The effectiveness of emotion-focused therapy on emotion regulation and coping strategies of women with somatic symptom

Abstract

BACKGROUND:

Somatic symptoms and related disorders are prevalent phenomena in the healthcare system. As the clinical observations have shown the relation of these symptoms with emotions and cognitive distortions, the present study aimed to investigate the effectiveness of emotion-focused therapy (EFT) on emotion regulation and coping strategies in women with somatic symptoms.

MATERIALS AND METHODS:

In this semi-experimental, two-group pretest-posttest phases study the sample consisted of 30 women with somatic symptoms aged between 20 and 60 years in the spring of 2023, who were selected through purposive sampling and randomly assigned to the experimental and control groups. To assess the research variables, the Patient Health Questionnaire (PHQ), Structured Clinical Interview for DSM-5 (SCID-I), Garnefski and Kraaij’s Cognitive Emotion Regulation Questionnaire, and Lazarus and Folkman’s Coping Strategies Questionnaire were used in both pretest and posttest phases. The EFT group received treatment for 12 sessions, while the control group remained on a waiting list. The data were analyzed using SPSS 23 software and covariance analysis.

RESULTS:

The results indicated that EFT improved emotion regulation and coping strategies in women with somatic symptoms in the posttest (P > 0.05).

CONCLUSION:

Based on the findings of this study, it appears that EFT can be used as a psychological treatment to improve emotion regulation and coping strategies in women with somatic symptoms.

Introduction

Somatic symptom disorder defined by physical disturbances impairing one’s daily functioning that is among the most common reasons for individuals seeking medical services.[1] In recent years, somatic symptoms have been considered a psychosomatic phenomenon that enhances physicians’ understanding of patients’ symptoms and suffering. Clinically, distressing somatic symptoms are a significant diagnostic criterion for somatic symptom disorder (SSD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and bodily distress disorder in the International Classification of Diseases (ICD-11), and these symptoms are significantly associated with patient’s quality of life. Continuous experience of these symptoms cannot be solely attributed to a specific medical condition and is often accompanied by psychosocial factors such as high negative emotions.[2]

According to DSM-5, the diagnosis of SSD is made when there are persistent (usually more than 6 months) and clinically significant somatic complaints that are associated with disproportionate thoughts, emotions, and behaviors related to health concerning these symptoms. It can occur both in individuals with well-established medical conditions (such as cancer and cardiovascular diseases) and in individuals without any known medical conditions.[3] The prevalence of SSD in the general population is estimated to be between 5% and 7%, and in primary care settings, it is around 17%, with a chronic course and up to 90% of patients with SSD reporting symptoms lasting for more than 5 years.[4] SSD leads to suffering and imposes costs on both the patients and the healthcare system, and delayed diagnosis causes more harm.[5]

Studies have confirmed the impairment in emotion regulation processes, such as encoding and regulating emotions, and their associations with SSD.[6,7,8] Emotion regulation in individuals involves various cognitive and behavioral mechanisms that affect emotional responses.[9] When emotional reactions disrupt adaptive behavior, emotional dysregulation occurs. Studies have shown that individuals with SSD exhibit more avoidant coping strategies and maladaptive emotion regulation strategies, such as catastrophizing,[10] emotion-focused strategies,[7] and greater suppression of expression, cognitive reappraisal, and lower emotional clarity and self-efficacy[11] in patients with SSD. Therefore, therapeutic approaches that modify emotional regulation strategies in individuals with somatic symptoms can be highly effective.[12] Various treatments have been explored to reduce somatic symptoms in patients. However, the effectiveness of these approaches is limited[13,14] because most of these approaches do not adequately address the psychological impact, psychosocial conflicts, and emotional processing difficulties commonly experienced by individuals with somatic symptoms.[15]

Behaviors that individuals adopt in response to stressful situations to reduce physical or psychological threats are known as coping strategies.[16] These coping strategies include problem-focused and emotion-focused strategies to deal with difficulties.[17] These strategies are relatively stable behaviors that can lead to adaptive or maladaptive management of various life issues.[18] Coping strategies adopted by individuals can play a mediating role in the perception and management of disease-related symptoms and stress.[19] Poor executive functioning can be a risk factor for increased vulnerability to pain.[20] Individuals with SSD tend to employ more avoidance coping strategies[21] and their coping strategies mainly involve reliance on medication, avoidance of stressors, distraction, and accommodation or acceptance.[19]

The meta-analysis studies have shown that cognitive-behavioral factors and emotional disturbances are fundamental predictors of physical health in the long term.[22] Furthermore, the effectiveness of emotion-focused treatments in moderating the symptoms of patients with chronic pain has been confirmed.[23] Emotion-focused therapy (EFT) is one of the effective treatments in the realm of mental disorders, based on the philosophy of emotion-focused authenticity and empirically developed techniques.[24] This therapeutic approach is based on the assumption that emotions are the most fundamental sources of human adaptation in life[25] and that these emotions determine the importance of environmental stimuli, needs, and goals. EFT operates under the premise that activating adaptive emotions leads to transforming maladaptive emotions.[26] Therefore, this therapeutic approach aims to increase patients’ awareness of their emotions and teach them adaptive regulation and acceptance.[27] Studies have shown that EFT is effective in reducing pain intensity in patients with chronic headaches,[28] improving catastrophic beliefs about pain and positive cognitive emotion regulation in chronic pain patients,[29] reducing fear of disease recurrence,[30] and coping strategies in patients with pain.[31]

Although a wide range of therapeutic approaches has been studied in relation to individuals with SSD, emotion-based therapies have been overlooked in these investigations. Most of the studies have focused on cognitive-behavioral treatments, which have shown limited to moderate efficacy. As identifying the best therapeutic approach to improve the most possible damage and prevent disease progression is of great importance, the investigation of new therapeutic approaches and their effectiveness has received attention. Comparing the results of various therapeutic approaches can lead psychologists and physicians to choose the best approach. Therefore, this study aimed to evaluate the effectiveness of EFT on emotion regulation and coping strategies in women with somatic symptoms.

Materials and Methods

Study design and setting

This quasi-experimental two-group designed study consisted of an EFT group and a control group with two phases of pretest and a posttest. The population of the study included all women with somatic symptoms who sought medical treatment in the healthcare centers in the spring of 2023.

Study participants and sampling

A sample of 30 individuals was selected among them, using purposive sampling based on inclusion and exclusion criteria, and randomly assigned to two groups of 15 individuals. The inclusion criteria were: obtaining a score higher than the cut-off 15 in the Patient Health Questionnaire, having a diagnosis of chronic back pain and migraines by a specialist physician, not having severe psychiatric disorders (based on the SCID interview), being 20 to 60 years old, not participating in psychological intervention sessions in the past 6 months, having at least a high school education, proficiency in the Persian language, and willingness to participate in the study. The exclusion criteria were unwillingness to continue the treatment, two absences from psychotherapy sessions, and not accurately performing homework and exercises at two consecutive or non-consecutive sessions. It should be noted that ethical considerations, such as complete confidentiality for all participants, being free to withdraw from the study, providing complete information about the research conditions, obtaining written consent, and using data solely for research purposes, were fully observed in this study. Additionally, the control group, which participated in this research, was provided with psychological treatment in a compressed and voluntary manner at the end of the research period. In this section, each of the instruments used in this study is introduced.

Data collection tool and technique

Patient health questionnaire (PHQ-15)

The PHQ-15 is a 15-item questionnaire that is part of the complete PHQ questionnaire and asks respondents about the occurrence of 15 distressing physical symptoms. Fourteen of these 15 items are the most common somatic symptoms described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) Fourth Edition.[32] The scoring indicates 0–4 none, 5–9 mild, 10–14 moderate, 15–19 moderately severe, and 20–27 severe. The concurrent validity of this questionnaire with the Somatic Complaints Scale of the SCL-90 was reported as 0.74, and its internal consistency coefficient using Cronbach’s alpha was 0.76.[1] The standardization of this questionnaire in Iran was carried out by Abdolhosseini.[33] Its internal consistency was obtained as 0.76 using Cronbach’s alpha, and its concurrent validity with the SCL-90 questionnaire was reported as 0.74 (P < 0.001).[34] In the present study, the internal consistency coefficient of the questionnaire was obtained as 0.88 using Cronbach’s alpha.

Structured clinical interview for DSM-5 (SCID-I)

SCID is a semi-structured interview that provides diagnoses based on DSM-5-RV. This tool was developed in 2017 by First, Spitzer, and their colleagues, and it has also been translated into Persian[34,35] In the present study, it was used to assess the absence of severe psychiatric illnesses (entry criteria) such as psychosis, acute bipolar disorder, etc., in the research sample.

Cognitive emotion regulation questionnaire (CERQ)

CERQ is a self-report questionnaire designed by Garnefski and Kraaij.[36] It consists of 36 items and nine subscales. These subscales represent strategies of self-blame, other-blame, rumination, catastrophizing, and positive cognitive emotion regulation strategies: acceptance, positive refocusing, refocus on planning, putting into perspective, and positive reappraisal. This questionnaire can be administered to clinical groups and individuals aged 12 and above. Responses to this questionnaire are collected on a 5-point Likert scale (always, often, sometimes, rarely, never). The creators of this questionnaire have calculated its reliability through Cronbach’s alpha, obtaining 0.91 for positive strategies, 0.87 for negative strategies, and 0.93 for the total questionnaire. Its validity and reliability have been studied in the Iranian population, and an acceptable value was obtained.[37] In another study, the highest positive reappraisal coefficient was 0.86, and the lowest was acceptance, with 0.60.[36] In the present study, the internal consistency was obtained as 0.74 using Cronbach’s alpha.

Way of coping questionnaire (WOCQ)

This questionnaire was developed by Lazarus and Folkman and consists of 66 items that assess eight coping strategies. These eight patterns are divided into two categories: problem-focused coping and emotion-focused coping, which are rated on a scale from zero to three. The emotion-focused coping strategies include direct coping, distraction, self-distraction, escape-avoidance, and problem-focused coping strategies include seeking social support, acceptance of responsibility, problem-solving, and positive reappraisal.[37] The questionnaire’s reliability was estimated at 0.80 using internal consistency in a single study. For the convergent validity of the coping strategies questionnaire, the raw scores obtained from this questionnaire were correlated with the raw scores from the LEO Stress Questionnaire, showing high convergent validity. Principal component analysis and varimax rotation results showed that the subscales were formed by ten factors with factor loading greater than 0.3.[38] The Cronbach’s alpha of this questionnaire was obtained as 0.83 in the present study.

The research process was as follows: After obtaining the necessary approvals for introduction to treatment centers, 30 individuals who met the inclusion criteria were randomly assigned to the experimental and control groups in the spring of 2023. Then, a pretest was administered to both groups, and subsequently, the experimental group received the intended intervention (a 90-minute weekly session) (Table 1 summarizes the intervention) while the control group did not receive any intervention. Treatment was conducted by an experienced psychologist weekly in a group format. Finally, a posttest was also administered for both groups. It should be noted that due to the loss of two samples in the experimental group and none in the control group, the analysis was conducted with 13 participants in each group.

Table 1.

Brief description of emotion-focused therapy sessions

Sessions		Content
First		Therapist’s introduction to the group and members’ introduction to each other, explaining the purpose of participating in the group, stating the group rules by the therapist, conducting a pretest, establishing rapport and empathy with patients, techniques of being present, understanding, exploration, tracking, and mirroring empathy
Second		Exploration of patients’ problems and observation of their emotional processing style through listening to current problems and identifying painful and prominent emotional experiences of patients
Third		Accompaniment, observation, and discovery of patients’ emotional processing style through stages of identification, awareness, acceptance, tolerance, and emotion regulation
Fourth		Exposure to patients’ primary emotion through the representation of trauma experiences related to attachment to identity
Fifth		Discovering and identifying primary, secondary, and instrumental emotions through work on minor and task-related markers and using techniques of chair work
Sixth		Continuing the identification, representation, and regulation of foundational, adaptive/in adaptive, or healthy/unhealthy emotions
Seventh		Identifying and working on blockages or obstacles to accessing primary and secondary emotions and experiences
Eight		Tracking and identifying themes and imagery of transference related to current problems and connecting them to self, father, mother, or other potential transferences
Ninth		Continuing identification and work on indicated markers and working with remaining images through expressive arts such as bodywork, sand tray, music, movement, etc.
Tenth		Coaching patients during the representation of transference and achieving insight through experiential processing
Eleventh		Evaluating how new meanings lead to the creation of new self
Twelfth		Consolidating the new self and extending it to future events

Ethical consideration

This study was approved by the Research Ethics Committee of the University of Shahid Beheshti (Code: IR.SBU.REC.1402.146). The participants were informed of the purpose of the research and its implementation stages. A written consent has been obtained from the subjects. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them.

Statistical analysis

Data analysis was performed using SPSS version 23 software at both descriptive and inferential levels. Descriptive statistics such as mean and standard deviation were provided, and at the inferential level, necessary assumptions were checked first, and then the one-way analysis of covariance (ANCOVA) method was used.

Results

The mean age of participants in the emotion-focused case group and in the control group was 26.58 ± 6.14 and 26.69 ± 7.85 years, respectively. Both groups had five unmarried individuals (38.5%). The married individuals were eight in the case group (61.5%), and seven in the control group (53.8%). There was one divorced individual (7.7%) in the control group, and two ones in the case group (4.15%). In the control group, three individuals (23.1%) had secondary school education, and in the case group, it was seven individuals (53.8%). In the control group, three individuals (23.1%) had high school diplomas, and in the case group, two individuals (15.4%). In the control group, three individuals (23.1%) had educational levels higher than diplomas, and in the case group, it was two individuals (15.4%). In the control group, four individuals (30.8%) had a bachelor’s degree [Table 2]. The results of the ANOVA and Chi-square tests indicated that there were no statistically significant differences between the two groups in the mentioned variables (P > 0.05).

Table 2.

Pretest and posttest descriptive statistics for emotion regulation and coping strategies in both groups (n=26)

Variable		Group		Pretest				Posttest
				Mean		SD		Mean		SD
Emotion regulation		Emotion-focused therapy		124		77/14		130/08		12/69
		control		125/15		12/48		124/31		15/99
Coping strategies		Emotion-focused therapy		80/92		14/41		88/15		14/16
		control		77/08		16/40		78/54		14/38

As seen in Table 3, the assumption of homogeneity of variances was met for both variables (P > 0.05).

Table 3.

The results of Levin’s test on emotion regulation and coping strategies

Variable		F-statistic		df1		df2		P
Emotion regulation		1/79		1		24		0/194
Coping strategies		0/451		1		24		0/508

The second hypothesis was that EFT has an effect on the coping strategies (problem-based and emotion-based) of women with physical symptoms. As shown in Table 4, a statistically significant difference was found in emotion regulation between the emotion-focused case group and the control group (P < 0.01). The effect size was 0.68, and the statistical power was 0.82, indicating an adequate sample size for this finding. Furthermore, a significant difference was found in coping strategies between the emotion-focused treatment group and the control group (P < 0.05). The effect size was 0.53, and the statistical power was 0.71, indicating an acceptable sample size for this variable.

Table 4.

Results of one-way ANCOVA for emotion regulation and coping strategies

Variable		Source of changes		Sum of squares		Degrees of freedom		Mean square		F-statistic		Significance		Effect size		Power test
Emotion regulation		Pretest		4213/40		1		4213/40		122/94		0/0001		0.84		1
		Group		307/73		1		307/73		8/98		0/006		0/681		0/82
		Error		788/29		23		34/27
Coping strategies		Pretest		4024/35		1		4024/35		107/06		0/0001		0/82		1
		Group		261/007		1		261/007		6/94		0/015		0/532		0/71
		Error		864/57		23		37/59

Discussion

The aim of this study was to investigate the effectiveness of emotion-focused treatment on emotion regulation and coping strategies in women with somatic symptoms. The results of the study showed that emotion-focused treatment is effective in improving emotion regulation in women with physical symptoms. These findings are consistent with the studies conducted by Shokrollahi et al.,[29] Boersma et al.,[23] Lumley et al.,[40] Linton and Fruzzetti,[41] Behvandi et al.,[42] Share et al.,[43] and Dillon et al.,[44] which all indicated the effectiveness of emotion-focused treatment on emotion regulation in individuals with pain and physical symptoms. The results suggested that emotional suppression and difficulties in emotion regulation play a significant role in the emergence of physical symptoms. The inability to identify and effective expression of emotions leads individuals to externalize their emotions through various means like somatization. Lack of emotional awareness and emotional suppression causes increased anxiety and stress in individuals,[39] which can reinforce catastrophic thoughts about pain[45] and increase avoidance behaviors.[46]

Emotion-focused treatment focuses on restructuring individuals’ emotional experiences, increasing emotional awareness, and teaching patients to approach their emotions rather than avoiding them. Patients also learn to cope with negative emotions effectively and adaptively. During therapy sessions, patients confront their traumatic past memories, which are the main cause of emotional suppression, and process and reframe them with the help of the therapist. Emotion-focused treatment encourages patients to approach and experience their emotions rather than suppressing or avoiding them. These people learn how to observe their emotions without judgment, empathize with themselves and others, and stop ruminating.[24] Creating the capacity to bear painful feelings has led to the improvement of their emotional understanding, which turns into the production of adaptive emotional responses.

The results of the study indicated the effectiveness of EFT in improving coping strategies in women with physical symptoms. Although a study that fully corresponds to the current research was not available, the findings were aligned with studies conducted by Fazeli et al.,[31] Shayeghian et al.,[47] Bani Hashemi et al.,[48] Hulbert-Williams et al.,[49] and Asl et al.[50] Previous research suggested that EFT has a positive impact on maladaptive coping strategies in emotional expression.[51] Therefore, improving emotion regulation in individuals with physical symptoms can lead to the adoption of more adaptive coping strategies. Additionally, the lack of emotional expression and the use of ineffective coping strategies such as somatization and rumination are related to this issue.[52]

On the other hand, it should be noted that ineffective coping strategies are influenced by maladaptive secondary emotions, which are demonstrated in interpersonal interactions as emotion-focused or avoidant responses. Individuals with physical symptoms hold maladaptive beliefs and emotions about their physical symptoms and feel that their condition is untreatable. These beliefs lead to avoidance of treatment, experiencing unpleasant emotions, and a sense of helplessness, resulting in the use of maladaptive coping strategies. During therapy sessions, patients gained acceptance and a better understanding of their emotions, which led to more logical perspectives in solving their issues. The acquired emotional awareness resulted in reduced emotional distress and ineffective thoughts, decreased physical tension, and improved mental health in the patients. As EFT addresses emotional problems and facilitates emotional expression in individuals, its effectiveness in improving coping strategies should not come as a surprise.

Finally, these findings are not exempt from limitations and should be considered when interpreting the results. Since the research sample consisted exclusively of Iranian women, it is desirable that the present study be replicated in other communities as well. Furthermore, despite finding effective results, the collection of longitudinal data is essential to ensure further generalization. Moreover, other relevant personal variables, such as socio-economic status, previous physical problems, or history of mental illnesses, were not controlled, which could have influenced the effectiveness of the results. Despite the mentioned limitations, this work is expected to be the beginning of the future studies aimed at understanding the effectiveness of EFT on psychological factors in individuals with physical symptoms.

Limitation and recommendation

Among the limitations of the current research, it can be considered that the follow-up stage was not implemented, the subjects dropped out, and the intervention was implemented by the researcher (not blinded). It is suggested that the effects of the EFT interventions and acceptance and commitment with other psychological interventions for the variables of self-care behavior, coping styles, and psychological toughness should also be tested and in future researches the follow-up stage should also be used and also for better understanding of the research problem, in future mixed method should be used in researches.

Conclusion

EFT is effective in addressing psychological symptoms in women with physical symptoms. This therapeutic approach may aid in improving emotion regulation and coping strategies in affected individuals and serves as a valuable tool for psychologists and physicians dealing with patients with physical symptoms.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.