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Person-Centered & Experiential Psychotherapies, 2014

Vol. 13, No. 4, 263–277, http://dx.doi.org/10.1080/14779757.2014.910131

“That chair work thing was great”: a pilot study of group-based


emotion-focused therapy for anxiety and depression
Adele Lafrance Robinsona,b*, Elizabeth A. McCaguea and Cynthia Whissella
a
Department of Psychology, Laurentian University, Sudbury, Canada; bMental Health and
Addictions Program, Health Sciences North, Sudbury, Canada
(Received 11 December 2012; final version received 9 February 2014)

Emotion-focused therapy (EFT) is an evidence-based treatment for depression and it


has shown promise for the treatment of anxiety. Only one other published study has
examined EFT in a group therapy setting. Using mixed-methods, the current study
explored the feasibility and outcomes of an EFT group with adults referred for anxiety
and depression. Pre-, post-, and 12-month follow-up measures of depression, anxiety,
and difficulties in emotion regulation were administered in addition to a semi-struc-
tured interview at one-year follow-up. The analysis of individual interviews suggested
improvements in various areas of functioning and quantitative data revealed a sig-
nificant decrease in emotion regulation difficulties. The results of this study provide
preliminary support for the application and further study of group-based EFT for
clinical presentations of anxiety and depression.
Keywords: anxiety; depression; emotion-focused therapy; group therapy

“Das Ding mit der Stuhl-Arbeit war toll”: eine gruppenbasierte


Emotionsfokussierte Therapie gegen Angst und Depression
Emotionsfokussierte Therapie (EFT) ist eine evidenz-basierte Behandlung gegen
Depression und bei der Behandlung von Angst ist sie vielversprechend. Nur eine
weitere publizierte Studie untersuchte EFT bislang in einem gruppentherapeutischen
Setting (Pascual-Leone, Bierman, Arnold & Stasiak, 2011). Mit einem Methoden-Mix
untersuchte die vorliegende Studie die Machbarkeit und den Outcome für eine EFT-
Gruppe von Erwachsenen mit Angst- und Depressions-Diagnosen. Pre-, Post-, und 12-
Monate Follow-up- Messungen von Depression, Angst und Schwierigkeiten in der
Emotionsregulation wurden eingesetzt. Dazu kam ein halb-strukturiertes Interview in
einem 1-Jahres-Follow-up. Die Analyse individueller Interviews zeigte
Verbesserungen in verschiedenen Bereichen an und die quantitativen Daten zeigten
eine statistisch signifikante Abnahme im Bereich der Emotionsregulationsprobleme.
Die Resultate dieser Studie liefern erste Unterstützung für die Anwendung und weitere
Erforschung von gruppenbasierter EFT bei klinischen Fällen von Angst und
Depression.

“El trabajo con la silla fue buenísimo”: un estudio piloto de terapia


grupal enfocada en la emoción para la ansiedad y depresión
La terapia enfocada en la emoción (EFT, siglas en ingles) es un tratamiento basado en
la evidencia para la depresión y ha mostrado resultados promisorios para el tratamiento
de la ansiedad. Solo hay otro estudio publicado que ha examinado la terapia centrada

*Corresponding author. Email: acrobinson@laurentian.ca

© 2014 World Association for Person-Centered & Experiential Psychotherapy & Counseling
264 A.L. Robinson et al.

en la emoción, EFT, en un contexto de terapia grupal (Pascual-Leone, Bierman, Arnold


& Stasiak, 2011). Usando métodos mixtos nuestro estudio ha explorado la viabilidad y
los resultados de un grupo de terapia enfocada en la emoción de consultantes adultos
derivados por temas de ansiedad y depresión. Se han realizado mediciones de
depresión, ansiedad y dificultades en la regulación de la emoción hechas pre, post
tratamiento y seguimientos de 12 meses. El análisis de entrevistas individuales sugiere
que hay mejoras en varias áreas de funcionamiento y la data cuantitativa revelo una
importante disminución en las dificultades de la regulación de la emoción. Los
resultados de este estudio proveen apoyo preliminar para la aplicación y posterior
estudio de la terapia de grupo enfocada en la emoción para las presentaciones clínicas
de ansiedad y depresión.

“Ce truc de travail avec les chaises était formidable” ; une étude pilote
sur la Thérapie de groupe “Emotion-Focused” pour l’anxiété et pour la
dépression
Lafrance
La thérapie centrée sur les émotions, EFT (TEF), est un traitement basé sur des données
probantes pour la dépression et elle a montré des résultats prometteurs pour le traitement
de l’anxiété. Une seule autre étude publiée a examiné la TEF dans le cadre de la thérapie
de groupe (Pascual - Leone, Bierman, Arnold et Stasiak, 2011). En utilisant des
méthodes mixtes, la présente étude a exploré la faisabilité et les résultats d’un groupe
TEF avec des adultes souffrant d’anxiété et de dépression. La dépression, l’anxiété et les
difficultés de régulation émotionnelle ont été mesurées avant le groupe, après et douze
mois plus tard. Un entretien semi-structuré de contrôle a eu lieu un an plus tard.
L’analyse des entretiens individuels suggèrent des améliorations dans différents
domaines de fonctionnement et les données quantitatives révèlent une diminution
statistiquement significative des difficultés de régulation des émotions. Les résultats de
cette étude fournissent un appui préliminaire à l’application et à la poursuite de la
recherche sur la TEF en groupe pour les cas cliniques d’anxiété et de dépression.

«Esta coisa de trabalhar sentado é ótima»: Um estudo piloto sobre


Terapia de Grupo Focada na Emoção para a Ansiedade e a Depressão
A Terapia Focada na Emoção (TFE) consiste num tratamento para a depressão
baseado em evidências e tem-se revelado promissora no tratamento da ansiedade.
Existe apenas mais um estudo que examinou a TFE em contexto de terapia de
grupo (Pascual-Leone, Bierman, Arnold & Stasiak, 2011). Com recurso a métodos
mistos, o presente estudo explora a exequibilidade e os resultados de uma TFE com
adultos referenciados com ansiedade e depressão. Foram realizadas avaliações de
ansiedade, depressão e dificuldades na regulação das emoções, pré e pós terapia, e
um follow up passados doze meses. Nesta última avaliação foi também realizada
uma entrevista semi-estruturada. A análise das entrevistas individuais apontou para
melhorias em várias áreas do funcionamento e os dados quantitativos revelaram um
decréscimo estatisticamente significativo nas dificuldades de regulação das
emoções. Os resultados deste estudo oferecem um apoio preliminar à aplicação e
a futuros estudos sobre a TFE de grupo, no caso de manifestações clínicas de
ansiedade e depressão.

Introduction
According to a survey conducted by the World Health Organization, anxiety and mood
disorders are the most common of all mental health problems worldwide (Demyttenaere
et al., 2004). Recently, the American Psychological Association (APA) Diagnostic and
Person-Centered & Experiential Psychotherapies 265

Statistical Manual of Mental Disorders (DMS) Task Force has considered a reclassification
of mental disorders according to clusters, with the “Emotional” cluster including both
anxiety and depression as a result of their many common features, including tempera-
mental antecedents, genes, and response to treatment (Goldberg, 2010). In terms of
treatment, individual emotion-focused therapy is recognized as an evidence-based treat-
ment for depression and trauma (APA, Division 56, 2012b; APA, Division 12, 2012a;
Courtois & Ford, 2009; Ellison, Greenberg, Goldman, & Angus, 2009; Goldman,
Greenberg, & Angus, 2006; Greenberg, 2010; Greenberg & Watson, 2006; Paivio &
Greenberg, 2001; Paivio & Nieuwenhuis, 2001; Paivio, Jarry, Chagigiorgis, Hall, &
Ralston, 2010; Watson, Gordon, Stermac, Kalogerakos, & Steckley, 2003), and it has
shown promise for anxiety disorders (Cisler, Olatunji, Feldner, & Forsyth, 2010;
Greenberg, 2010; MacLeod, Elliott, & Rodgers, 2012; Pascual-Leone & Greenberg, 2007).

Emotion-focused therapy
A key principle of EFT is that emotion is fundamental in the construction of the self and is
a key determinant of self-organization or how one understands him or herself in the world
(Greenberg, 2010). EFT supports the development of emotional intelligence in order to
enable clients’ ability to perceive and respond to environmental situations in both healthy
and adaptive ways (Elliott, Watson, Goldman, & Greenberg, 2004; Greenberg, 2008;
Greenberg & Pascual-Leone, 2006). Painful or distressing maladaptive emotions are
identified and experientially explored in order to access and experience adaptive emotion,
transforming the problematic maladaptive emotion responses to adaptive ones (Elliott
et al., 2004; Greenberg, 2008, 2010; Greenberg & Pascual-Leone, 2006; Pascual-Leone,
2009; Pascual-Leone & Greenberg, 2007; Pos & Greenberg, 2007).
EFT is marker-guided and process-directive (Elliott et al., 2004; Greenberg, 2010, 2011;
Pos & Greenberg, 2012); meaning that specific problematic emotional-processing states are
identified in-session (i.e. markers) and provide an opportunity for specific intervention
techniques (i.e. therapeutic tasks) such as increasing awareness of the emotional experience
via the bodily felt sense (i.e. focusing; Gendlin, 1996), emotional evocation, and chair-work
(Greenberg, 2008, 2010, 2011). Traditional EFT involves three types of chair-work: two-chair
dialogue for internal conflict splits, two-chair enactment for self-interruptive processes, and
empty-chair dialogue for unresolved injuries with a significant other (Greenberg, 2008, 2010,
2011). Chair-work is a therapeutic technique used to resolve affective-cognitive problems and
is derived from traditional Gestalt therapy (Greenberg, 2008, 2010, 2011). Gestalt therapy and
extensions of it (e.g. Focused Expressive Psychotherapy) have been found effective in both
individual and group formats (Engle, Beutler, & Daldrup, 1991; Kepner, 1980; Rosner,
Beutler, & Daldrup, 1999); however this research base is limited.

Humanistic group therapies


Humanistic group therapies have a rich history dating back to the late 1940s and early 1950s.
Process and outcome research has examined client-centered, Gestalt and existential forms of
group-based psychotherapy with diverse populations, including but not limited to hospitalized
inpatient psychiatry patients, hospitalized alcoholic patients, couples, and cancer patients.
Overall, participation in humanistic group therapies has been found to be significantly related
to positive outcomes across multiple domains (see Page, Weiss, & Lietaer, 2001, for a review).
266 A.L. Robinson et al.

Current study
Despite the strong history of humanistic group-based therapy research, its cost-effective-
ness, as well as the therapeutic elements unique to this modality (such as universality,
altruism, interpersonal learning, etc.; Scott, 2011; Tiuraniemi & Korhola, 2009; Yalom &
Leszcz, 2005), only one EFT group study has been published to date (Pascual-Leone,
Bierman, Arnold, & Stasiak, 2011). Pascual-Leone et al. (2011) examined outcomes of an
EFT group for incarcerated men with a history of intimate partner violence and reported
positive treatment outcomes comparable to those of best practice treatment. As such, the
current pilot study explored the feasibility and preliminary outcomes and experiences of
an EFT group for individuals suffering from anxiety and depression.

Method
Participant recruitment and characteristics
Ten participants who presented with symptoms of anxiety and depression were contacted
from a wait-list for a regional hospital’s outpatient service to participate in the study.
Exclusion criteria included documented personality disorder, active suicidality, and/or
substance abuse. Of those contacted, eight individuals agreed to participate in the nine-
week group. Pre- and post-group data were collected from six participants for whom a
sufficient amount of data was collected (four women and two men).1 Participants pre-
sented with severe depression, moderate levels of anxiety and emotion regulation pro-
blems (e.g. over- and/or under-regulation) and employment of unhealthy emotion
regulation strategies (e.g. over consumption of alcohol, over/under eating, causing inter-
personal conflict, self-harm). All participants reported significant impairment in function-
ing. The mean age of participants was 41.5 (range 30–53) and four of the six participants
were married or in long-term relationships. Only two of the participants were employed.
The participants reported diverse mental health treatment histories prior to the EFT group,
including involvement with a psychiatrist, individual counselling, and/or group therapy.
Participants were not engaged in any other treatments during the course of the group. All
participants were contacted to complete follow-up measures and participate in a semi-
structured interview. Four participants (three women and one man) completed this final
stage of the pilot study.2 Ethical approval was obtained from the appropriate institutions
and informed consent was obtained from study participants at each time interval.

EFT group and follow-up procedures


Sessions were held over the course of two hours on a weekly basis for nine weeks. Two
registered clinical psychologists facilitated the group, both with competency in the area of
clinical psychology. The primary therapist’s theoretical orientation was emotion-focused.
She received over 100 hours of formal training in this modality in addition to supervision
on a number of individual cases.
In order to translate individual EFT into a group-based format, the intervention was
developed in consultation with a supervisor in individual EFT who assisted in the design
and delivery of a group-based emotion-focused intervention for women suffering from
bulimia nervosa (Wnuk, 2010; unpublished dissertation).3 Similar to their design, the first
session focused on group introductions, pre-measures, and psycho-education. Psycho-
education included teachings on: the nature of emotion, emotions and their associated
needs, the differences between primary and secondary emotion, and the ways in which
Person-Centered & Experiential Psychotherapies 267

emotions are implicated in psychopathology. Subsequent sessions consisted of: (1) a


review of the past week and participant updates, (2) single participant chair-work session
(approximately 45 minutes) with other participants observing (the primary therapist
facilitating the piece of chair-work with a participant, while the co-therapist observed
the group members for reactions), (3) reflections on the participant’s chair-work, and (4)
weekly end-of-session questionnaires. The ninth and final session also consisted of a
termination discussion and the completion of the post-measures. Follow-up measures
were completed one year later on an individual basis along with a semi-structured inter-
view. The interview was audio recorded, transcribed verbatim and reviewed for accuracy.
Follow-up interview times ranged from 1.5 to 2.5 hours per participant.

Measures
The Beck Depression Inventory 2nd Edition (BDI–II; Beck, Steer, & Brown, 1996) is a
21-item measure used to assess depressive symptoms experienced over a two-week
period. These items are rated on a 4-point Likert scale and summed to produce a total
scale score, with higher scores reflecting greater depression severity. The BDI-II is a
reliable and valid tool for assessing the severity for depression (Beck et al., 1996).
The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) is a 21-item self-
report measure of the physiological and cognitive symptoms of anxiety over a one-week
period. The symptoms are rated on a 4-point scale and then summed to produce a total scale
score, with higher scores reflecting greater anxiety severity. The BAI is a reliable and valid
tool for assessing the severity of anxiety (Beck et al., 1988; Grant, 2004).
The Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) is a
brief, 36-item self-report questionnaire designed to assess multiple aspects of emotion
dysregulation. The DERS items reflect difficulties within six dimensions of emotion
regulation: awareness of emotions (Awareness); understanding of emotions (Clarity);
acceptance of emotions (Non-acceptance); ability to engage in goal-directed behaviour
(Goals); refrain from impulsive behaviour (Impulse) when experiencing negative emo-
tions and access to emotion regulation strategies perceived as effective (Strategies).
Higher scores indicate difficulties with emotion regulation (scores range 36–180). This
scale has been shown to be a reliable and valid tool for assessing emotion regulation
difficulties (Catanzaro & Mearns, 1999; Grats & Tull, 2010).

Follow-up interview
Construction of the semi-structured interview questions was based on qualitative inter-
view guidelines outlined in the literature (Creswell, 2003, 2007; Merriam, 2009), phe-
nomenological perspectives (Creswell, 2003, 2007; Smith & Eatough, 2007; Smith &
Osborn, 2008), and group-based psychotherapy interview schedules (Kimball, Wieling, &
Brimhall, 2009; Seamoore, Buckroyd, & Stott, 2006). The interview schedule was not
prescriptive; rather, it served as a basis for conversation with the participants and aimed to
keep the participants engaged, talking freely, and sharing all thoughts about their experi-
ence, both positive and negative (Creswell, 2007; Merriam, 2009). Sample questions
included: “Overall, what was the EFT group like for you?”; “How would you describe
the overall impact of the therapy group on you?”; “What elements of the group process
were helpful/unhelpful, if any?”
268 A.L. Robinson et al.

Table 1. BDI, BAI, and DERS: participant means and (standard deviations).

Measure/Subscale/Item Pre (n = 6) Post (n = 6) Follow (n = 4) Partial eta squared (n2)

BDI Total 36.00 (4.56) 25.17 (7.60) 22.0 (15.98) 0.40


(clinical range) Severe Moderate Moderate
BAI Total 20.50 (9.67) 21.00 (12.25) 13.50 (7.35) 0.48
(clinical range) Moderate Moderate Mild
DERS Total* 134.83(13.96) 111.83(15.46) 88.63(24.89) 0.59

Note: *Significance (p = .10 to p = .06) in mean difference across time.

Results
Repeated measures analyses of variance were conducted on the data collected at pre, post,
and follow-up. Repeated measures t-tests were conducted to further explore significant
findings. An alpha value of 0.10 was employed as the significance criterion due to the
exploratory nature of the study and the low statistical power. Utilizing an alpha level of
0.10 is recommended for research of this nature to minimize the risk of Type 2 Error and
to indicate where further exploration is advisable (Hays, 1994; Stewart & Ammeter,
2002). Means and standard deviations of the BDI, BAI, and DERS are presented for
the pre-group, post-group (n = 6), and one-year follow-up group (n = 4; Table 1).

Beck Depression Inventory


Although there were no statistical differences found for the BDI total scores across time,
effects sizes were notable (.40) and clinical differences emerged. Specifically, pre-BDI
scores fell in the severe clinical range (36.17), while post-group scores fell in the moderate
clinical range (25.17). This clinical difference was maintained at follow-up with BDI
scores falling in the moderate range (22.00).

Beck Anxiety Inventory


Similar to the overall BDI results, no statistical differences were found for the BAI total
scores; however, effect sizes were notable (.48) and clinical differences emerged. Pre- and
post-group BAI scores fell into the moderate clinical range (20.50 and 21.00, respec-
tively), while follow-up scores improved over time and fell in the mild range (13.50).

Difficulties in Emotion Regulation Scale


Statistical and clinical differences in the DERS scores emerged across time (effect size: .59).
In terms of statistical significance, post-group scores were significantly lower than pre-group
scores (F(2) = 4.36, p = .068, ɳ2 = .59; t(5) = 2.39, p = .062).
In terms of clinical significance, the DERS means at pre- and post-group (134.83 and
111.83, respectively) exceeded the average range for clinical populations (average clinical
range 85–105; Grats & Tull, 2010). However, at follow-up, the DERS score (88.63) fell
slightly above the average range for nonclinical samples (nonclinical range 75–80; Grats
& Tull, 2010), suggesting further improvement in emotion regulation difficulties.
Person-Centered & Experiential Psychotherapies 269

Table 2. Summary of super-ordinate and sub-themes.

Super-ordinate theme Sub-theme

1. Benefits of interacting with other Commitment and motivation


participants Group as positive, protective, and hopeful
Corrective emotional experience (validation, empathy,
interpersonal soothing, altruism, universality/
normalization)
Value of peers
Peer-to-peer learning
2. Personal chair-work and reflection Honest and in the moment
as most powerful in-session Critical component in therapy
experience Educational and transformative
Nerve-wracking, challenging, and intense
3. Other powerful EFT-specific Interest in, and application of emotional education
in-session experiences Experience of emotional interrupters
Paradoxical feelings toward the chairs
Vicarious emotional processing and learning
4. Post-therapy effects on personal Attribution of lasting change to group
healing and growth Increase in emotional competence/intelligence
Emotional, cognitive, and interpersonal gains
5. Preference for group EFT and Preference for group EFT over other therapies
desire for follow up Sad at group’s termination
Desire for follow-up/more work on self
Recommendations for future EFT groups

Interview analysis
The follow-up interviews were analyzed using Interpretative Phenomenological Analysis
(IPA; Smith & Eatough, 2007; Smith & Osborn, 2008). Various procedures were
employed to increase validity. Specifically, descriptive validity was increased via a review
of all interview transcriptions for accuracy. Comparisons were made between quantitative
results and qualitative themes generated on the basis of participants’ transcripts, and
independent investigators analyzed the qualitative data, compared their findings, and
collaborated until consistent themes were formed. Member checking was also employed,
wherein participants were invited to review the themes and provide feedback on their
accuracy in terms of their perspectives and experiences. Table 2 illustrates the super-
ordinate and sub-themes identified.

1. Benefits of interacting with other participants


Participants described many positive experiences as a result of their involvement in the
group. All participants described feeling accountable and committed to one another (i.e.
desired to report back weekly, hear how others’ weeks had gone, and continue to work as
hard as everyone else), as well as motivated to make healthy emotional changes: “I felt
accountable, not only to myself, but to other people!” The group was described by all as a
“team environment” and a “family” in addition to being a “safe” and caring place that was
non-judgmental, accepting of emotion and incredibly powerful and uplifting (e.g. “I don’t
think I missed a class, I enjoyed it. It was enlightening!”). One participant described
feeling “blessed” to be a part of the group. The group instilled hope and optimism for
270 A.L. Robinson et al.

positive change in all (e.g. “...I never left feeling angry or feeling sad, I always left feeling
a little bit more hopeful”). Participants also praised the therapists in their therapeutic
approach, techniques, and personalities.

The group made me feel, made me feel safe, I could share stuff. That they were really willing
to listen and understood that maybe I just need to do work and that a pill wasn’t you know,
the answer for me, I felt accepted, and … I didn’t feel like they were coming at me, “Well,
you’re depressed, we need to fix you, you’re depressed, and we need to make you stop
crying”. I didn’t feel like that at all, it was more like well, “maybe you do need to cry! Maybe
you do need to get it out!”

According to participants, an important group element related to the experience of a


corrective emotional experience. Group members experienced healthy validation, empa-
thy, and interpersonal soothing from one-another and from the therapists. In addition, a
relieving sensation of universality was described (e.g. validation: “it’s like you have all of
these thoughts in your head and you can’t put it down on paper and you can’t articulate it,
... These people put words to those thoughts and sometimes just putting words to those
thoughts, it’s like, ‘oh you get it there. Oh okay!’ So it’s not an issue anymore. I can put
this aside that emotion, it’s all good”; universal emotions: “I don’t remember the people’s
stories… I just remember the emotions… they were all the same!”). Furthermore,
participants described how uplifting it felt to realize that they could be helpful to others
despite their own emotional challenges (e.g. “…it’s just that it makes you feel, like ‘yeah’,
I’m screwed up but I can still provide some valuable input or insight to some other
people!”). Value was also placed on the feedback and insights received from fellow group
members due to a felt sense of equality and mutual understanding: “To share and get other
peoples perspective. It’s not like... it’s people like us, who are on the street and their not
trained like you guys right? And to see how they deal and work, we can bring some of
those tools around as well.” Participants reported learning a great deal from other group
members – from their advice to specific emotion regulation techniques (e.g. “while he was
up there spilling his guts, I was listening to what was going on, thinking that ah, that’s ah,
coping skill that I’m going to try using now”).

2. Personal chair-work and reflection as most powerful in-session experience


Discussion relating to the participants’ personal chair-work session brought forth much
emotion and tears. One participant dubbed the technique as being in “the hot-seat.” The
chairs were viewed as the catalyst of the experience of raw, true and honest emotion. A
powerful sense of determination to work with the most personally distressing emotions in
the chair-work was expressed: “I remember forcing myself get on ... you gotta do this, you
gotta do this!” When participants engaged in their own chair-work, they described
becoming fully focused and “forgetting” about everyone else in the room (e.g. “…once
the questions start, you don’t feel like you’re centered out anymore. You’re in there,
you’re focusing…”). The personal experience in the chairs was viewed as the main tool,
the most helpful, and the absolute critical component in the therapy:

I think everybody should be put through that chair, that’s... I was lucky, I consider myself
lucky to have been involved … I feel blessed actually, just to be exposed to all of that. I’m
going to get emotional here, but the chair work thing was great. It was ...yup. You can’t
replace that. You can’t even… No, you have to go through it to experience it.
Person-Centered & Experiential Psychotherapies 271

Personal experiences in the chairs were described as having “opened the door” to self-
improvement and health. A strong sense of relief, weightlessness, healing, and peace was
described after the personal chair-work session. One participant who experienced a
personal loss described an emotional transformation in the “hot-seat” during a piece of
unfinished business:

When I was able to talk to [him], that was the shift... see not being able to talk to him out
loud,... to be able to talk to him, was it... It made things better! You know I don’t want to say
super fantastic but it made things better. I walked out of there that day feeling pretty good.

A sense of freedom and new-found optimism was described after participants’ chair-session
(e.g. “When I did the chair work … it was very freeing….because I didn’t feel so much like a big
cluster of emotional mess…”; “You’re relieved after … [you] would come in the next week …
refreshed… and positive … ready to start addressing some issues!”). Finally, the chair-work was
described as the most challenging and intense aspect of the entire group therapy: “It’s hard to
describe the intensity, there are no words for it”; “… it was off the charts, right off the charts!”

3. Other powerful EFT-specific in-session experiences


The first time participants observed the chair-work of another group member, they
reported experiencing shock, skepticism, and disbelief while also experiencing excite-
ment, anticipation, and nervousness:

At the beginning I thought it was a joke. But then over time I started to really see the absolute
benefits of it; I was scared gearing up for my own chair work; Holy shit man. I can’t believe it
... this is cool! … and I can’t wait for my turn!; it was a shock at the beginning, like “oh man
we’re centering this guy out!” Right in the middle of the room! Wow!

At various points in the therapy process all participants also experienced emotional
interrupters in the form of confusion, uncertainty, avoidance, or denial about their emo-
tions (e.g. “Back then I’d have that big mental block, if they would ask me the right stuff,
I would go brain-dead. I’d just completely blank!”) followed by an increase in “emotional
competence” throughout the group duration, including enhanced emotion regulation skills
(discussed further).
A noteworthy group element described by all participants was that of vicarious
emotional processing and learning while observing others doing chair-work (i.e. “What
that person was saying, that’s when I realized, I had those feelings. And it made me go
even further into myself”). Vicarious processing was described as a critical component of
the group because participants were able to learn about their own emotions, including
emotions previously outside of their awareness. All participants described high emotional
intensity while watching others in the chairs, particularly if the emotions that emerged via
the chair-work were relatable to their own emotional experiences (e.g. “Pretty much every
day was intense...., if I could really relate then I’m crying right along with this person”).

4. Post-therapy effects on personal healing and growth


The participants described healing, self-growth, or renewal of their life that they attributed
to the overall group experience: “…I am not the same person anymore... Now I am a
different person because of this group,” as well as to each of the group’s processes: “There
272 A.L. Robinson et al.

is a reason for each part of the session. Like to not have a piece, something would be
missing.”; “Everything was helpful. … Everything had its purpose.”
Many positive changes were described in the participants’ overall mood, significant
relationships, sense of self (i.e. increased optimism, self-acceptance, initiative, perception
of resiliency/inner strength, independence, self-worth, confidence, and pride), and overall
distress levels (i.e. decreased symptoms of anxiety and depression):

It changed my outlook.; Relationships are changing because I’m not flying off the handle …
It’s really helped me cope with my emotions therefore changing the way that my life was;
With my children. Being more in the moment and doing activities with them... You appreci-
ate. I continued it ... it’s not just a one shot deal here I figured ok, I’m going to work on it all
the time.

Participants also described improvements in emotional competence (improvements in


emotional awareness, acceptance and expression, emotion regulation and control). For
example, participants described using new-found self-soothing strategies (e.g. for the first
time in “a long time”, one participant described turning up his car stereo and enjoying the
music, another “stopped crying 24/7”) and emotion regulation techniques (e.g. one
participant described regularly performing “mental checks” outside of the group where
she mentally checked off items from the session questionnaires to enhance her emotional
attunement and coping ability). Participants described a general sense of becoming more
aware and attuned to their emotions as a result of the group: “I became more aware. You
know, I know what’s going on, I’m in tune with my emotions and my thoughts.”

5. Preference for group EFT and desire for follow up


One year later, participants expressed their preference for group EFT over other individual
or group therapies: “the group is much better than an actual counselor, [that is] a passive
thing … I felt like I was actively involved in an active process of getting healthier and
understanding…. I would do it again!” When the group terminated, the group members all
reported a sense of sadness at the loss: “By the time I left there, I missed it! I really, I was
really sad the last day... And when I think of it, it makes me sad (chokes up).”, and
expressed desire to do further self-work in therapy: “I still feel that I have issues … but at
least I’m aware, a little bit more aware, I have those issues, and they do need to be
attended to.” Valuable recommendations for future EFT groups including more group
sessions (e.g. 15), longer group sessions (e.g. 2.5–3 hours), and greater access to the
service: “That is something that everybody should go through. Everybody!”

Discussion
The current pilot-study examined the feasibility and preliminary outcomes of a short-term
EFT group for anxiety and depression. Despite low statistical power, the strong effect
sizes and clinical significance provide evidence to suggest that with a larger sample,
statistically significant improvements on measures of depression and anxiety could be
expected. Statistically and clinically significant improvements were also found with
respect to emotion regulation difficulties. Qualitative themes emerged that were in line
with these findings. For example, prior to the group, participants described having
tremendous difficulty with their mood, anxiety and ability to regulate emotion. These
reports were consistent with the groups’ pre-scores which all fell within the severe clinical
Person-Centered & Experiential Psychotherapies 273

ranges. Throughout the group, the participants recognized that they faced emotional
interruptions in the early sessions and that they became more emotionally competent
throughout the group’s duration (tuning into their emotions, becoming aware of emotions,
identifying emotions, learning emotion regulation techniques). One year after the group,
the members reported that their mood, anxiety and emotion regulation had improved, and
they attributed these improvements to their involvement in the EFT group.
Common therapeutic factors essential for success in group therapy were also identified
by participants (Yalom & Leszcz, 2005) including (1) imparting of information (the
participants’ descriptions of their interest in and application of the psycho-educational
material); (2) instillation of hope, group cohesiveness, and catharsis (the perception of the
group as positive, protective, a safe place to share, and instilling of hope and optimism);
(3) universality and altruism (the corrective emotional experiences of validation, empathy,
interpersonal soothing, altruism, and universality or normalization); and (4) imitative
behaviour (where participants described learning from others’ advice and coping
strategies).
In addition to these well-documented factors, elements unique to EFT were also
identified. Specifically, an interesting finding related to the group environment and how,
according to participants, it appeared to heighten the power of the experiential chair-work.
For example, a strong theme emerged that revealed the participants’ experience of their
chair-work and reflection as the most profound. The chair-work (both their experience and
that of the other participants) propelled them to focus on their emotions and process them
moment-by-moment; hence, paying attention to, acknowledging and processing their
emotions. In classic group therapy, sporadic “moments” of heightened affect are reported
by group members to be particularly salient and critical in their personal discovery,
healing, and growth (Beebe & Lachmann, 1994; Gray, 2001). It appears that beyond
sporadic “moments” of heightened affect that are typical in classic group therapies, this
group may have allowed for regular intervals of heightened affect (by way of chair-work),
potentially promoting group members’ emotional attunement, processing and consequen-
tial positive outcomes (Pascual-Leone & Greenberg, 2007).
Vicarious emotional processing also emerged as a strong theme and a novel finding of
this study that warrants further exploration. In other brief group therapies, the phenom-
enon of vicarious processing has been described when group participants who show high
levels of change seem to have the ability to maximize their learning opportunities by
engaging in the experience of other members (Leiberman, Yalom, & Miles, 1973). In
general, however, the evidence indicates that the more active and influential a member is
in the group, the more he or she is to benefit; in other words, the more silent a client is, the
less likely he or she is to benefit significantly from the group (Yalom & Leszcz, 2005). In
fact, some research indicates that vicarious experience, as contrasted with direct participa-
tion, is “ineffective in producing significant change, emotional engagement, or attraction
to the group process” (Yalom & Leszcz, 2005, p. 398). In this study, the members of the
EFT group reported occurrences of vicarious emotional processing when observing chair
work. In fact, while one group member engaged in their chair work each week, the
remaining participants sat quietly observing for up to 45 minutes. Although the study’s
design did not allow for a systematic investigation of vicarious emotional processing, this
finding suggests that further study of this phenomenon could be worthwhile.
In terms of feasibility, it was interesting to note that despite the group members’
diversity (in terms of age, gender, medical and treatment histories, etc.), improvements
were found and reported across participants suggesting that group-based EFT may be a
viable treatment option for a diverse group of clients.
274 A.L. Robinson et al.

Based on the results of this preliminary study, we feel that there is potential for the
delivery of EFT in a group format with mixed symptom-presentations. Group-based EFT
may also add a therapeutic element to group therapy processes, being that of EFT chair-
work, which appears to influence the participants’ emotional processing, including the
possibility of vicarious emotional processing. These findings are also important in light of
the fact that group-based delivery of EFT could increase access to services and reduce the
financial strain on the mental health system.

Limitations and recommendations for future research


This exploratory pilot study was the first of its kind and limitations are important to note.
Although this EFT group for anxiety and depression appears to have benefitted the clients
who completed treatment, firm conclusions about its effectiveness cannot be drawn due to
the small sample size and low statistical power. The generalization of our results are also
weakened by the fact that the follow-up period was restricted to one year. This pilot study
needs replication with a larger sample and control group, as well as an examination of the
specific impact of chair-work on changes in depression, anxiety and emotion regulation. It
will also be important to focus on additional outcomes perhaps more related to the strong
focus on chair-work throughout the group, such as the degree of resolution achieved. In
terms of processes, the investigation of the experiential process – group dynamic inter-
action (e.g. the potential phenomenon of vicarious processing) as well as group outcomes
varying session structure (e.g. EFT task usage, session schedule) and group duration (e.g.
16–20 weeks) are recommended. Finally, although the authors chose to study group-based
EFT using a particular structure, the possibility to explore creative alternatives is encour-
aged. Overall, the current study contributes to the EFT literature in that it brings attention
to the potential for the delivery of group-based EFT and offers a starting point for the
future study of this modality with individuals suffering from anxiety and depression.

Acknowledgements
This research was sponsored in part by the Canadian Institute of Health Research Frederick Banting
and Charles Best Canada Graduate Scholarship – Master’s Award awarded to the second author. The
authors would like to acknowledge the clients who generously offered to share their personal and
private experiences.

Notes
1. One participant dropped out following the third session. The other participant attended sessions
sporadically and data from this participant was considered insufficient for this study’s purpose.
2. Of the two remaining participants, one was unreachable and the other stated that he was willing
to participate however he was not able to attend the follow-up session due to other
commitments.
3. Throughout the duration of the group, the primary therapist also engaged in weekly supervision
with this supervisor.

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