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The effectiveness of emotion-focused therapy on distress tolerance, fear of positive experience, and psychosomatic symptoms in individuals experiencing grief due to COVID-19
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Maryam Bahraminia    , Shahnaz Khaleghipour * , Fatemeh Soltani |
| Department of Clinical Psychology, Nae. C., Islamic Azad University, Naein, Iran , sh.khaleghipour@iau.ac.ir |
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| Keywords: cognitive therapy, emotion regulation, psychosomatic disorders, grief, COVID-19 |
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Full-Text [PDF 1698 kb]
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| Abstract (HTML) (166 Views)
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Type of Study: Original |
Subject:
Military Psychiatry
Received: 2024/11/22 | Revised: 2025/03/14 | Accepted: 2025/04/1 | Published: 2025/04/5
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Extended Abstract: (28 Views) |
Introduction
The COVID-19 pandemic has ushered in an unprecedented global health crisis, profoundly impacting not only physical health but also the mental and emotional well-being of people around the world [1]. Among the various psychological consequences that have arisen, grief and sorrow following the loss of loved ones have been especially pervasive. For many individuals, the experience of grief during this period has been extraordinarily challenging and complicated, often diverging significantly from the typical bereavement process [2]. This complexity stems from a combination of unique pandemic-related factors such as enforced quarantine, social distancing mandates, the disruption of traditional mourning rituals, limited access to social support networks, and the inability to say final goodbyes to hospitalized relatives [4].
These extraordinary circumstances have contributed to the increased prevalence of complicated grief, or prolonged grief disorder—a condition characterized by intense yearning for the deceased, emotional numbness, persistent preoccupation with the loss, and a marked difficulty in resuming normal daily activities. Unlike standard grief, which tends to diminish over time, complicated grief results in enduring psychological distress that significantly impairs an individual's functioning [3].
Complicated grief often coexists with a range of other psychological difficulties, including depression, anxiety, and post-traumatic stress disorder (PTSD). It is also frequently associated with psychosomatic symptoms such as chronic fatigue, headaches, gastrointestinal problems, and other physical complaints, underscoring the deep mind-body connection in emotional trauma responses [1]. In light of the multifaceted impact of grief aggravated by the pandemic's social and environmental conditions, there is a growing imperative to design, test, and implement effective, evidence-based psychological interventions. These interventions aim specifically to support individuals grieving the loss of close family members during these extraordinary and distressing times [4].
Emotion-Focused Therapy (EFT) is one such therapeutic approach that holds particular promise. Developed by Leslie Greenberg, EFT is a humanistic and experiential form of therapy centered on the pivotal role of emotions in psychological change [6]. It helps clients identify, access, and regulate difficult emotional experiences through targeted techniques such as empty-chair work, focusing, and emotion coaching. EFT is especially well suited to grief work because it facilitates the processing of unresolved emotional pain, promotes the construction of meaning around loss, and supports emotional reintegration. While EFT has demonstrated robust effectiveness in treating depression and trauma, its application specifically for grief-related distress and psychosomatic symptoms stemming from pandemic-related loss has been insufficiently explored. Thus, This study aimed to investigate the effectiveness of EFT on distress tolerance, fear of positive experience, and psychosomatic symptoms in individuals suffering bereavement related to COVID-19.
Methods
This study utilized a semi-experimental design with a pre-test/post-test control group to evaluate the impact of EFT on psychological outcomes in adults bereaved by COVID-19. The target population consisted of adults aged 25 to 55 years, residing in Tehran, who had lost a first-degree relative due to COVID-19 within the past year. After a rigorous eligibility screening to confirm clinical criteria for complicated grief, 20 participants (all female) were recruited via convenience sampling. These participants were then randomly assigned to either an experimental group receiving EFT or a control group on a waitlist, with 10 people in each group.
Inclusion criteria were: 1) participants had to meet clinical diagnostic criteria for complicated grief as determined by structured clinical interviews, 2) not be currently taking psychiatric medication or engaged in psychotherapy, and 3) provide informed consent to attend all treatment sessions. Those in the experimental group participated in ten weekly EFT sessions, each approximately 90 minutes long, carried out by a certified psychotherapist specialized in EFT. The intervention followed Greenberg’s EFT framework, incorporating essential components such as increasing emotional awareness, identifying and differentiating primary emotional experiences, resolving unfinished emotional conflicts through dialogue-based techniques like empty-chair work, and building emotional resilience [7].
During therapy, participants were encouraged to engage deeply with complex feelings including guilt, anger, sadness, and fear, while also reconnecting with positive memories and emotions associated with the deceased.
To evaluate the intervention’s effectiveness, data were collected using three validated instruments:
The Distress Tolerance Scale (DTS), measuring participants’ capacity to endure and regulate emotional discomfort [11];
A researcher-developed Fear of Positive Experience Questionnaire, assessing avoidance or anxiety related to experiencing positive emotions such as joy and satisfaction;
Lacourt’s Psychosomatic Symptoms Questionnaire, evaluating the frequency and severity of physical symptoms linked to unresolved emotional distress [29].
Data analysis was performed using SPSS software. Descriptive statistics summarized demographic characteristics, and paired-sample t-tests compared pre-test and post-test scores within and between groups to assess the impact of EFT treatment on the psychological and somatic variables.
Results
The statistical analysis demonstrated notable improvements across all measured variables in the experimental group compared to the control group. Specifically, distress tolerance increased significantly. The experimental group’s DTS scores rose from a pre-test mean of 53.95 (SD = 4.28) to a post-test mean of 65.85 (SD = 3.90).
Concomitantly, scores on the fear of positive experiences questionnaire dropped substantially from 25.40 (SD = 3.12) before treatment to 17.35 (SD = 2.87) after.
In addition, the psychosomatic symptom scores decreased significantly, from a pre-test average of 69.85 (SD = 5.41) to a post-test mean of 58.35 (SD = 4.76).
Between-group comparisons confirmed the statistical significance of all these findings, with p-values less than 0.001 for distress tolerance, fear of positive emotions, and psychosomatic symptoms at post-test assessments.
Discussion and Conclusion
The results of this study support the hypothesis that EFT can substantially alleviate the psychological burden of grief and enhance both emotional and physical well-being among bereaved individuals. The improvement in distress tolerance suggests that participants developed a stronger capacity to endure painful emotions and regulate their intensity without resorting to maladaptive strategies such as emotional avoidance or suppression. This enhancement in emotional resilience is essential for adaptive coping and gradual recovery following the death of a loved one.
Moreover, the reduction in fear of positive emotions reveals EFT’s powerful role in helping individuals reintegrate positive affectivity into their emotional lives. This reintegration is crucial for recovery from bereavement, enabling individuals to experience joy, love, and satisfaction without accompanying guilt or anxiety. This finding aligns closely with existing grief literature that emphasizes emotional processing and the reinstitution of positive emotional experiences as vital components of adaptive mourning [18, 31-36].
The observed decline in psychosomatic symptoms further underscores the importance of addressing grief’s somatic dimension. Emotional pain that remains unprocessed frequently manifests as physical complaints, creating a vicious cycle of distress that can exacerbate suffering. By focusing on core emotional wounds, EFT effectively alleviated both psychological and somatic symptoms, illustrating the intimate connection between mind and body in grief recovery [37].
These findings bear significant implications for clinical practice, especially in the context of large-scale traumatic events like the COVID-19 pandemic, which disrupt traditional mourning rituals and amplify isolation. EFT provides a structured yet flexible experiential framework that can be effectively applied to facilitate emotional healing in bereaved individuals. Such interventions are crucial for mitigating the prolonged suffering often seen in complicated grief and for fostering a pathway toward psychological and physical restoration.
Ethical Considerations
This research adhered strictly to ethical standards governing psychological research. Participants were informed thoroughly about their rights and the nature of the study and provided written informed consent before participation. Confidentiality and anonymity of personal information were rigorously maintained throughout the study. Approval for the research protocol was granted by the Ethics Committee of Islamic Azad University, Isfahan (Khorasgan) Branch, under the ethical code IR.IAU.KHUISF.REC.1402.022.
Funding
There is no funding support.
Authors’ Contribution
Authors contributed equally to the conceptualization and writing of the article. All of the authors approved the content of the manuscript and agreed on all aspects of the work.
Conflict of Interest
Authors declared no conflict of interest.
Acknowledgments
We would like to express our sincere appreciation to all participants in the study and the research team for their collaboration and support throughout the project.
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Ethics code: IR.IAU.KHUISF.REC.1402.022
Bahraminia M, Khaleghipour S, Soltani F. The effectiveness of emotion-focused therapy on distress tolerance, fear of positive experience, and psychosomatic symptoms in individuals experiencing grief due to COVID-19. EBNESINA 2025; 27 (1) :23-35 URL: http://ebnesina.ajaums.ac.ir/article-1-1375-en.html
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