The Impact of Emotion-focused Therapy on Anxiety and Depression among Female-Headed Households in Imam Khomeini Relief Committee

1. Clinical Psychology, Islamic Azad University, Yazd Branch, Yazd, Iran
2. Psychiatrist Researcher of Department of Psychiatry, School of Medicine, Shahid Sadoughi University of Medical Science, Yazd, Iran
3. Clinical Psychology, Faculty of Psychology and Educational Sciences, Yazd University, Yazd, Iran

ARTICLE INFO		ABSTRACT
Original Article Received: 11 Nov 2017 Accepted: 6 May 2018		Introduction: The existence of female-headed households is a global fact. These women are the most vulnerable members of the society, who experience some degrees of emotional distress, general signs and symptoms of anxiety and depression. So, this study was conducted to evaluate the effect of emotion-focused therapy on anxiety and depression of the female-headed households. Methods: This quasi-experimental study had a pretest-posttest design in which the experimental and control groups were investigated. The study was performed on 30 women who headed the households and were supported by the Imam Khomeini Relief Foundation of Yazd city. The participants were selected randomly in 2016. The data collection tool of this study included the Beck anxiety and depression questionnaire. Finally, the collected data were analyzed using SPSS version 20. Results: The findings showed that the emotion-focused treatment method reduced the anxiety of the participants. Moreover, the effect size was equal to 0.52, which indicated that 52 percent of the variance changes were attributed to the independent variable. In addition, the emotion-focused therapy reduced the level of depression among the women. The reported effect size was 0.734, which showed that 73 percent of the variance changes were due to the independent variable. Therefore, we can conclude that the emotion-focused therapy had a significant effect on the anxiety and depression of the female-headed households (p < 0.001). Conclusion: According to the results of this study, the multivariable model of covariance analysis indicates that changes in the groups can be caused by the intervention. Therefore, it can be concluded that the emotion-focused therapy was effective on the anxiety and depression of the women. Consequently, this therapy can be used to reduce the anxiety and depression of the female household heads. Keywords: Emotion-Focused Therapy, Anxiety, Depression, Family Characteristics
Corresponding Author: Marjan Khosravi Asl

A rise of new challenges in today's societies, such as the occurrence of divorce in the first years of marriage, addiction, imprisonment, along with traditional factors such as death and some paralytic diseases gave rise to some conditions for a large number of households in which a single parent (mostly women) take care of their families. In the current period, the phenomenon of female-
headed households has risen throughout the world.  These households often experience a variety of problems so that an increase in the number of this population stratum has recently emerged as a social problem (1). Female-headed households have been recognized as those who hold responsibility for the living of the family without continuous support and presence of an adult male (2). According to the Population and Housing, the number of female-headed households has been estimated more than one million and 641 thousand people (3).  In Iran, an approximately 83% of female-headed households have got the custody of the family because of husband's death, 7% due to divorce and separation, and 5% because of male disability. However, according to the Imam Khomeini Relief Committee statistics, this group accounts for 19% of the total female-headed household's population covered by the Relief Committee (4). These different statistics suggest that many women, who took responsibility for most of the care in their families for reasons other than husband's disability, did not receive appropriate social support and financial resources. Furthermore, other statistics show that about two-thirds of female-head households are alone responsible for providing for their families (i.e., without the presence of a working family member) and get low incomes because of their limited availability of employment opportunities for women compared with men, and are mainly engaged in part-time jobs (5).  Hence, they are among the most vulnerable social groups faced with many difficulties and obstacles in their personal, family and social lives. The findings of the study also indicated that female-headed households experience more stress than other women. In addition to a wide array of economic difficulties, they encounter with some negative social pressures, such as negative attitudes toward widows and divorced women (6). Nowadays, the increasing growth of this family in all countries of the world, whether industrialized and developing countries, including Iran and its fundamental problems, necessitated bringing forth appropriate and scientific strategies and solutions to improve the position of this population group. Psychologists maintain that female-headed households are exposed to a series of issues and challenges such as stress, anxiety, mental illness and depression with different roles and, thus their mental and psychological health can be damaged. Anxiety and depression are associated with emotions affecting the performance, productivity, social and family relationships as well as individual's interactions, especially those in female-headed households as well as prevent the creation of social cohesion; as a result, the social relations of this group of women have lost their positions and raised many problems for them.  Given the importance of female-headed households and the undesirable effects of anxiety and depression on the community, psychologists and researchers have proposed different techniques to decrease the negative effects and mitigate the anxiety and depression of these women, including the use of emotion-focused therapy for treatment of anxiety and depression of female-headed households which has recently been raised in the studies. Emotion-focused therapy has been proposed as an alternative for two major approaches of interpersonal and cognitive-behavioral therapy in the treatment of anxiety
and depression (7). Emotion-focused therapy
focused on the emotional schema processes underlying interpersonal and cognitive-behavioral determinants and introduced emotional processing as its fundamental therapeutic goal (8). Emotion-focused therapy is an empirically-supported, neo-humanistic approach. In emotion-focused therapy, the therapist must not only capture the content of what the client is feeling being denied or distorted but also note the vitality effects of the client mirroring the tempo rhythm and tone of the experience (9). Emotion-focused therapy is based on the premise that humans act as monitoring systems that integrate many dialectical processes at different levels, from chemical nerve level to the conscious and conceptual levels, and this integration creates an integral bond between emotion and recognition. Therefore, people can make a more efficient life through constant incorporation and management of the combination of biological information and cultural learning which are seemingly contradictory (10). Emotion-focused therapy aims to make therapeutic changes in the patient enhancement of emotional processing. To enhance emotional processing and the process of change in depression, this approach relied upon four basic principles. These principles are based on the learning framework emphasizing emotional and environmental support (11). Environmental and emotional support as the basis of therapeutic effectiveness encompasses the four principles of emotional processing: (a) increasing emotional awareness; (b) enhancing emotion regulation; (c) contemplating on emotion, and (d) emotion transforming. These four principles are the general direction concerning working with emotion. Emotion regulation can be defined as a process through which individuals consciously modulate their emotions (12) to respond to diverse environmental demands (13) adequately. Emotion regulation can also lead to physical impairment, abnormalities, and discomfort which has received much less attention up to now (13). Emotion-Focused Therapy treatment has been broken into three major phases for the treatment of anxiety and depression: 1) bonding and emotional awareness 2) evoking and exploring 3) transformation. The steps for emotion-focused therapy summarize the two basic principles of this treatment, namely facilitate the therapeutic relationship and the advancement of therapeutic care (Table 1).

Stage	Step
Bonding and awareness	1. Attending to, empathizing with and validating the client's feeling and current sense of self 2. Providing a rationale for working with emotion 3. Promoting awareness of internal experience 4. Establishing a collaborative focus
Evocation and exploration	1. Establishing support for emotional problems 2. Evoke and arouse problematic feelings 3. Undoing interruptions of emotions 4. Helping access primary emotions or core maladaptive  schemes
Transformation	Helping the clients to generate new emotional responses to transform  core maladaptive  schemes Promote reflection to make sense the experiences Validate new feelings and support an emerging sense of self

So far, there have been three major studies to examine the efficacy of emotion therapy in the treatment of depression (9). These three studies evaluated the efficacy of this treatment with side effects of 0.71 to 1.73 and sustainable improvement in 6 months and 18 months follow-ups, all of which indicate the high effectiveness of this treatment for depressive disorder.  Emotion-based interventions have been influential in creating positive self-talk and novel experiences for depressed patients, facilitating forgiveness, and reducing emotional problems (14). Given the high prevalence rate of depression and its complex nature, and since emotion-focused therapy is considered a novel and effective treatment, the present study seeks to assess the effectiveness of this treatment in Iranian culture and for anxiety disorders and depression.
Methods
Statistical population, sample, and procedure: The present study is quantitative research regarding way which aimed to assess the effectiveness of emotion-focused therapy. This study was administered through a pre-test post-test control group design. The statistical population consisted of all female-headed households in Imam Khomeini Relief Committee of Yazd which met the anxiety and depression. This study used convenient sampling method. After obtaining consent from the clients to participate in the research project, the researcher explained to them that to confirm the assessment, it was necessary to respond to the Beck anxiety and depression scale before the start of treatment, during the next month and in two stages. The first series of questionnaires were administered after the interview and the second series one month later. The subjects entered the treatment process after the selection and evaluation.
In this research, the sample size criterion is calculated according to the formula below:

The primary selection was screened, and then the substitution method was done in two experimental and control groups randomly. Accordingly, 15 people will be tested as the experimental group, and 15 will be the controlled group.
In order to analyze the data in this study, two parts of the descriptive statistics of the central indices and dispersion (mean, standard deviation, ...) in the inferential statistics of the one-way covariance analysis test and instrumental reliability of the Cronbach's alpha test The results of this method were used to study the more accurate and more explicit effects of independent variables on dependent variables in each group. Data were also analyzed using SPSS version 20 software.
They were evaluated in such a way that anxiety and depression scale was initially obtained from the subjects and the questionnaire was performed twice after the completion of the treatment process. Emotion-focused therapy has been described as a short-term treatment (8-10 sessions), and each session lasts for 50 to 60 minutes (13). The researcher developed and used the therapeutic package used in the study of 8-session program format based on emotion-focused therapy (14).
The content components of this treatment are as follows: (A) the relationship components include: 1) momentarily and  empathizing match  of therapist: attention to the style of speech, sound quality, body language and emotional processing style, 2) By sharing empathic understanding with clients, creating a safe and genuine environment where the clients  feel  fully acceptance and understanding, 3) facilitating collaboration for doing homework and treatment goals: listening to client's narrative to identify problematic aspects of the client's experience, sharing the therapist's perceptions and clients  from client's experience.
(B) Assignment components included: 1) an empty chair technique for unfinished business, 2) a two-chair technique to change the critical and punitive practices of dealing with oneself or being stuck (dilemma), 3) Reopening a systematic revocation  to resolve problematic reactions from the point of view of clients 4) Focusing  to facilitate reflection on emotional content and awareness of inner experience, and 5) to make meaning for solving the frustration of a challenge with beliefs that were known as honorable (8).
Assessment tool
The validity coefficient of this questionnaire was reported at 0.80% using a re-test method and within two weeks. Also, to investigate the psychometric properties of this test in the Iranian population, Kaviani and Mousavi (15) estimated the valid coefficient of this questionnaire (0.72%), and its test-retest reliability coefficient, as well as Cronbach's alpha, was reported to be 0.83% within one month.
Beck Depression Inventory (BAI) is a 21-item, self-report questionnaire to measure the severity of symptoms of anxiety in adults with anxiety disorder diagnosis. The questionnaire is scored based on four options (0-3) according to the patient reported severity (16) administered this inventory among 94 Iranian subjects, and their alpha coefficient was obtained at 0.91%.  The retest reliability coefficient was also obtained 0.94% within one week. The BDI-II alpha coefficient for outpatients and students was 0.92% and 0.93%, respectively (17). Generally, the internal consistency coefficients of each item and other statistical characteristics of the questionnaire as well as the Cronbach's alpha coefficient show that BDI-II has an appropriate validity among the Iranian population and can be used for statistical analysis and psychometric assessment of scores obtained from subjects (Table 2).

Treatment Steps	Description
First step	Communication  and commitment to treatment (explaining the nature of anxiety and depression, their factors and symptoms, conceptualizing emotion-focused therapy, and observing and evaluating subjects based on their ability to focus on inner experiences).
Second step	Identification a defective interactive cycle and emotions underlying interactive situations (identifying contradictory, dual and critical feelings about themselves and people who are important and influential in our life.
Third step	Changes in issues related to basic emotional needs and desirable emotional cycles: creating conditions for experiencing of uncomfortable emotional experiences in the relationship and family contexts and challenging them.
Fourth step	Using relaxation techniques (for reaching a relaxed and self-critical speech as well as helping to reduce the helplessness experience among subjects).
Fifth step	Identification and controlling the needs, desires and underlying factors of emotions (smoothing the way for expression of needs and inadequacy feelings among subjects) and exploring the two aspects of their own experience.
Sixth step	Facilitation the expression and description of feelings needs and desires (through description and discussion of voice, inconvenience, irritation and pain).
Seventh step	Development of new solutions for previous problems (training on transfer process for feelings of frustration, anger and shame of subjects to build and enhance the ability to face problems and change important aspects of their life).
Eighth step	Development of a new cycle of behavior (providing examples of the quality of interpersonal relationships in people's lives to strengthen the learning of previous new skills)

Results
To measure the effect of emotion-focused therapy on anxiety and depression in female-headed households, the covariance analysis method with the presumption of the normal distribution of data and also the equality of intergenerational variances was administered, and the overall results of covariance analysis are presented in the following tables. (Table 3).

Table 3. Mean and standard deviation scores of women's depression and anxiety scales in both the experimental and control groups in the pre-test and post-test

	Variables	pre-test	Post-test
Examination		Mean±SD	Mean±SD
	Depression	39.73±11.32	19.00±12.44
	Anxiety	26.60±5.17	18.86±3.09
Control	Depression	43.93±12.55	42.53±9.92
	Anxiety	26.80±5.15	26.46±5.55

The table above shows that the anxiety and depression scores of women in the post-test of the test group decreased compared to the pre-test. Also, in the control group, the post-test scores did not change much compared to the pre-test.
Hypothesis 1: Emotion-focused therapy has an impact on the reduction of anxiety in female-headed households in the Imam Khomeini Relief Committee of Yazd.

Table 4. Results of covariance analysis and post-test comparison in two groups with control of pre-test effect of anxiety in female-headed households

Effect size	Significance level	Source of change
0.316	0.002	Pre-test
0.522	<0.001	Group
<0.05	<0.05	Error
30	30	Total

The results of the (Table 4) show that the first hypothesis of the research, the effectiveness of emotion-focused therapy on the reduction of anxiety in female-headed households in the Imam Khomeini Relief Committee of Yazd was confirmed and the first hypothesis of the research was confirmed; (p< 0.05); therefore, we can conclude that the emotion-focused therapy approach could reduce the level of anxiety among female-headed households. Also, the effect size has been reported to be 52%, suggesting that 52% of variance result from an independent variable.
The second hypothesis of research: emotion-focused therapy has an impact on the reduction of depression in female-headed households in the Imam Khomeini Relief Committee of Yazd.

Table 5. Results of covariance analysis and post-test comparison in two groups with control of pre-test effect of depression rate in female-headed households

Effect size	Significance level	Source of change
0.504	<0.001	Pre-test
0.734	<0.001	Group
<0.05	<0.05	Error
30	30	Total

The results of the (Table 5) show that the second hypothesis of the research, namely, the effectiveness of emotion-focused therapy on the reduction of depression rate in female-headed households in the Imam Khomeini Relief Committee of Yazd was confirmed (p< 0.05); therefore, we can conclude that the emotion-focused therapy approach has the ability to decrease the depression level among female-headed households. Also, the effect size has been reported to be 734%, suggesting that 73% of variance result from independent variable. As a result, we can say that the multivariable model of covariance analysis of the present study suggests changes in groups can be due to the effect of intervention and emotion-focused therapy approach is influential on changes in the anxiety and depression rates as dependent variables.
Discussion
The present study was designed and implemented with the aim of answering the question of whether emotion-focused therapy could affect the reduction of anxiety and depression among female-headed households in Imam Khomeini Relief Committee. The findings of this study confirmed the main hypothesis. Since subjects in this study were selected among the female-headed households in the Imam Khomeini Relief Committee of Yazd as well as were randomly assigned into control and experimental groups, it was expected that the mean of both groups was equal regarding anxiety and depression variables. The match  between  research groups in terms of the variable studied in the pre-test was confirmed using the findings of covariance analysis; hence, in accordance with the principles of statistical inference, if there was a match among  comparison groups in the pre-test, we can offer  a more acceptable judgment regarding  the discrepancy of the groups in the post-test and can accept the confirmed discrepancies in the hypothesis test and explain the results based on them.  The findings of the present study suggest that the emotion-focused therapy approach is effective in reducing the anxiety and depression levels in patients with major depression. The results of this study are consistent with the findings of the study by Greenberg and Watson (9), suggesting the effectiveness of emotion-focused therapy on reducing anxiety and depression. As mentioned earlier, emotion-focused therapy is an empirically-supported, neo-humanistic approach. It has been found that instantaneous therapist-client interactions along with an emotional therapist's assistance predict the treatment outcomes (9, 18). Emotion-focused therapy emphasizes the role of experimental - experiential techniques influenced by gestalt therapy (9). Found that the implementation of these two fundamental emotion-focused therapy tasks is capable of predicting intra-sectional treatment, the result of treatment, 18-month follow-up, and more importantly, the tendency for sustained non-recurrence during the follow-up.  These first assignments are mainly solving problems, and unfinished businesses are implemented through experimental techniques within the sessions. At the end of the treatment, the therapist is supposed to have a supportive role rather than a director and encouraging agent. Ultimately, clients promote a sort of coordination among the achievements of treatment including increasing awareness of emotion, expressing new emotions, coping with difficulty in emotion regulation and appropriate emotional expression and achieve a new self-perception.  At this stage, acknowledgment of client's effort to self-regulate is considered a crucial factor in maintaining their self-respect. In this situation, they don't need a therapist to find or offer a solution; rather, they are seeking for acknowledgment or confirmation as a chooser and agent (an existential aspect of emotion-focused therapy). The clients of the current study reached the emotional stability in the final session, and their scores on the Beck anxiety and depression scale indicated their readiness to disconnect from the treatment process.  However, it seems that family and disease challenges interfered with the treatment process and thus the therapist made an attempt to focus upon the relationship therapy largely and restored them to the treatment process by acknowledging their sadness and distress. The clients reached a stable mood and left the treatment process with relative subsidence of the disease. Frequent exposure to bitter mental and emotional experiences is often considered a complicated process for clients. In this regard, in addition to the establishment of an efficient relationship, the mission of the therapist is to train some basic skills for emotion regulation. The founders of emotion-focused therapy maintain that emotion regulation is conceptualized a process rather than a unified educational plan with a specific protocol, and as a result, the therapist's task looks like a trainer rather than a teacher (9). In a study by Warwar (19), it was shown that the combination of emotional arousal with emotion experience could better predict the results in comparison with each of these individual indicators. The improvement was accelerated when clients were able to share their emotional experience with others. In these situations, they expressed in a variety of different ways that their better understanding of the inner world leads to better communication with others and they play more effective roles. Based on meta-analysis findings by Elliott et al (7)., it was found that at least eighteen studies, along with diverse clinical populations used emotion-focused therapy and this approach was generally used in 344 references (7,9,18,19). In general, people undergoing this type of treatment are classified into four categories: 1) Major. 2) Clients with abusive, traumatic, and other unresolved interpersonal communication (19, 20). 3) Conflict of decision making. 4) Mixed problems (7).  According to the findings, significant changes were observed among clients during the treatment. Several studies also demonstrated the effectiveness of the emotion-focused therapy approach to treat various types of anxiety disorders such as general anxiety disorder and social phobia (7). Based on the explanation above, this approach has an impact on the reduction of abnormal emotional symptoms in many different mental disorders. The novelty of this research in using the therapeutic approach imposed some limitations, which we will refer to several major ones.  The first limitation of this study was the use of a quasi-experimental design. This suggests that we can't demonstrate that the intervention of the independent variable influenced the changes made in the dependent variable. In the implementation of the research, the researcher merely used the self-report questionnaire. The second limitation of this research was related to the data collection method. This method can lead to the negligence and lack of attention to the quality and processes of changes in patients. The third limitation was the lack of a follow-up period.  Concerning the limitations mentioned, the authors of the study make some recommendations for future researchers: 1) Use of experimental designs to determine the effectiveness of emotion-focused therapy. 2) Use of other assessment tools, especially physical and emotional symptoms along with self-report questionnaires. A practical solution is that researchers can take pictures of their treatment sessions so that they can examine and track change indicators, such as the actions and reactions of the therapist and the clients during the sessions, and identify the mechanisms of change based on them. 3) They can take measures to capture the qualitative experiences of the treatment of clients and therapists in measuring instruments resulting in the emergence of qualitative and mixed research. 4) Use of longer follow-up periods to measure the efficacy of treatment.
Conclusion
This research was conducted on the population of women headed by households living in Yazd city. Since living conditions in different cities of Iran are different, for women heads of other cities in Iran, separate research should be done.
Since various researches showed the effects of the excitement circuit on the psychological problems of women and other groups and given the timely provision of these interventions, Prevent further mental issues or exacerbate current problems, and improve drug compliance. Therefore, it is suggested that policies be introduced to incorporate these interventions into common drug interventions.
Therefore, interested researchers can influence the effect of excitement therapy in other areas such as prevention and treatment, promotion of mental health and quality of life, adaptability, coping with stress in women and other groups are studied and studied.
It is recommended that follow-up investigations be conducted in the future, to ensure the



effectiveness of complete assurance.
Acknowledgments
It should be noted that the project was carried out with the support of Imam Khomeini Relief Committee of Yazd Province with the code number of 1/1635977, which we hereby would like to thank the institution. The study was conducted in accordance with the ethical guidelines of the declaration of Helsinki.
Conflict interest
The authors declare no conflict of interest.

 
References