Volume 7, Issue 3 (Summer 2021)                   JCCNC 2021, 7(3): 227-236 | Back to browse issues page

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Zadafshar B, Sharifi T, Ahmadi R, Chorami M. Effects of Emotion-focused Therapy and Existential Group Therapy on Depression, Anxiety, and Stress in the Victims of Child Sexual Harassment. JCCNC 2021; 7 (3) :227-236
URL: http://jccnc.iums.ac.ir/article-1-315-en.html
1- Department of Psychology, Shahrekord Branch, Islamic Azad University, Shahrekord, Iran.
2- Department of Psychology, Shahrekord Branch, Islamic Azad University, Shahrekord, Iran. , tsharifb@gmail.com
Full-Text [PDF 644 kb]   (1191 Downloads)     |   Abstract (HTML)  (1589 Views)
● Existential group therapy reduced depression symptoms in the victims of child sexual harassment. 
● Existential group therapy and emotion-focused group therapy effectively reduced anxiety symptoms in the study participants. 
● Emotion-focused group therapy was significantly more effective than existential group therapy in reducing stress symptoms.
Plain Language Summary 
Traumatic childhood experiences, especially sexual harassment, are among the most important factors causing anxiety disorders. They can negatively affect the mental health of victims and lead to the occurrence of depression, anxiety, and aggression. According to the results of this study, existential group therapy reduced depression symptoms. Besides, existential group therapy and emotion-focused group therapy reduced anxiety symptoms in the victims of child sexual harassment. Emotion-focused group therapy was more effective than existential group therapy in reducing stress symptoms.

Full-Text:   (1008 Views)
Sexual harassment is a major traumatic event that may threaten individuals throughout their lives. It is unwanted sexual behavior that leads to discomfort and negative effects (Syarifah Fathynah & Sharifah Syahirah, 2015). Kahsay (2020) defines sexual harassment as inappropriate sexual behavior that includes seductive, unwanted, and repetitive sexual offers aiming to convince someone for sexual relationships. It means to impose one’s sexual desire on a subject regardless of their content in a context of unequal power relations. Sexual harassment can involve various behaviors from street harassment to sexual abuse, and rape. It can be generally considered a range of sexually explicit gestures, behaviors, and practices, from lecherous looks to rape, and is categorized under verbal, nonverbal, and physical harassment (Khodabakhshi-Koolaee et al. 2019). The rate of sexual harassment is high among both genders; however, girls are more harassed than boys (Vega-Gea et al. 2016). Evidence suggests that females are three times more likely than boys to experience sexual harassment. Moreover, children from poor families are 18 times more prone to be sexually abused than those from high-income families (Banducci et al. 2014).
Sexual harassment can adversely affect victims’ mental health and cause them depression, anxiety, and aggression (Carey et al., 2018). Individuals who are sexually harassed or abused in childhood are more prone to be the victim of sexual harassment or commit this behavior against others in adulthood. Child sexual harassment by a family member or close relative can lead to more severe and prolonged mental health problems (Radell et al. 2021; Dworkin et al. 2017). Traumatic childhood experiences, especially sexual harassment, are among the major factors causing anxiety disorders. There is a high correlation between child sexual harassment and anxiety symptoms, including Post-Traumatic Stress Disorder (PTSD). Studies outlined a high prevalence of aggression among children with a history of sexual harassment (Nemeroff 2016; Boroughs et al. 2015). A study conducted in the US on individuals with a history of suicide or physical violence against others demonstrated that 18% of them had been sexually harassed in childhood (Harford et al. 2014). Sexual harassment may also lead to stress, mood, anxiety, and bipolar disorders (Post et al. 2015). 
Emotion-Focused Therapy (EFT) is a new humanistic and experimental therapy that emphasizes the important role of emotions and emotional communication in organizing communication patterns (Shahar 2020). This intervention is a combination of empathy and positive acceptance techniques from client-centered therapy, and the techniques of focus on the “moment-by-moment experiencing” and “empty chair”, from Gestalt therapy (Timulak et al. 2018). Carryer and Greenberg (2010) reported that EFT could significantly reduce the symptoms of depression and trauma. Both individual and group EFT can effectively improve Major Depressive Disorder (MDD), quality of life, PTSD, and adaptive functions. Numerous studies have emphasized the major role of groups in psychotherapy; they suggested that groups can improve adaptation skills by providing an opportunity for the members to support one another and participate in a larger social network (Mohammadi et al. 2020; Victoria Cerezo et al. 2014). According to its unique features in emotion regulation as well as the promotion of environmental and psychosocial adaptation, EFT can be an effective intervention for reducing psychological distress in the victims of sexual harassment (Flecha et al. 2020).
The existential approach to psychology addresses deep and central issues, such as loneliness, meaninglessness, death, and freedom for all individuals regardless of their culture, religion, ethnicity, and race (Heidenreich et al.2021; Chabok et al. 2017). Emphasizing important concepts, such as responsibility, presence in existence, freedom, choice, search for meaning, and self-knowledge, existential psychotherapy offers a unique approach to treat existential anxiety (Feizi et al. 2019). This approach encourages the clients to face some aspects of their lives they have always escaped from. Instead, they are encouraged to bravely recognize unfortunate events to believe that they can achieve happiness and vitality when accepting that these are not ever-lasting issues in life (Yılmaz et al. 2019). Existential Group Therapy (EGT) facilitates working on existential issues and the process of searching for value and meaning in life. It is critical to review the sexual records of individuals. This is because sexual behaviors are an essential part of psychological life and can affect individuals’ mental health (Bahmani et al. 2015). Those with a history of sexual harassment seriously need to be examined and receive effective psychological interventions. If the psychological effects of sexual harassment on the health status of individuals remain untreated, they can cause other mental problems and trap individuals in a vicious cycle (Brown et al. 2019). 
Existential therapy can also help the victims of sexual harassment to reduce their feelings of loneliness and helplessness by finding new meanings in life and coping with their unpleasant experiences (Yılmaz et al. 2019). Most victims of sexual harassment have a sense of loneliness and guilt as they assume themselves to be the only ones who have experienced an unfortunate event; they usually do not discuss it with other due to a sense of shame or fear of its consequences. Group therapy provides them the opportunity to improve their mental health in a supportive group of people with the same problem. Accordingly, this study aimed to compare the effects of group EFT and EGT on depression, anxiety, and stress in the victims of child sexual harassment.

2. Materials and Methods
This was a quasi-experimental study with pre-test-post-test and a control group design. The research population consisted of all men and women with a history of child sexual harassment referring to the counseling and psychological service centers of Isfahan City, Iran, in 2019 and 2020. The sample size included 45 subjects, i.e., determined by G*power software. The study subjects were selected by convenience sampling method. The inclusion criteria of the study included a history of child sexual harassment based on the clinical interviews, providing informed consent forms for participation in the study, being 20-30 years old, not taking psychiatric drugs and non-affliction with psychiatric disorders or acute physical illnesses that could interfere with the research process. The exclusion criteria were undergoing any other interventions, absence from >2 therapy sessions, affliction with a disease that could disrupt the treatment process, and unwillingness to continue the study. The study subjects were randomly assigned into two experimental groups (EFT & EGT) and a control group (n=15/group). The research instrument included the following:
Depression Anxiety Stress Scales (DASS-42): This self-report, 42-item scale was developed by Lovibond in 1995 to measure depression, anxiety, and stress (14 items per construct) over the past week. All items are scored on a 4-point Likert-type scale, ranging from 0 to 3. The minimum and maximum scores obtained for each subscale (depression, anxiety, & stress) are 0 and 42, respectively. A higher score indicates a higher level of depression, anxiety, and stress. Although this scale can diagnose and screen these symptoms among adolescents, it is better to be used for individuals over the age of 15 years. Afzali et al. (2007) reported the reliability of the depression, anxiety, and stress subscales to be 0.94, 0.85, and 0.87, respectively, based on Cronbach’s alpha coefficient. In the present study, Cronbach’s alpha coefficient for depression, anxiety, and stress subscales were measured as 0.88, 0.82, and 0.90, respectively.
The first intervention program consisted of nine 90-minute sessions of EFT (Watson, Goldman & Greenberg 2007), and the second intervention program consisted of eight 90-minute sessions of EGT (Tantam & van Deurzen, 2019). The intervention programs in the experimental groups were conducted by the first author. Due to the COVID-19 pandemic, treatment sessions were held online using educational slides. The dependent variables were assessed after the interventions and 3 months later. Furthermore, all study subjects attended the sessions and no attrition was observed. Tables 1 and 2 present a summary of the therapy sessions. 
The obtained data were analyzed by descriptive and inferential statistics, such as mean, standard deviation, and repeated-measures Analysis of Variance (ANOVA) in SPSS.

3. Results
The Mean±SD age of the control, EFT, and EGT groups were 25.46±3.65, 25.26±4.12, and 25.53±4.72 years, respectively. The collected data suggested that 75.60% of the research subjects were female and 24.40% of them were male. The demographic variables of the research subjects are presented in Table 3.

Table 4 lists the Mean±SD scores of the research variables in the experimental and control groups in the pre-test, post-test, and follow-up phases. Based on the results presented in Table 4, the mean post-test and follow-up scores of depression, anxiety, and stress have reduced, compared to the pre-test in the intervention groups.

As per Table 5, there was a significant difference between the pre-test, post-test, and follow-up phases as well as the time×group interaction in the mean scores of depression, anxiety, and stress (P<0.01).

Based on Table 6, the intragroup effect of time (F-value) was equal to 46.11 for depression, 37.86 for anxiety, and 70.16 for stress; this corroborated the significant difference between the pre-test, post-test, and follow-up measurements (P<0.01).

Considering the time×group interactive effects measured by F-value (10.46 for depression, 14.89 for anxiety, & 26.89 for stress) and the group effects measured by F-value (3.26 for depression, 3.45 for anxiety, & 5.99 for stress), there was a significant difference between the mean scores of EFT, EGT, and control groups (P<0.05).
The results of the LSD test for the pairwise comparison of mean scores signified a significant difference between the control and EGT groups in the mean score of depression (P<0.05); however, there was no significant difference between the control and EFT groups or between the EFT and EGT groups in this regard. The relevant results also indicated a significant difference between the control group and both experimental groups in the mean score of anxiety (P<0.05); however, no such difference was observed between the intervention groups. Finally, there was a significant difference between the control and EFT groups, also between the EFT and EGT groups in the mean score of stress (P<0.05). However, there was no significant difference between the control and EGT in this regard (Table 7).

4. Discussion 
The present study determined the effects of EFGT and EGT on depression, anxiety, and stress in the victims of child sexual harassment in Isfahan City, Iran. The study findings revealed a significant difference in the mean scores between the study groups. The results also indicated that EGT was more effective than EFGT in reducing depression symptoms. Additionally, both interventions effectively reduced anxiety symptoms in the research subjects. The obtained data also indicated that EFGT was significantly more effective than the EGT in reducing stress symptoms in the victims of child sexual harassment. Timulak et al. (2018) stated that EFT was effective in treating generalized anxiety disorder in the clients referring to a primary care psychology/counseling service. Greenberg (2017) reported that EFT reduces depression in patients by implementing specific therapeutic techniques.
Major elements of sexual harassment are illegal action and force; as the force deprives the other party of his/her will and makes his/her a victim and a worthless tool, instead of a sexual partner (Heidenreich et al. 2021). Children or adolescents who are sexually harassed may experience various mood-anxiety disorders or family problems. Moreover, the fear of disgrace or disclosure of the event (sexual harassment) makes the victims more and more dependent on their family or trusted relatives; this can cause numerous social problems for victims. Existential therapists argue that this intervention enables individuals to be honest with themselves, expand their view of themselves and the world, and clarify what can make their lives meaningful. 
When clients realize that they have not had a fully developed personality in their lives and how they should actualize their potentials, set and pursue their objectives in life, and identify their criteria and values, they can find a new style for their lives to be an informed subject who can responsibly make decisions (Heidenreich et al. 2021). 
It seems that the victims of sexual harassment can control their negative emotions and thoughts if they learn to be responsible for their decisions, accept the anxiety caused by changes, and cope with unchangeable or unavoidable matters (Feizi et al. 2019). In other words, the originality of existence in groups is a view that involves finding choices to give meaning to life. This process enables individuals to understand they can be the author of their lives, instead of remaining a passive victim of conditions (Schippers & Ziegler 2019). Finally, the group allows individuals to review their values and compare them with others (Cowan et al. 2020). Realizing that they are not the only victims of sexual harassment, individuals in a group can increase their self-esteem and have a sense of usefulness. This is because they can share their experiences with others to overcome problems. The above-mentioned data can help us to justify the effectiveness of EGT in reducing depression and anxiety symptoms among the victims of sexual harassment.
EFGT is based on a specific manner of communicating with clients, as a prerequisite for practical treatment. This situation can be described in different ways; e.g., the therapist helps the client to combine “being” with “doing”, something similar to the difference between “following” and “directing” the client. The therapist follows the ever-changing inner experience of the client; this does not mean the mechanical interpretation of the client’s words. It rather refers to the therapist’s attempts to maintain an empathetic connection with the client’s internal experience and examine their understanding of that experience (Duriez 2021). Furthermore, the therapist attempts to actively lead the therapy; this does not mean at all that therapist makes a lecture, advises, and controls the clients or attempts to solve the problems and clarify the clients. The main objectives of EFGT are to create and enhance adaptive early emotions and change the abnormalities to help the clients to manage their emotions, develop empathy, and choose more adaptive emotional responses; a process, i.e., disrupted in the victims of sexual harassment because of their frustrating experiences (Shahar 2020). It seems that this method can reduce anxiety and stress because it helps clients to face the current conditions of their lives and review the unpleasant memories that lead to sadness, anger, and stress to take a more responsible role in the face of events, be able to change the changeable conditions and situations, and accept unchangeable conditions without suffering (Timulak et al. 2020). Similar to behavioral aspects, the cognitive aspect of emotion-focused techniques aims to manage emotions to increase psychological adjustment and adaptation (Soltani et al. 2014). Thus, one’s awareness of the present helps one to find a new manner to understand and respond to all the inner feelings and recognize all their emotions, thoughts, and experiences. This can justify the effectiveness of EFGT in reducing anxiety and stress.
This study was conducted on the victims of child sexual harassment; therefore, the obtained findings should be cautiously generalized to other groups, such as adult female victims of sexual rape and violence or those encountering other psychological disorders. Moreover, due to time constraints, it was impossible to conduct a second follow-up test to measure the long-term stability of the results.

5. Conclusion
 The present study findings indicated the effectiveness of EFGT and EGT in reducing depression, anxiety, and stress among the victims of sexual harassment. Thus, psychologists and psychiatric nurses are recommended to hold courses and workshops based on these therapies to improve psychological wellbeing and the negative consequences of sexual harassment, such as anxiety, stress, and depression.

Ethical Considerations
Compliance with ethical guidelines

The study was approved by the Ethics Committee of Islamic Azad University- Shahrekord Branch (Code: IR.IAU.SHK.REC.1400.012). Informed written consent was signed by all the participants before the study.

The article was extracted from the PhD, dissertation of Behrad Zadafshar at the Department of Psychology, Shahrekord Branch, Islamic Azad University, Shahrekord, Iran.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflicts of interest.

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Type of Study: Research | Subject: General
Received: 2021/05/20 | Accepted: 2021/07/10 | Published: 2021/08/1

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