The best route to resolving complicated grief: Emotional sequences amplified by arousal

Abstract

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This study investigated emotional processes associated with change in brief emotion-focused therapy for complicated grief delivered via videoconference. We focused on emotional arousal, depth of experiencing, and the frequency with which clients first accessed primary maladaptive emotions and subsequently processed grief, a process known as the emotional transformation sequence. We also examined whether depth of experiencing and arousal during the central and final session segments moderated the effects of these sequences on therapeutic outcomes. Twenty-six clients meeting criteria for complicated grief received three emotion-focused therapy sessions. The second session, which included empty-chair work for unfinished business, was coded using the Classification of Affective Meaning States, the Client Experiencing Scale, and the Client Emotional Arousal Scale–III. Outcomes were assessed pretreatment, posttreatment, and at 2-month follow-up, including complicated grief, emotional well-being, and depressive symptoms. Depth of experiencing predicted reductions in depressive symptoms at follow-up. Emotional transformation sequences predicted improvements in well-being and depressive symptoms at follow-up. The importance of emotional transformation sequences as a mechanism of change is further supported by the finding that good-outcome cases showed more sequences than poor-outcome cases, despite similar levels of depth of experiencing and arousal. Emotional arousal further amplified the effect of transformation sequences on depressive symptoms, emotional well-being, and complicated grief, explaining an additional 30% of variance in grief outcomes at follow-up. These findings indicate that emotional transformation sequences during empty-chair work, particularly when accompanied by sufficient arousal, constitute a key mechanism of therapeutic change in brief emotion-focused therapy for complicated grief.