Depth of experiencing and therapeutic alliance: What predicts outcome for whom in emotion-focused therapy for trauma?

OBJECTIVE: The purpose of this study was to determine the extent to which therapeutic processes - working alliance and depth of experiencing - contributed to outcome. METHOD: Individual differences in these processes were examined at the early and working phases to determine their impact on symptom reduction. An archival data set of N = 42 individuals who underwent emotion-focused therapy for trauma for childhood maltreatment was used to examine the differential quality of client processes throughout treatment. RESULTS: For those who had difficulty forming an alliance early in therapy, alliance scores during the working phase were the best predictor of outcome (ß = -.42). This was complemented by a process change of improvement in alliance from the early to working phases (d = 1.0). In contrast, for those who had difficulty engaging in deepened experiencing early in therapy, depth of experiencing in the working phase was the best predictor of outcome (ß = -.36). This was complemented by an improvement in depth of experiencing from the early to working phases (d = .69). CONCLUSIONS: The findings of this study suggest that focusing on the process that clients have trouble with early in therapy contributes to the best treatment outcome. PRACTITIONER POINTS: Sometimes early treatment sessions reveal an abundance of one kind of processing but limitations to another, which poses a puzzle for treatment planning. Our findings suggest that within the first four sessions, therapists could develop tailored treatments based on the relative presence or absence of critical therapeutic changes processes. When it becomes evident that therapy is progressing with a weaker alliance between client and therapist, therapists should redouble their efforts in alliance-building. However, when therapy is developing in a fashion that lacks deep emotional experiencing on the part of the client, treatment efforts should aim to facilitate a richer exploration of moment-by-moment experience. As such, our findings suggest relying on the existing processing strengths within a dyad (e.g., emphasis on an already strong relationships, or augmenting an existing aptitude for deeper experiencing) while shortcomings exist in another kind of process is not optimal responding. Therapists should focus their work on the process that clients have trouble with early in therapy to facilitate the best treatment outcome.

Emotional processing of trauma narratives is a predictor of outcome in emotion-focused therapy for complex trauma.

This study tested a model of emotional processes over the course of emotion-focused therapy for trauma. The model of emotional processing (Pascual-Leone & Greenberg, 2007) proposes a sequential order of shifting from "early expressions of distress" to "primary adaptive emotion" that aid in adaptive functioning. Thirty-eight participants were taken from a randomized clinical trial to examine in-session process from video recordings of treatment. The sample had an average age (M = 44.3 years) and the majority was female (55.3%) and of European descent (89.5%). The Classification of Affective Meaning States was used to examine changes in emotional processes during trauma narratives in both early and late sessions. Processes were related to treatment outcome as measured by the Impact of Event Scale and the Resolution Scale. Sessions later in treatment showed a higher frequency of primary adaptive emotions compared with early sessions (p < .001, r = .76). Primary adaptive emotions were also more frequent in good-outcome cases (p = .017). Using emotional processes as predictors correctly classified 67% of poor-outcome cases and 80% of good-outcome cases. Increases in primary adaptive emotions from early to late treatment sessions more than doubled the odds (2.2) of having a good treatment outcome. The order of emotion was concordant with the sequential model in early sessions and partially concordant in late sessions. Findings have implications for guiding therapeutic process in a productive manner that leads to trauma recovery. Changes in discrete emotions were related to good treatment outcome. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Essential processes in emotion-focused therapy.

Emotion-focused therapy is an evidence-based approach grounded in current experiential therapy theory and research which, in turn, draws on emotion theory and research. Fundamental assumptions are that (1) emotions are associated with a multimodal network of information, (2) accessing emotion in therapy accesses this information, and (3) attention to, and exploration of, subjective internal experience (feelings and meanings) is the primary source of new information used in construction of new meaning. The two primary mechanisms of change are thought to be the therapeutic relationship and emotional processing of problematic material. Emotional change processes include awareness, regulation, reflection, and transformation of emotion. Four intervention principles that are essential to every session are as follows: (1) collaborating on a focus for the session, (2) empathically responding to client struggles and pain, (3) responding to the emergence of adaptive emotion and associated healthy resources, and (4) promoting client experiencing (i.e., attention to, and exploration of, feelings and meanings). These in-session intervention principles are consistent with posited change process.

Characteristics of client-identified helpful events in emotion-focused therapy for child abuse trauma.

This study investigated the characteristics of client-identified helpful events (n=29) in emotion-focused therapy for child abuse trauma (EFTT). Helpful events (HE) were identified on the Helpful Aspects of Therapy Questionnaire and in Post Therapy Interviews, located in video-taped therapy sessions, and compared to researcher-defined control events (CE) for each client. Results indicated a greater focus on childhood abuse (particularly during the imaginal confrontation procedure), higher levels of emotional arousal, and comparable alliance quality in HE compared to CE. HE contained deeper levels of experiencing compared to CE, but only for clients who achieved the greatest depth of experiencing. Client perspectives converged with theory and research on change processes in EFTT and have implications for practice and training.

Narrative quality and disturbance pre- and post-emotion-focused therapy for child abuse trauma.

This study predicted that the quality of trauma narratives written before and following emotion-focused therapy for child abuse trauma would be positively associated with psychological disturbance before and following therapy. Narratives for 37 clients were coded for emotion words, temporal orientation, incoherence, and depth of experiencing. At pretreatment, negative emotion words and experiencing were correlated with abuse resolution, r(35) = -.36, and r(35) = -.34, respectively. At posttreatment, narrative incoherence was correlated with trauma symptoms, r(35) = .33, whereas present-future orientation and experiencing were correlated with abuse resolution, r(35) = -.37, and r(35) = -.31, respectively. Pretreatment incoherence was associated with posttreatment trauma symptoms, r(35) = .42, and pretreatment depth of experiencing was associated with posttreatment abuse resolution, r(35) = -.37. Results support narrative quality as an index of trauma disturbance.

Efficacy of two versions of emotion-focused therapy for resolving child abuse trauma.

This study evaluated and compared emotion-focused therapy for trauma (EFTT) with imaginal confrontation (IC) of perpetrators (n=20) and EFTT with empathic exploration (EE) of trauma material (n=25). Clients were women and men with histories of different types of childhood maltreatment (emotional, physical, and sexual abuse; emotional neglect). Clients were randomly assigned to treatment condition. Outcome measures assessed symptom distress, self and interpersonal problems, and abuse resolution. Results indicated statistically and clinically significant improvements on eight measures at posttest, maintenance of gains at follow-up, and no statistically significant differences between conditions. There were higher rates of clinically significant change in IC and a lower attrition rate for EE (7% vs. 20%). More severe personality pathology negatively influenced some dimensions of outcome, particularly in EE.

Factor structure and reliability of the Childhood Trauma Questionnaire in a Canadian undergraduate student sample.

OBJECTIVE: The aims of this study were to examine (1) the psychometric properties of the Childhood Trauma Questionnaire [CTQ; Bernstein, D., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., Sapareto, E., & Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. American Journal of Psychiatry, 151, 1132-1136; Bernstein, D., & Fink, L. (1993). Manual for the Childhood Trauma Questionnaire. Unpublished manuscript. Bronx, NY: VA Medical Center] in an undergraduate sample and (2) the prevalence of abuse and neglect in this sample. METHOD: Principal components analyses (PCA), coefficient alpha, and correlations were used to analyse data for 470 undergraduate students from a mid-western Canadian university. Cut-offs from a short-form of the CTQ [Bernstein, D., & Fink, L. (1998). Manual for the Childhood Trauma Questionnaire. New York: The Psychological Corporation] were used to estimate prevalence. RESULTS: PCA yielded a five-factor solution comprised of emotional, physical, and sexual abuse, as well as emotional, and physical neglect. All factors, except physical neglect, demonstrated good internal consistency and test-retest reliability. This factor structure largely replicated results reported for an adolescent clinical sample [Bernstein, D., Ahluvala, T., Pogge, D., & Handelsman, L. (1997). Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 340-348], with the exception of the physical neglect factor which was comprised of considerably different items. Rates of childhood trauma were largely comparable to those reported for community and student samples in more densely populated regions of North America. CONCLUSIONS: The CTQ appears to be a valid measure of abuse and neglect in student samples, although experiences are somewhat differentially identified as different types of abuse and neglect depending on age and patient versus nonpatient status.

Alexithymia as a mediator between childhood trauma and self-injurious behaviors.

OBJECTIVE: The aim of this study was to test whether alexithymia mediates the relationship between childhood maltreatment and self-injurious behaviors (SIB) in college women. METHOD: The sample was comprised of 100 female undergraduate students. Measures were the Childhood Trauma Questionnaire [D. Bernstein, L. Fink, Manual for the Childhood Trauma Questionnaire, The Psychological Corporation, New York, 1998], the Toronto Alexithymia Scale-20 [Journal of Psychosomatic Research 38 (1994) 23; Journal of Psychosomatic Research 38 (1994) 33], and the Self-Injurious Behaviors Questionnaire which assessed the lifetime frequency of six methods of superficial self-injury (hair pulling, head banging, punching, scratching, cutting, and burning). Regression analyses were used to test the proposed mediational model. RESULTS: Forty-one percent of respondents reported having engaged in SIB; most engaged in multiple methods, and self-cutting was the most frequently endorsed method. Results of regression analyses supported the proposed mediational model for all types of maltreatment except sexual abuse. Sexual abuse, considered alone, was not significantly associated with alexithymia which precluded testing for mediational effects. CONCLUSIONS: Results support a link between a history of childhood maltreatment and SIB among college women and the hypothesis that alexithymia mediates this relationship.