgiven
,

either

a lot


or

completely


was used to indicate
that forgiveness had been attained

Unfinished Business Empathy and Acceptance Scale
(UFB EA). Singh (199
4
) developed
the Unfinished Business Scale to measure resolution of unfinished business with a significant
other. For the present study,
items were extracted from

this scale and adapted

to create the
empathy and acceptance subscale (UFB EA)
. The UFB EA Sca
le
is comprised of six items and
measures the extent to which clients feel acceptance and empathy towards the individual who

17

injured them. Clients were asked to indicate

their agreement with the statements of empathy or
acceptance
on a
five
-
point Likert sc
ale
(
ranging from
1 =
not

at all
,

to
5 =
very much
)
.
For
example
, empathy items consist
ed

of statements such as ‘I feel compassionately understanding
of the other person’, or ‘I have a real appreciation of this person’s own personal difficulties.’
Acceptan
ce items
included

statements such as:

‘I feel accepting toward this person’ and
reverse
-
scored items like
‘I see this person negatively.’
The

items

on this subscale have been found to
inter
-
correlate highly
in a sample of clients in treatment
for unfinishe
d business (Paivio &
Greenberg 1995)
and a sample of university students

(Singh 1994)

and the overall
scale has been
found to correlate with other outcome measures

(Watson & Greenberg 1996
;

Paivio &
Greenberg 1995)
.

The Cronbachs alpha for the subscale
in
this sample

was .8
7
.

Letting Go Measures


Unfinished Business Feelings and Needs Scale

(UFB FN). This scale was

adapted from
Singh
’s

(199
4
)

Unfinished Business Scale
. It measures the resolution of feelings
and needs as they relate to the
injur
er,

and positive changes in the perception of self. This
measure is comprised of
eight

items on a
five
-
point Likert scale
(
ranging from
1 =
not at all
,

to
5
=
very much). The UFB FN Scale contains three sets of items that refer to feelings, needs, and
the
self. The
feelings
subscale
contains

items such as ‘I feel unable to let go of my unresolved
feeling
s

in relation to this person.’ The needs subscale
includ
e
s

items like ‘I feel frustrated about
not having my needs met by this person.’ Finally, self ite
ms
included
statements
such as
, ‘This
person’s negative view or treatment of me has made me feel badly about my self ’, or ‘I feel
worthwhile in relation to this person.’

This subscale of the UFB
has

shown
inter
-
item reliability
in a sample of clients in t
reatment and a sample of university students
and has been found to

18

correlate with other outcome measures

a sample of clients in treatment
.

The Cronbachs alpha for
the subscale
in this sample
was .79.



Letting Go Measure.

This measure
was
constructed for t
his study to
parallel

the
single
item
forgiveness m
easure
. It

is a single item self
-
report measure that asks clients
to what extent
they have let go of their hurt and angry feelings in relation to the injurer.

Responses are
indicated on a
five
-
p
oint Like
rt scale (
1 = not at all, 3 = in progress,

5 =
completely).

Other Outcome Measures


Target Complaints (TC) Discomfort and Change

Scale

(Battle, Inber, Hoehn
-
Saric
,
Stone, Nash, & Frank
, 1968
). The Target Complaints Discomfort
Scale
asks clients to specify
three problems they
would like to see change as a result of treatment. Clients were asked to rate
each problem at three points in time (pre
-
treatment, post
-
treatment and three
-
month follow
-
up)
in terms of how distressed they are by it
. In addition, at tw
o points in time (post
-
treatment and
three
-
month follow
-
up) clients were asked to rate
how much they fe
lt

it ha
d

changed since the
beginning of

treatment. Battle et al. (1968
) reported high correlations with other outcome
measures and test
-
retest reliabil
ity (
r

=

.68) between pre
-

and post
-
psychiatric interviews.

Global Symptom Index (GSI) of the Symptom Checklist 90 Revised (SCL
-
90
-
R).

The
SCL
-
90
-
R (Derogatis, 1983) is a well known instrument that measures general symptom distress,
with high internal con
sistency (.77 to .90) and test
-
retest reliability
(.
80
-
.90) over a
one
-
week
interval
with people with a variety of disorders
(Derogatis, Rickels, & Roch, 1976).
Calculations
of change on the Global Symptom
Index
(GSI)

was

used as
an
outcome measure

at thre
e points in
time (pre
-
treatment, post
-
treatment and three
-
month follow
-
up)
.

Cronbachs alpha for GSI
in this
sample
was .82


19

Beck Depression Inventory.
This 21
-
item inventory is widely used to assess depression
(Beck, Ward, Mendelson, Mock, Erbaugh, 1961).
It has high internal consistency and correlate
s

highly with other self
-
report measures of depression and with clinician’s ratings of depression

(
r

= .60 to .90; Beck et al., 1988).

Cronbachs alpha for BDI
in this sample
was .87

Process Measure
s


Working A
lliance Inventory
(WAI
;
Horvath & Greenberg, 1989).

The WAI is a 36
-
item
scale

rated on
a seven
-
point Likert scale. The WAI is made up of three alliance subscales that
assess the
therapist
-
client
bond and agreement on therapy tasks and goals. Internal con
sistency

is
high

for the whole scale (.87 to .93) as
well as
the subscales (.89

to
.92) (Horvath & Greenberg,
1989).
Cronbachs alpha for WAI was .89


Emotional Arousal Session Report Measure

(Warwar & Greenberg, 2002)
.

The EA
Session Report Measure was dev
eloped in order to evaluate the intensity of emotional arousal
experienced during therapy.
This

measure consists of 18
emotions

items
,

which the client
rates
on a
seven
-
point Likert scale

(
1
=
not at all
,
5
=
moderately
,
7
=
very much
).
C
lients are
instruct
ed t
o indicate the degree to which they

felt each of the
18
emotions during their

sessio
n
.

To account for the possibility that the 18 emotion categories omitted an emotion the client
believed to be vital in describing their emotional experience, an additio
nal item (question 19)
gives
the client an opport
unity to rate the intensity of
any other emotion they may have felt.
The
EA Session Report Measure

was

completed
by client
s

after each session.

This me
asure was
constructed as a self
-
report form of the obser
ver Emotional
A
r
ousal
S
cale (Warwar &
Greenberg,

1999) which has been show to predict outcome.


Procedure


20

Clients were recruited through advertisements in local community newspapers and flyers
distributed to the university and general community.
The adver
tisements

announced that a
treatment study was being conducted at the York
University
Psychotherapy Clinic and that
individuals over the age of 18 who had been emotionally injured by a significant other in the past

who
were interested in participating in a

treatment study should call for more information. The
advertisements for the study also indicated that the
injury
should have
occurred at least two years
prior to responding to the advertisement
,

and
that
respondent
s

should

still

be

experiencing some
lin
gering feelings of hurt or anger
towards the other
in relation to the injury.

Eighty six participants who called were first briefly interviewed over the telephone to
assess initial suitability regarding general inclusion and exclusion criteria, and to dete
rmine
whether they were presenting with a specified unresolved target injury from
at least
2 years prior
and were willing to participate in a videotaped research treatment. Fifty nine s
uitable

potential
participants
were invited to undergo a further assess
ment
process
to

e
nsure that the proposed
treatment program could meet their
treatment
needs
. The
initial
two hour
assessment
interview
was

designed
to obtain consent

for assessment and treatment
and
assess clients in terms of Axis I
and Axis II disorders u
sing
the
Semi
-
structured Clinical Interview and Diagnosis protocol
(SCID
;

Spitzer, Williams,

Gibbon,

& First, 1990)
.

C
lients
also
completed the Beck Depression
Inventory and the SCL
-
90
-
R

at the first assessment appointment
. If
this initial assessment
supp
orted the appropriateness of the proposed treatment for the client, he or she was
invited to
participate in the treatment study, and asked to come in to complete
the rest of the
pre
-
treatment
measures.
Forty six clients were successfully assigned to treatm
ent.

Participants were randomly assigned to
either

the
PG

or EFT treatment. Clients in the
individual EFT treatment were
seen for
12
one
-
hour weekly
individual therapy sessions
.

C
lients

21

in the
PG
group were
seen for six two
-
hour

sessions
that were held bi
-
weekly for 12 weeks
.
Three
PG

groups

(of n=9, n=8 and n=6)

were run for

a total of 23 participants.
In the EFT
treatment o
ne therapist saw f
ive

client
s,

one saw
four,

two saw three and four saw two each
.
Sessions in the

PG

group were audiotaped only, wh
ereas sessions in the EFT treatment were both
audiotaped and videotaped.
C
lients in both groups completed questionnaires following each
treatment session

and were assigned

homework
at approximately the same time intervals
throughout the course of treatment
. Clients completed outcome measures at pre
-
treatment,
termination of treatment, during a post
-
therapy interview, and at
a three
-
month follow
-
up

interview
.
A short form of the Working Alliance Inventory was given to the
PG


clients
following session one, a
nd to the individual EFT clients after session three.
Therapists completed
a post
-
session questionnaire after
each
session
.

Results

Adherence to the therapy treatment manual
in the EFT treatment
was monitored by
therapist and supervisor report
s
.

Adherence
to
the
PG

group manual was monitored only by the
therapists.

Therapists reported on a 5 point scale ranging from

not
at
all


to

completely

,
the
degree to which they judged
themselves to have
adhered
to
the
treatment
protocol
and
in the
individual therap
y
condition
reported
whether
they
had
used chair dialogues

during the session
.
The supervisor
using the same five point scale,
reported an adherence
judgment

from
supervising
a video

tape
of at least
four
of

the individual therapy

sessions
.
Means and stan
dard deviations of
therapist reports
for the individual treatment over the sessions
were
4.2
3

(1.1
1
)
and supervisor
ratings were 4
.1
4

(.5
2
) indicating

good adherence
. The therapists reported a mean of
5
.
1
3

chair
dialogues per
treatment

with a range of
4



7

per client
. T
he
PG treatment
leader

reported

successful

implementation of the group

manual for each session.


22


Given that clien
t
s

were groupe
d within treatment with 9
,
8 and
6
respectively
in the 3
PG

groups
,

and
a

different n
umber

of
clients

were

seen b
y each therapist
,

there
wa
s a non
-
independence in the data and this could introduce a statistical bias

in the analyses

(
Kenny,

1995
)
.
T
reatment outcome
s
cor
e
s

thus

w
ere

investigated
for bias by looking at intra class correlation to
measure homogeneity with
in groups in relation to variation between groups

and the F statistic
s
used in the analyses of variance were

adjusted if the correlation was larger than
0
.1
.
For the
analyses that d
id

not compare treatments,
effects,
the
importance
of ignoring statistical

dependencies among observations, are likely to be relatively minor
,

and so

in these cases

dependence was ignored
.

Correlations were conducted be
tween all pretreatment variables
1
. The pre
-
treatment BDI
did not correlate with any of the other symptom measur
es at pretreatment. However, there were
positive correlations between the Enright Forgiveness Inventory (EFI) and the Forgiveness
Measure (r=.35, p<.05),
and

between
the EFI and the Unfinished Business Empathy and
Acceptance Scale (r=.56, p<.001). There
were no significant differences at the .05 level between
treatments on any of the pretreatment, demographic or other assessment variables assessed by
means of one
-
way ANOVAs.
A t
-
test conducted to evaluate whether therapeutic alliances were
different in t
he two treatments showed that clients’ early working alliances were not significantly
different


at the .05 level
(
EFT individual therapy, M=5.89, SD=0.84;
PG

group, M=5.75,
SD=0.78
)
.


Outcome


In order to test the hypothesis that EFT would be more ef
fect
ive than
PG

r
epeated
measures analyses of covariance were performed
. Pre

test
scores of the dependent measure was
us
ed as the covariate with

post treatment and follow up as the
repeated measures and type of

23

therapy received
(
either
PG

or individual EFT
)

a
s the between groups factor.
Target complaint
change which does not have a measure at pre
treatment
was analyz
ed by a repeated me
a
sure
analysis of variance with post and follow
-
up as the two occasions
.

The means for each of the
measures for pre
-
therapy, po
st
-
therapy, and follow
-
up are provided in Table
2
.
T
here were no
significant
group by time interactions

on
any of the

measures
. The groups were significantly
different on almost all measures such that the EFT groups exhibited the highest levels of
forgive
ness
-
related gains (i.e. Enright Forgiveness, Forgiveness, Empathy and Acceptance,
Feelings and Needs, and Letting Go) as well as the greatest levels of symptom reduction (i.e.
Target Complaints Discomfort, Target Complaints Change, and GSI)

2
. However, th
e differences
for the BDI were not statistically significant.


Clinical
S
ignificance and Effect
S
ize

Cohen's
d
’s

(1988),

the standardized mean difference, which
provide

an index
of the

practical, as well as statistical significance of the differences

betwe
en treatments and between pre
and post treatment were calculated.
T
he effect size for
differences between
treatment
s

on the
EFI
was moderate d = .4
1
, while

pre
-
post effect sizes were large
for both treatment
s
,
with d = 1
for EFT and .7
1

for

PG treatment
.

This de
monstrates that both treatment
s led practically
to a
large amount of change and that there was a meaningful difference between groups on the major
measure of forgiveness
.

Pre
-

post effect on the GSI were d = .6
2
, for
the EFT

treatment and
was
negl
igible for the
PG

treatment. T
he between treatment effect size was d = .
66
, again

showing
large

effects

for EFT over

PG
.

The pre
-
post effects on empathy and acceptance were 1.73 and
.74 for EFT and PG respectively and the between treatment effect size wa
s .98. For feeling and
needs the pre
-
post effects were 3.22 and 1.62 respectively with between treatment effects size of
1.62.
The pre
-
post effects on TC discomfort were 3.84 and 2.27 for EFT and PG respectively

24

and the between treatment effect

was 1.56.
All these effects are very large.

The between
treatment effects on BDI was very small d =.06 and the pre
-

post effects of .47 and .69 altho
u
gh
large were much smaller than on other measures
.

Forgiving and Letting Go

Cut

off Scores were used on the relevant

outcome measures to classify clients according
to whether they
forgave

their injurers
and/
or
let go

of their negative feelings towards the injurer
(level 4 or above on each measure)
.

The classification of clients

on this dichotomous
classification

is
show
n
in Table
4
.


Di
chotimization
on these

single item measures
however
are

suggestive rather than definitive
because
the dividing lines
between forgiving and
not forgiving
and
letting

go and not letting

go
may

not
be
that sharp.

All of the
nine

clients in E
FT who
forgave

the injurer
also
let go
,

as did the
four

people in

the
PG treatment
who
forgave

the injurer
.
However
, f
ive people in the EFT treatment
and three
in the PG treatment
let go

but
did not

forgive
.
A Chi square

analysis
of the distribution
comp
aring

forgivers and th
o
se who let go was significant
,

X = 21.5 p<.001showing that 100%
who forgave let go
,

while 38% who let go did not forgive.
This suggests that letting go
may be

a
necessary requirement of forgiveness (i.e., everyone who forgave also le
t go), but is not by itself
sufficient for
,

nor the same thing as
,

forgiveness, since clients who met the criteria for letting go
did not always consider themselves to have forgiven the injurer
.
It is important to note that in
both groups a large proportio
n of those people who were classified as not forgiving or letting go
rated themselves as in progress
(
level
3)
on these tasks so it was not the case that they did not
benefit from treatment. They simply had not yet reached as full a resolution
according to

our
cutoff criteria

as those who indicated they had more fully
forgiven

or let go.


Test of emotional arousal in groups


25


Clients in each of the treatment modalities were compared on the intensity of self
-

reported emotio
nal arousal (EA) experien
ced in the
session

to test for the hypothesized
difference
between treatment
in
reported
emotional

arousal
. The EA measure was divided into
positive and negative or unpleasant emotion clusters for the following periods: total duration of
treatment and thre
e phases of therapy (early, middle and late). The positive emotion cluster
included happy and content, while the negative cluster included sad, angry, afraid, and pain.



Changes in reported intensity of negative/unpleasant and pleasant in
-
ses
sion emotional
arousal across
three
phases of each treatment were examined.
For

treatment comparison
s t
he
EFT
sessions were

grouped to form early (3 sessions)
,

middle

(
5 sessions
) and late

phases

(last 2
sessions)
. This structure was thought to best reflec
t the phase structure of the treatment. The six
group sessions

were broken into three sets of two session
s each.
A 2x3
x2

repeated measures
ANOVA compared reported in
-
session intensity
of positive and negative emotions
in the two
treatment conditions
overal
l and
by each phase of therapy.
Means and standard deviations are
shown

in Table
4

and the graph over phases is given in figure1.

There was a significant emotion by time interaction F

(2,

43)

=12.853, p<0.001
,

a
significant emotion by group interaction F

(
1,44) = 24.6, p<0.001, and a significant three way
emotion by time by group

interaction F(2,43) = 3.29, p

<

.05
. Post hoc analyses using a
Bonferonni adjustment for multiple comparisons found the groups differed significantly (p <
.001) on the amount of

reported
negative affect arousal
overall in

the treatment but that there
were no significant differences at the .05 level between the treatment in self
-
reports of overall
positive emotion experienced in
-
session over all. This acted as a form of implement
ation check
showing that the individual EFT treatment was effective in arousing more unpleasant emotion.
The clients in the EFT treatment reported significantly higher levels of negative/unpleasant

26

emotional arousal

than the PG treatment
, in
th
e initial p
hase of treatment (p
<
.01
)

and i
n
the
middle phase of therapy, (p
<

.
01
).
The clients in the
PG
treatment reported significantly higher
levels
of
positive emotional arousal than the EFT treatment
, in
the middle phase of therapy
(p

<

.01
)
.

Finally, during t
he late phase of therapy there was no significant difference at the .05 level
between the groups in reported intensity of negative/unpleasant or positive emotional arousal.

The EFT clients’ reports of in
-
session negative/unpleasant emotional arousal were
found
to be relatively stable over the first two phases, demonstrating no significant differences at the
.05 level between early and middle phases. However, the EFT clients reported significantly less
in
-
session negative/unpleasant emotional arousal in the

final phase of therapy a
s compared to the
middle phase (p
<

.05
). Analysis of the PG clients’ reports followed a similar pattern. Differences
between early and middle phases of treatment were not significant at the .05 level. However, a
significant decline

in reported negative emotional arousal from the middle to the late phase of
therapy was present (
p
<

.05
).


In an examination of the pattern of reported positive in
-
session emotional arousal, EFT
clients reported a significant increase in

the intensity of positive emotional arousal from the
middle phase to the final phase of treatment
(p<.001
). In the PG group, a trend of increasing
positive emotional arousal from the early to late phases of therapy was found. The PG clients’
ratings of po
sitive emotions
increased

significantly from the early to middle treatment phase,
p

<

.01
and

from the middle to late phase,
p
<

.05.


Degree of reported in
-
session intensity of
emotional arousal averaged over the whole treatment, or averaged of any of the
phases of
treatment, did not correlate significantly with change on any of the outcome measures for the
combined sample or for either treatment
.


Correlational Analyses


27

Correlations calculated between residual gains in the forgiveness and letting go relate
d
variables, and symptom va
riables are displayed in Table 5
. Pre
-
post changes were calculated as
the standardized residuals by regressing initial scores onto final scores for all the symptom and
outcome measures (Cronbach & Furby, 1970). As can be seen in
the table, an increase in
forgiveness and empathy and acceptance, and of feelings and needs all were related to a decrease
in overall symptom distress


Discussion

The results of this study showed that clients in the individual EFT treatment showed
signific
antly more improvement than those in the
PG treatment
on all measures of forgiveness
,

on measures assessing the degree to which clients had let go of distressing feelings and unmet
needs in relation to the injurer

and on target complaints at termination an
d follow
-
up
.
The two
groups however were found to not
differ significantly on the change in feelings and needs

at
termination
,

when possible dependence in the
PG

group was taken into account
.
Greater
improvement also was reported
in the

EFT
condition
on
the Global Symptom Index of the SCL
-
90
-
R.
The
r
e

however

was no difference between groups on the BDI
,

but

given

clients
in t
his
study were not depressed
this is not surprising.
The significant change in general psychological
symptoms on the SCL 90
-
R in EFT
,

with no change in PG on symptoms
,

is notable
,

suggesting
that an individual emotion
-
focused trea
t
ment

in addition to enhancing forgiveness and letting go
of the emotional injury
,

has

positive
effects on a person

s

general level of well being that exceed

that of a psycho
-
education group.
Taken as a whole, this study provides support for the
differential effectiveness of an EFT approach for
promoting forgiveness,

resolving emotional
injuries
and reducing general symptoms
over a
PG treatment
intervention of

the same duration
.



28

In addition a
ll those

clients

who reported that they forgave the injurer, regardless of
group, also indicated that they had let go of the distressing feelings and unmet needs previously
associated with the injury. In contrast, there we
re some individuals who indicated that they had
let go of the distressing feelings and unmet needs associated with the injury, but had not forgiven
the injurer. This suggests that letting go of persisting unresolved feelings such as anger, grief,
sadness a
nd/or hurt
may be

a necessary step in

resolving past interpersonal hurtfulness
, but
may
not
be
sufficient
n
or equivalent
to

forgiveness.
Further research on this question is needed

but
seeing that
t
he
process
of
reducing
un
-
forgiveness
or
letting go
of bad

feelings
is distinct from
the process of generating positive feelings, such as loving kindness,
may be useful one
s

when
examining the
process of
forgiveness

and the possibility of the

resolution of an emotional injury
in the absence of forgiveness
.


C
on
trary to what the forgiveness literature suggests

(McCullough &
Witvliet, 2001
,
Orcutt 2006
)
, forgiveness was not initially correlated with the pre
-
treatment variables measuring
emotional health such as the BDI and
particularly
the Global Symptom Index (GS
I) of the SCL
-
90R.

Thus clients

at the start
of treatment who
were more forgiving were not
psychologically
healthier.

This
however
may have been due to lack of range on
both
the forgiveness measure

and
the GSI and BDI

and because participants were seeking
help for presenting problems involving a
lack of letting go and forgiveness
.
In our study p
re
-
post increases in forgiveness and letting go

var
i
a
bles

however
were related to a decrease in GSI.

Thus, it seems that increase
s

over treatment
in forgiveness
,

in
empathy and acceptance
,

toward the injurer, and

being able to
resolve

feelings
and needs,
we
re

related to improved health as measured by the GSI

suggesting
health
benefits to
resolving injuries both by forgiveness and letting go.

Recently
Orcutt (2006)
fou
nd that offence
-

specific forgiveness at

initial assessment
correlated significantly with symptom distress

29

approximately 9 months later
controlling for symptoms distress at

initial assessment
,
and that
time since offence mediated the relationship b
etween f
orgiveness and symptom
distress
,

suggesting a complex relationship between forgiveness and symptoms.

D
ata

on our treatment
seeking population

does not support that forgiveness correlates with distress at
initial assessment
but does show that
increase in fo
rgiveness certainly

correlates with

reduction
in distress.

In addition to showing better outcomes
,

t
he EFT group was found to involve more
client
-
reported
emotional arousal, especially of negative emotions in the mid
-
phase of treatment,
confirming that th
e EFT
treatment
was more emotion
-

arousing than the

PG treatment
. The
finding that there was more negative emotional arousal in the early phase of therapy for the EFT
treatment than for the
PG treatment
was probably because EFT clients were more likely to

access
negative emotions right from the start as a function of therapy, rather than because they entered
treatment with more negative emotions than clients in th
e

PG treatment
.
This finding also
suggests than the emotional change processes
in therapy
are
not necessarily simply ones of
replacing bad feelings with good feelings
in

a linear process but that at times feeling bad can in
fact lead to feeling good. Thus working through bad feelings by
facing them,
allowing and
accepting them
,

can lead to change (
Greenberg 2002).
It should be noted however that
reported
in
-
session
emotional arousal did not relate to outcome in either group
.

This
is likely

because not
all
arousal of
emotion is the same
.
For example s
ome arousal may be a sign of distress rather
than

a sign of working through distress (Greenberg & Watson
,

200
6
)
. Recently Greenberg,
Auzra and Hermann (2007) showed that

arousal alone is not necessarily a measure of productive
emotional processing

and that it is productive processing of arousal emotion
that
best
discriminates good from poor outcome cases.

In other studies the intensity of observed expressed
emotional arousal however has been shown to predict outcome in the working phase of the EFT

30

treatment of depression
(
Missirilian, Toukmanian, Warwar
& Greenberg, 2005;
Warwar, 2003
).
The difference in
the finding on the relationship between emotional arousal and outcome in this
study to the finding in the studies on depression, if they are not because of differences in a
depressed and an emotional inju
ry population,
may be
explained by the differences between the
nature of the
experience of emotion, as measured by

post session self
-
reports of emotional
arousal in the session
, and

the expression of emotions
,

captured by
observational measures of
arousal.


In the present study we observed that the session in which some clients reported high
emotional intensity in the session (experienced emotion) showed few visible signs of the
reported arousal (expression) and in fact often the clients were quite constric
ted in their
expression of emotion in the session. They appeared to have felt a lot of anger or sadness but not
necessarily expressed it, so although the self reports were indicative of emotion experienced,
they were not indices of how much emotion was al
lowed and expressed in the session and made
accessible for further processing. As Greenberg (2007) has suggested emotion awareness and
expression are different emotion change processes and the latter
,

by revealing the self to the
other, overcoming constric
tion and altering physiology and neurochemistry may be
what is most
therapeutic

when dealing with unresolved painful emotions.

Limitations


T
he clients
in this study
were volunteers
who responded
to advertisements
,

and
the
refore

may not be representative o
f the general population seeking help for emotional injuries
.
Furthermore,

equivalence of
type and intensity of injuries
was not taken into consideration
in
assigning clients to

groups,
based on the
assum
pt
i
o
n

that
this w
ould be
handled by
randomization
,

but in small samples
such as this,
this may not be the case
.
In addition,
resolution or forgiveness was not assessed in relation to
whether the injured
person
still had an

31

ongoing relationship with the injurer, (as in the case wi
th a living parent versus
a deceased

parent)
or not
.
It
al
s
o

would

have been preferable to insure a balance of men and women

in both
groups
. To the extent that
there were more women in EFT
, this may have introduced a confound.
Taking
all
these factors into consideration will requir
e
further research with a larger sample
of
clients
.

Because therapist
and researcher
allegiance to treatment model (and
their
possible
ability
to persuade clients of
the

relevance
of the treatment process
to their presenting problems) is a
common factor
known to improve outcomes
,

regardless of specific treatment models employed
,

one might attribute observed differences in this study to therapist training/allegiance,
or
researcher allegiance,
rather than differences in specific treatment techniques.


The E
FT
therapists had at least 1 year of experience with EFT, and received an additional 30 hr of training
in this specific intervention prior to participation in the study. Similar training did not occur for
the
PG treatment

leaders

although the one leader wa
s the developer of the group Psycho
-
education treatment. Investigators

were proponents of EFT and this t
o
o could influence results.


In addition differences between
factors
operating
in
group and individual
therapy
mod
a
l
i
t
i
es
could account for
the
differe
nces in effectiveness
of treatment
. C
lients receiv
ing

individual therapy
receive a treatment

tailored

to their needs, whereas
in groups there is

less
flexibility
and
in
dividualization
.

S
pacing of session
s also

was different

in the two treatments
.
Individu
al therapy met weekly whereas
the

group session
s

w
ere

twice the length of individual
sessions, but met

only once every two weeks.
This could provide more continuity of treatment
and support in the individual therapy.
On the other hand group participants
b
enefit

from other
factors in groups that promote change

that are
not available

to the individual participants,

such as
group support
and a

sense
of the

universality of their problems

and having

two therapists
.


32

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40

Authors
F
ootnotes

1.
Readers can request a complete matrix of intercorrelations between all variables by writing to
the first author at lgrnberg@yorku.ca.

2.
In order to test for

possible dependence in the data Intra Class correlations (ICC) were
computed on the output from two separate one
-
way ANOVAs on the effect of the therapists in
the EFT condition and of the 3 groups in the Psycho
-
Ed condition. ICC measures the relative
homo
geneity within groups in comparison to the between group variation. ICC is large and
positive when there is no variation within the groups, but group means differ. It will be at its
largest negative value when group means are the same but there is great va
riation within groups.
A negative ICC occurs when between
-
group variation is less than within
-
group variation. In this
situation, checking for independence, we would want the ICC to be close to 0 or negative,
indicating that group mean differences are neg
ligible relative to individual differences i.e., the
grouping doesn’t matter. ICC recently is used in the context of hierarchical linear modeling
(HLM) to measure the extent to which data clustering (i.e., non
-
independence of observations) is
present. If t
he ICC is near 0, then HLM will give very similar results to a traditional ANOVA or
regression that assumes independence (Raudenbush & Bryk, 2002, Shrout, & Fleiss1979).

ICCs on post test were found to be low, below .08 or negative for both treatment
cond
itions for all of the dependent variables except for Feelings and Needs (ICC=.15), in the PG
group. This provides evidence that the grouping of clients within therapists and within groups
was not a strong factor influencing the findings on the majority of

measures in the study except
possibly for the Feelings and need scale. Fs were adjusted according to the design effect, which
is a function of ICC and sample size (Skinner, Holt, & Smith, 1989) for post test scores on the
Feelings and need scale and no si
gnificant difference between groups was found at post

41

F(1,43)=2.65, p=.112 thereby altering the conclusion of difference on this measure. There was
no difference in the between group comparisons on the other measures in which ICC had been
lower than .08



42


Table 1


Interpersonal Emotional Injuries Reported by Client Sample

___________________________________________________________________





EFT

PG


_________________________________________________________________
_
_

Issue


Betrayal


5



8





Criticism


6

4



Neglect

4

3



Aband
onment


5




4



Physical abuse


2

3



Sexual abu
se

1


1



Total


23


23

Significant other


Both Parents


5

5



Mother


8


4



Father

5


4



Ex
-
partner



2


5




Sibling


2


2



Child


0

1





Other


1 2



Total 23

23

____________________________________________________________

Note. Each participant targeted 1 injury

only


43

Table 2


Pre, Post and Follow
-
up Means and Standard Deviations of Outcome Measures

Measure

Pre

Post

Follow
-
up


Ancova

EFT


(
n

= 23)

P
G

(
n

= 23)

EFT


(
n

= 23)

PG

(
n

= 23)

EFT

(
n

= 23)

PG

(
n

= 23)

F(1,43)


M SD

M SD

M SD

M SD

M SD

M SD



Enright
Forgiveness

Inventory


199.22


60.58


197.09


58.14


261.13


47.24


237.30


51.28


277.52


51.41


243.43


55.01


4.
98*



Forgiveness

Measure


2.18


.72


2.39


.78


3.74


.81


2.87


1.06


3.83


.75


3.43


1.01


7.91**


UFB Empathy

and Acceptance


14.04


4.43


14.26


4.97


22.17


5.42


17.78


5.48


22.13



4.38


18.87


4.78


9.28**



UFB Feelings

and Needs
1



14.87


5.06


17.48


4.63


30.95


6.0


25.58


8.35.


31.32


6.56


28.05


7.15


4.32*



Letting Go



2.00


.71


2.17


.94


4.09**


.79


2.17


.98


4.06


.71


3.42


.76


437.69**




1

See footnote 2


44

Table 2

(continued)


Measure

Pre


Post


Follow
-
up

Ancova


M SD

M SD

M SD

M SD

M SD

M SD


TC Discomfort



10.48


1.53


10.07


1.64


4.40


2.25


6.48



3.03


4.61


2.41


6.22


2.56



7.03*

TC Change



--

--


--

--


7.16


1.64


5.39


1.99


7.70


1.29


6.3


1.91


12.67**

GSI




.70


.43


.58


.36


.46*


.47


.60


.45


.35


.31


.45


.32



6.73*

BDI



12.18

10.32


10.79


6.34


7.26


7.59


6.39


5.88


6.79


7.13


5.47


5.43



1.1



Note. Pretreatment scores used as covariates

*p
<

.05, **p
<

.01


45


Table
3
: Frequency of Forgiveness and Letting Go
*




Let Go






EFT

PG

% of
Total






Yes

No
Yes No


Yes

No






Yes

9

0
4



0


28
.26%


0

Forgive



No 5

9
3 16


17.39%

54.34%




Total

30.43% 19.56% 15.21%


34.78%


45.65% 54.34%

Note: A Chi square analysis of the distribution comparing forgivers and those who let go was
significant, X = 21.5 p<.
001
.

46

Table 4

In Session Emotion Clusters by Phase of Therapy: PG and EFT

________________________________________________________________________



Phase of Therapy


Emotion
Early Middle Late



PG EFT PG EFT PG EFT


(N=23) (N=23) (N=23)

(N=23) (N=23) (N=23)

________________________________________________________________________


Positive

Emotions


M 3.03 2.97 3.62** 2.73 4.17 3.82


SD



1.17 1.16 1.26 1.23 1.53 1.44


Negative

Emotions


M 2.82 3.58* 2.67 3.50** 2.11 2.60


SD



1.40 0.91 1.12 0.98

1.04
1.09

________________________________________________________________________


Asterisks indicate between group differences

*
p
<.05

**
p
<.01



47

Table 5:
Corr
elations between Pre
-
Post Residual Gain Scores On
Forgiveness, Letting go

and
Symptom Variables(n=46):





GSI

BDI


Enright Forgiveness Inventory



-
.41**


-
.08

Forgiveness Measure




-
.36*


-
.22

UFB Empathy & Acceptance



-
.37*


.05

UFB Feelings & Needs



-
.38**


-
.29

Letting Go Measure



-
.23


-
.17

Target Complaints

(Discomfort)


.27


.14



*
p

< .05,

**
p

<.01



48

Table 2


Pre, Post and Follow
-
up Means and Standard Deviations of Outcome Measures

Measure

Pre

Post

Follow
-
up


Ancova

EFT


(
n

= 23)

PG

(
n

= 23)

EFT


(
n

= 23)

PG

(
n

= 23)

EFT

(
n

= 23)

PG

(
n

= 23)

F(1,43)


M SD

M SD

M SD

M SD

M SD

M

SD



Enright
Forgiveness

Inventory


199.22


60.58


197.09


58.14


261.13
*


47.24


237.30


51.28


277.52


51.41


243.43


55.01


4.98



Forgiveness

Measure


2.18


.72


2.39


.78


3.74
**


.81


2.87


1.06


3.83



.75


3.43


1.01


7.91


UFB Empathy

and Acceptance


14.04


4.43


14.26


4.97


22.17
*
*


5.42


17.78


5.48


22.13


4.38


18.87


4.78


9.28



UFB Feelings

and Needs
2



14.87


5.06


17.48


4.63


30.95
*



6.0


25.58


8.35.


31.32


6.56


28.05


7.15


4.32



Letting Go



2.00


.71


2.17


.94


4.09
**


.79


2.17


.98


4.06


.71


3.42


.76


437.69




2

See footnote 2


49

Table 2

(continued)


Measure

Pre



Post


Follow
-
up

Ancova


M

SD

M SD

M

SD

M
SD

M

SD

M
SD


TC Discomfort



10.48


1.53


10.07


1.64


4.40


2.25


6.48


3.03


4.61
*


2.41


6.22


2.56



7.03

TC Change



--

--


--

--


7.16


1.64


5.39


1.99


7.70
**


1.29


6.3


1.91




12.67

GSI




.70


.43


.58


.36


.46
*


.47


.60


.45


.35


.31


.45


.32



6.73

BDI



12.18

10.32


10.79


6.34


7.26


7.59


6.39


5.88


6.79


7.13


5.47


5.43



1.1



Note. P
retreatment scores used as covariates

*p

<

.05
,

**p

<

.01


50

Figure 1.
Emotional Arousal Across Phases






4.5
























4.0





















































3.5






























3.0




























































2.5















2.0















Early




Middle





Late




Phase of Therapy





PG





EFT


Means

Negative Emotion

Positive Emotion