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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, Wanda M. Malcolm
YorkUniversity,Toronto
Correspondence should be sent to the first author Leslie S. Greenberg, Dept. of Psychology York University 4700 Keele St.Toronto, ON, CanadaM3J 1P3. Email:
This study was supported by a grant ID# CRF 5202 from the Campaign for forgiveness research to the first author.
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 witha 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 total of forty-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 follow-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 measures 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
Differential Effects of Emotion Focused Therapy and Psycho-education in Facilitating
Forgiveness and Letting Go of Emotional Injuries
Forgiveness has recently been proposed as an important aspectof emotional recovery following an interpersonal injury(Enright & Fitzgibbons, 2000;Worthington,1998,2001). 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 psycho-educational group programs designed to promote the benefits of forgiveness to self and others, and these provide the knowledge and skillsassociated with a particular model of forgiveness. To date only two studies have been published that report on an investigation of the effectiveness of individual therapy in facilitating unilateral forgiveness (Coyle and Enright, 1997; Freedman and Enright, 1996).The present study examined the effectiveness of Emotion-focused Therapy (EFT) comparedto a psycho-educational group in facilitating emotional resolution and forgiveness.
Numerous investigators have proposed that both emotion work and empathy play important roles in forgiveness (Davenport, 1991; Enright & Fitzgibbons, 2000; Fitzgibbons, 1986; Hope, 1987; Karen, 2001; Malcolm, Warwar, & Greenberg, 2005). One of the assumptions of EFT is that the blocking of primary biologically adaptive emotions subverts healthy boundary setting, self-respectful anger and necessary grieving, and that adequate processing of unresolved 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 forgiveness 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 experiences of violation, the therapist is promoting ownership of a client’s emotional experience and is empowering clients to appropriately assign responsibility for harm done. Ownership of emotion also helps clients focus on their own needs and concerns rather than getting stuck in blaming the other or feeling victimized. The danger in short-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 injury.
Therapists also need to facilitate 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 involves a process of facilitating normal grieving in which anger and sadness play central roles. Facilitating an imaginary 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 (Greenberg Rice & Elliott 1993; Elliott, Watson, Goldman & Greenberg 2004).
Emotion-focused Therapy (Greenberg 2002), which employs empty-chair dialogue for
the resolution of unfinished business as one of itsmajormethods has been found to be an effective intervention in the treatment of depression, interpersonal 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, supported the efficacy of the empty-chair intervention. The results demonstrated a significant reduction in symptomotology, target complaints, and interpersonal distress and more resolution of unfinished business.The empty-chair method as it is employed in EFT is also a particularly effective tool in promoting empathy felt toward the offender(Paivio, Hall, Holowaty, Jellis, & Tran,2001;Paivio& Nieuwenhuis 2001;Paivio & Greenberg, 1995). In imaginatively bringing the injurer and injury alive, the client moves 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 awareness 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), and this suggests that a maladaptive emotion state can be effectively transformed by undoing it with the presence of another more adaptive emotion. More specifically Frederickson, Marcuso, Branigun & Tugade (2002) have shown that positive emotion undoes the cardiovascular after-effects of negative emotion. Greenberg (2002) has suggested that the 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, feelings related to unforgiveness such as 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 forgiveness (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, Worthington, & 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 interpersonal 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, cognitive perspective taking of this nature does not have to involve warm benevolent feelings associated with forgiveness. Something more is required for forgiveness and this appears to be compassion for the injurer, or affective empathy.
Affective empathy is best understood as a means of imaginative entry into the world of the other, which generates a bodily 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 herself into the other person’s place in an attempt to understand the unfolding of events from the injurer’s perspective.
Unforgiveness has been defined as the combination of a complex set of negative feelings towards an injurer, and it has been shown that people 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, & Thoresen, 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 injurer. 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, forgiveness 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 emotional 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-focused Therapy (EFT) (Greenberg et al.,1993) involving empty-chair dialogue in the treatment 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 offender; 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 the 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 forgiveness 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 group that was less emotion-activating.
This study also examined the emotional process of forgiveness in resolving interpersonal injury and evaluated whether forgiveness was necessary to resolution of the injury. In the present study, recovery from an emotional 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 other; 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, withoutthe 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 theEFT, than in PG
Treatment 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 programwould 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 diagnosed with antisocial, borderline or narcissistic personality disorder, post-traumatic stress disorder, or a psychotic disorder. Individuals who were already in psychotherapyelsewhere were also excluded.
The average age for clients in the EFT treatment was 43 years. The average age for the PG treatment was 46. The overall population thus had a mean age of 44.5 and S.D = 8.3 (range 22 - 67). There were seven males and 16 females in the EFTtreatment and 13 males and 10 females in thePG treatment. In the EFT treatment, eight individuals had never been married, 13 were married, and two were separated or divorced. In thePG treatment, five had never been married, nine were married, and nine were separated or divorced. In terms of their level of education, 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 thePG treatment, five individuals had completed high 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 in each treatment group.
In terms of pre-treatment diagnosis on DSM Axis I and II, there were nine clients (39%) with a least one Axis I diagnosis in the EFT treatment, andseven clients (30%) with at least one Axis I diagnosisin thePG treatment. In the EFT 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 for the EFT treatment and 60-90 for thePG treatment. There were no statistically significant differences between treatment conditions on any of these variables.
Emotional Injuries
The typesof emotional injuries clients presented in this study, and the nature 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 injury in relation to at least one parent and two (8%) with an ex-partner, while in thePG treatment, 13 (57%) of the participants were dealing with an injury regarding at least one parent and five (21%) with an ex-partner. The people in the “other” category included a boss, a neighbor, and people in non-parental positions 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 doctorate 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 experience as a therapist. 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 leaders. One of thegroup 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 conditions received weekly supervision throughout the study to promote adherence to treatment manuals.