Journal of Psychiatric and Mental Health Nursing, 2015, 22, 379–389
Narrative therapy with an emotional approach for people with depression: Improved symptom and cognitive-emotional outcomes M . S E O 1 Ph D S. M. CHAE4
RN,
H. S. KANG2
Ph D
Ph D
RN,
Y. J . L E E 3
Ph D
RN
&
RN
1
Associate Professor, Department of Counseling, Dankook University, Seoul, 2Professor, Red Cross College of Nursing, Chung-Ang University, 4Associate Professor, College of Nursing, Seoul National University, Seoul, and 3 Assistant Professor, Department of Nursing, Daegu Health College, Daegu, Korea
Keywords: depression, emotional
Accessible summary
approach, hope, narrative therapy, self-awareness
•
Correspondence: M. Seo Counseling Dankook University
•
126 Jukjeon-dong, Kyounggi-do Yongin City Korea
•
E-mail: [email protected] Accepted for publication: 5 January 2015 doi: 10.1111/jpm.12200
Narrative therapy is a useful approach in the treatment of depression that allows that person to ‘re-author’ his/her life stories by focusing on positive interpretations, and such focus on positive emotions is a crucial component of treatment for depression. This paper evaluates narrative therapy with an emotional approach (NTEA) as a therapeutic modality that could be used by nurses for persons with depression. A nurse-administered NTEA intervention for people with depression appears effective in increasing cognitive-emotional outcomes, such as hope, positive emotions and decreasing symptoms of depression. Thus, NTEA can be a useful nursing intervention strategy for people with depression.
Abstract Narrative therapy, which allows a person to ‘re-author’ his/her life stories by focusing on positive interpretations, and emotion-focused therapy, which enables the person to realize his/her emotions, are useful approaches in the treatment of depression. Narrative therapy with an emotional approach (NTEA) aims to create new positive life narratives that focus on alternative stories instead of negative stories. The purpose of this study was to evaluate the effects of the NTEA programme on people with depression utilizing a quasi-experimental design. A total of 50 patients (experimental 24, control 26) participated in the study. The experimental group completed eight sessions of the NTEA programme. The effects of the programme were measured using a self-awareness scale, the Nowotny Hope Scale, the Positive Affect and Negative Affect Scale, and the Center for Epidemiological Studies-Depression Scale. The two groups were homogeneous. There were significant differences in hope, positive and negative emotions, and depression between the experimental and control group. The results established that NTEA can be a useful nursing intervention strategy for people with depression by focusing on positive experiences and by helping depressed patients develop a positive identity through authoring affirmative life stories.
Introduction People with depression may experience negative interpretations of their lives and of themselves, and decreased © 2015 John Wiley & Sons Ltd
interest in participating in their usual activities. They might exhibit bleak, pessimistic views of the future and discouraged future-directed thinking, anxiety about upcoming events, and inability to look forward to future positive 379
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events (Feeser et al. 2013). Their negative thoughts reinforce dysfunctional beliefs, thereby consolidating the emotion of depression. Depressogenic schemata in Beck’s cognitive theory of depression provides access to a complex system of negative themes and cognitions that contribute to the onset of a pattern of negative self-referent information processing characterized by systematic errors in thinking (Abela & D’Alessandro 2002). Engaging in such cognitive processing increases the likelihood that individuals will develop a negative cognitive triad, such as a negative view of the self, negative awareness of the world and negative perceptions of the future. The negative cognitive triad is a sufficient cause of depression and is responsible for the onset of depressive symptoms (Beck 1967). The abundance of these negative stories leads people with depression to overly identify with problematic life narratives (White & Epston 1990), from which they need to be separated. In the modern biomedical model, a therapist is an expert with special knowledge that allows him/ her to observe, assess, diagnose and treat (Weingarten 1998). However, when the patient with depression needs to possess a positive outlook on himself/herself and the world around him/her, it is desirable to put the patient at the centre of the narrative. That is, the patient should become the narrator rather than the listener. Postmodernism relies on the notion that the outcome of one’s own experience will necessarily be relative, rather than certain and universal. Postmodernism is a shared state of mind for individuals to interpret according to their own personal inclination. It assumes that there is no single truth that must be favoured, according to one scale or another. Instead of finding the truth, it sees what is in front of our eyes, is enthralled by it, and interprets it in one way or another. Instead of standard moral judgement, postmodernism suggests the individual consideration of each specific occurrence and seeks a departure from rigid patterns for a place of subjectivity and collapsed boundaries (Weinblatt & Avrech-Bar 2001). According to the postmodern theorist Foucault, power and knowledge cannot be separated from each other (Glazer 2004). In Foucault’s theory, discourse functions as knowledge, which is constructed by an author, or narrator. The author of a narrative produces and controls the discursive field. The equivalence of power (of a narrative author) and knowledge (that a narrative contains) is secured in this way. Foucault’s notion of power/knowledge can help us understand the relationship between the narrative author and the act of narration. Traditionally, the therapist is the powerful author who controls the patients. In particular, psychoanalysts see the patient in a clinical problematic context as sick, suffering and inferior, rather than seeing the patient’s point of view as a person like himself or herself (Van Wyk 380
2008). Therefore, when a patient’s expression of lived experience becomes a therapeutic concern to the nurse, the roles of the therapist as a talker and the patient as a listener are reversed. The patient comes to have the authoritative power as narrator. Narrative therapy is based on the postmodernist view of clients as having the power to create new meaning and to overcome a medical model that sees disabled people as the problem through retelling stories that contribute to their problems. It involves ways of re-authoring the stories of people’s lives, which are considered pivotal to an understanding of the individual (White & Epston 1990, Morgan 2000). All people, including persons with depression, create meaning through their narratives. Dominant stories tend to prevent the infiltration of alternative experiences, hopes and capabilities. It is the aim of narrative therapy to liberate and empower individuals to break free from the dominant problem-centred story and separate their identity from the problem (Freeman et al. 1997). Narrative therapists take the role of supporting patients in order to help them find positive identities. They begin with the premise that the problem is not the person, but is the problem itself. Thus, the problem should be separated from the client (White & Epston 1990). In this context, people with depression dissemble their negative stories and attempt to live their lives according to what they see as their strengths (Drewery & Winslade 1997). Narrative therapists listen to the negative stories of people with depression and search for unique outcomes and experiences in which patients successfully solved problems in the past. Through the therapy process, the narrative therapist helps people with depression to ‘re-author’ their stories by focusing on positive interpretations. This can help patients develop alternative, more positive life narratives. Thus, narrative therapy can be a useful approach in the treatment of depression. Emotional approach is a crucial component of treatment for people with depression. As a part of therapy sessions, these interventions can decrease patients’ depressive moods because emotion is a central force in maintaining old patterns and learning new, more adaptive ones (Magnavita 2006). More emotionally intense therapeutic approaches might facilitate more active learning and lead to new selfrepresentations (Grigsby & Stevens 2000). The dominant emotions of people with depression are sadness, anxiety, helplessness, horror and fear (Davidson 2000). These negative emotions seriously affect one’s mental health and psychological resilience (Cohn et al. 2009). Negative emotions lead to negative thoughts and behaviours (Greenberg & Paivio 2008). Thus, the negative emotions of people with depression might lead to negative thoughts about the self and the world, as well as to isolation and avoidance of © 2015 John Wiley & Sons Ltd
Narrative therapy with emotional approach
social interactions. In consequence, stories of people with depression can be dominated by problems, and stories of the future are often negative stories with little hope. Hope provides the motivational power to overcome the harshness of life; it helps one make the necessary steps towards a better life. People with depression, however, might have decreased motivation to live in the present moment and to make a better future. At the same time, not only can hope motivate a positive change in the present, but positive emotions also buffer the deleterious effects of negative emotions (Cohn et al. 2009). Additionally, positive emotions serve to expand a person’s cognition. The more people have hope, the more they experience positive emotions and enjoy social interactions (Snyder 2002). Some people with depression may lack the ability to have positive emotions due to the symptoms of depression itself. In therapy for people with depression, it is necessary to intentionally find positivity through focusing on positive experiences, events and emotions. These positive experiences, events and emotions can form a basis for new life stories that focus on positivity instead of negativity. For this reason, the narrative therapy with an emotional approach (NTEA) programme, which is narrative therapy (White & Epston 1990) combined with skills of emotion-focused therapy (Johnson 2004), is provided for people with depression in this study in order to test its effectiveness. Narrative therapy has not been commonly used in nursing, although it has been widely used in the realms of counselling, family therapy and social work. Previous nursing studies on people with depression have focused on cognitive behaviour therapy (CBT) (Grey et al. 2000, Gellatly et al. 2007, Sudak 2012, Fiellin et al. 2013), a guided self-help programme based on computerized cognitive behavioural therapy (National Institute for Health and Clinical Excellence 2014), group cognitive therapy (Watt & Cappeliez 2000), problem-solving therapy (Alexopoulos et al. 2003, D’zurilla & Nezu 2007) and mindfulness therapy (Day & Horton-Deutsch 2004). However, no rigorous empirical support exists for narrative therapy (Vromans & Schweitzer 2011). Although CBT, which is problem-focused, is well known as an effective intervention for reducing symptoms, including depression, there exists a need for a more humanistic and holistic approach to clients (Sierpina et al. 2007) because it did not help create a comprehensive view of the self (Wampold 2012). Postmodern critiques of CBT address the importance of separating the problem from the person, valuing the meaning of individual’s experience, acknowledging that individuals are embedded within a social context and giving clients a central role as authors who construct stories (White & Epston 1990). © 2015 John Wiley & Sons Ltd
The NTEA, which reflects these views, has the potential to help clients and nurses as well. The client may benefit from externalizing him/herself to view himself/herself as separate from the problem. This can also give clients an opportunity to identify problem-dominant stories about their lives and to actively engage in the creation of selfenabling stories about their lives. This latter kind of story can help patients deal with their problems. This approach helps nurses view people with depression in a holistic way so that nurses do not equate patients with their problems nor blame them for those problems (Bacon 2007). This method can also help nurses understand each individual’s unique lived experience and its meaning by giving them the opportunity to listen to their patients’ life stories. By utilizing NTEA, nurses can help people with depression separate negative thoughts and emotions from themselves, change their self-perceptions and their problems, and explore alternative stories that connect to future options (White & Epston 1990). This new self-recognition could help patients have hope for the future.
Purpose of the study The purpose of the study was to identify the effects of NTEA on self-awareness, hope, positive emotion, negative emotion and depression in people with depression.
Hypothesis The hypothesis is that the intervention group will have significantly higher scores of self-awareness, hope and positive emotion and lower scores of negative emotion, and depression than those of the control group following eight sessions of the NTEA programme.
Intervention programme The NTEA programme consisted of a total of eight sessions (Table 1) based on White and Epston’s narrative therapy (1990) and Johnson’s emotion-focused therapy (2004). White (2007) proposed steps to deconstruct problems, promote externalization, dissemble unique outcomes, construct alternative stories and culminate in a definitional ceremony with new position statements. Through these steps, patients can have new perspectives of life and of themselves rather than focusing on their problems. During the narrative therapy programme, emotion-focused therapy was used as an additional technique to help people with depression express themselves well; they would realize their inherent inner emotions when they told their stories, and this experience helped them express their emotions better. Johnson’s (2004) emotion-focused therapy skills, 381
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Table 1 Intervention programme Session
Subjects
Goals
Programme contents
Emotional approach
1
Orientation for programme
Understanding the programme
Careful listening, validation
2
Deconstruction of the problems
To have better understanding of the problem
3
Externalization of the problems
To separate person and problem
4
Exploring unique outcomes
To have positive identity
5
Construction of an alternative story
To have alternative stories
6
Building new story
To recognize storylines in lives
7
Definitional ceremony
To reinforce positive identity
8
New position statement and closing
To take root unique outcome and summarization
To have rapport with participants To introduce each other To express each participant’s expectancy To explain goals and programme contents of each session To identify problems in experience-near To explore consequences of the problem To explore influence of the problem To produce evidence of the evaluation To give a name to the problem To make the naming problems with clay To see the difference when problems separate from self To feel true self without problems To recall the time when they were not overwhelmed by problems To talk about stories without problems To know the differences between stories with problems and without problems To find out their original identity To have participants know their intentional state To know the value in alternative stories To give meaning to the alternative story To tell their goals, dreams and vision To think about precious things in their life To have rich positive stories To present new stories to members as a witness To validate the participants’ new story To retell group members’ thoughts To reinforce the participants’ value of life To tell the influence of a unique outcome To tell changes of life before and after the programme To tell changes of their stories before and after the programme To share feelings and thoughts about the programme
such as empathic response, validation, reflection, evocation, reframing and restructuring, were used during all sessions. Sessions 1 and 2 included introductions, a discussion regarding the aims of the programme, and a discussion aimed at the development of a therapeutic relationship. Participants’ dominant negative stories, the influence of recent problems on their lives and the reasons for the negative evaluation of problems were stated and explored. Sessions 3 and 4 focused on externalizing depression by separating the depression from the person. Depression was regarded as a problem to be separated from the self rather than a pathology that needed to be removed. Depression was externalized. In order to have a positive identity, participants explored unique outcomes. The emotional approach, which calls for validation, reflection, reframing 382
Empathic response, validation
Validation, reflection
Evocation, reframing
Validation, empathy, reframing, heightening Validation
Validation, reflection
Validation, reflection
and evocative questioning, was used in the process of expression to reshift focus to positive feelings and thoughts. Sessions 5 and 6 focused on constructing alternative stories that were contrasted with the problem stories. Participants were encouraged to explore the personal meaning of past events, which were related to depression, preferred ways of living and hope. The therapist validated and heightened the patients’ positive identities. Sessions 7 and 8 comprised a definitional ceremony and a new position statement. Participants presented and shared their new positive stories in the definitional ceremony within the people-with-depression community. Participants resolved to live a new life once again and were also affirmed in their excitement about their new lives. The differences in their lives before and after the programme were shared in the group. © 2015 John Wiley & Sons Ltd
Narrative therapy with emotional approach
Approved community mental health centres A/B/C/D
Methods Study design and data collection
Drawing lots
This study was a quasi-experimental design with two randomized study groups using a pre- and post-test design. Practicability and feasibility are the strengths of a quasiexperimental study (Polit & Hungler 1999). Prior to the study, a letter explaining the purpose of the study and selection criteria of the study population was sent to the directors of 15 community mental health centres in Seoul, Korea. Four community mental health centres in South Korea took part in the study. The centres were similar in size, number of users and programme offerings. In Korea, all community mental health centres offer similar programmes. In this case, the four centres provide similar rehabilitation programmes, such as social skills training to improve social performance and reduce social situation-associated stress (Pilling et al. 2002), art therapy to experience rather than verbalize feelings and to produce tangible evidence of the emotional progress (Withrow 2004), and education on medication. Two centres were randomly picked and assigned to the experimental group, and two additional centres were assigned to the control group. All study participants received medical treatment regularly and took antidepressants. The research team visited each institution, and explained the purpose and the process of the research to the potential subjects/patients. Written consent was received from those who wished to participate in the programme. The selection criteria for participants were the following: (1) adults from ages 18–65, (2) have been diagnosed with depression and (3) have scored over 25 points on the Mini Mental State Examination (MMSE; Yeo et al. 1998). The MMSE was conducted to check if the candidates had any isolated cognitive impairment. A total of 51 participants, 25 in the experimental group and 26 in the control group, agreed to participate in the study. To minimize intentional or unconscious bias, data were collected by one member of our research team who is not an NTEA therapist. The data collector was blinded to the control and experimental condition. A pretest was conducted 1 week prior to the first NTEA session. A post-test was performed 1 week after the completion of the final NTEA session, and it took approximately 20 min. Data were collected from 4 September 2011 to 30 October 2011. NTEA was held for the same period at two community mental health centres, which were included as the experimental group. Each session ran for 90 min, with two sessions per week during the 4 weeks. The NTEA was conducted by the primary investigator of this research, who is a practitioner of NTEA as well as a professor of family © 2015 John Wiley & Sons Ltd
Control group B and C
Experimental group A and D Selection criteria Adults in ages 18–65 Diagnosed with depression Scored more than 25 in MMSE Signed the agreement
n = 24 Pretest (4 September 2011) Provide NTEA Post-test (30 October 2011)
n = 26 Pretest (4 September 2011) No NTEA provided Post-test (30 October 2011)
Data analysis
Figure 1 Process of data collection
counselling. One participant from the experimental group dropped out of the programme, however, to accept a new job. Finally, a total of 50 people with depression, 24 individuals in the experimental group and 26 in the control group, completed the programme. These 50 participants met the requirements for the sufficient sample size by power 0.95, effect size 0.5, and P-value 0.05 of the G-power programme. Figure 1 shows the process of data collection. The most important part of this experiment is the equivalency of the experimental group and the control group. To ensure the homogeneity of both groups, and to clarify that the effects of the experiment were not caused by the intervention of additional variables, but by NTEA, we verified that patients in both groups had similar durations and severity of depression. They have also participated in similar programmes, such as social skill training, art therapy and medication group at institutions. Importantly, we made sure that both groups had taken similar medication in order to clarify that the effects of the experiment were not caused by medications taken at any point. In other words, both the experimental group and the control group had chronic depression and had taken the lowest dose of antidepressants once or twice a day for over 10 years. During the experiment, there was no change to the medication dose caused by symptom relapse. Every patient received case management to ensure that he/she regularly took his/her medication.
Instruments Self-awareness Self-awareness was measured using the Korean version of the rating of self and other scales, originally developed by 383
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Lee et al. (2001), with the authors’ permission. This measure is composed of a total of 10 positive selfawareness questions, such as ‘I am more reliable than others’ or ‘I am a more warm-hearted person than others’; and 10 negative self-recognitions, such as ‘I am a cooler person than others’ or ‘I am more selfish than others’. A 5-point Likert scale, ranging from 1 (not at all) to 5 (always), was used. The total score was in the range of 20–100, with higher scores representing a greater positive self-recognition. Cronbach’s alpha was 0.75 in the original study (Lee et al. 2001) but 0.68 in the current study. Hope Hope was measured using the Korean version of Nowotny Hope Scale, originally developed by Nowotny (1989), which was translated by Choi (1990). The questionnaire is composed of 29 items and consists of six subscales: confidence, possibility of a future, relates to others, spiritual beliefs, comes from within and active involvement. A 4-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree), was used. The total score was in the range of 29–116, with higher scores representing higher hope. Cronbach’s alpha was 0.90 in the original study (Nowotny 1989) and 0.93 in the current study. Positive and negative emotions Positive and negative emotions were measured using the Korean version of the Positive Affect and Negative Affect Scale, originally developed by Watson et al. (1988), which was translated by Lee et al. (2003). This scale is composed of a total of 10 positive adjectives, such as ‘passionate’ and ‘vitality’, and 10 negative adjectives, such as ‘painful’ and ‘aghast’, representing emotions. Each item is rated on a 5-point scale ranging from 1 (very slightly or not at all) to 5 (extremely) in order to indicate the extent to which the respondent has felt this way in the indicated time frame. The total score was in the range of 10–50 in each positive and negative emotion, where higher scores represented higher positive and negative emotions. The Cronbach’s alphas of the positive emotion and negative emotion were 0.88 and 0.87, respectively, in the original study (Watson et al. 1988), and were 0.73 and 0.73, respectively, in the current study. Depression Depression was measured using the Korean version of the Center for Epidemiological Studies-Depression Scale (CESD). This scale was originally developed by Radloff (1977) and was subsequently translated by Cho & Kim (1993). It has been shown that the CES-D scale is a valid instrument that can be useful for assessing depression in clinical settings and for the screening of depressive disorders in the 384
context of epidemiological studies (Morin et al. 2011, Ruiz-Grosso et al. 2012). It was used to measure degree of depressive symptoms in this study. The questionnaire is composed of 20 items, and each item is rated on a 4-point Likert scale, ranging from 0 (not at all) to 3 (always). The total score was in the range of 0–60, where higher scores represented more depressive symptoms. A score of 16 or higher was used as the cut-off point for higher depressive symptoms (Radloff 1977). Cronbach’s alpha was 0.87 in the original study and 0.90 for the current study.
Ethical consideration Members were assured that their participation was voluntary and anonymous. All participants received a small gift, equivalent to $10, upon completion of the programme. While NTEA was ongoing in the experimental group, the control group was going through their regular programme, such as physical exercise and ceramics programme, at their community mental health centres. With ethical consideration, the NTEA was provided to the control group after the completion of the experiment. The Ethical Committee of the Dankook University Hospital (DKUH-IRB-2011-100371) approved the study.
Data analysis Data were analysed using SPSS-PC (version 18.0 for Windows; SPSS, Chicago, IL, USA). χ2 test and t-test were used to test the homogeneity of demographic characteristics and dependent variables between the experimental and control groups. Shapiro–Wilk test was used to test the normal distribution of variables. For testing the differences between the experimental and control groups after the experiment, one-way analysis of the covariance (ANCOVA) test was conducted using the pretest scores of all the variables as the covariants. A covariate analysis was performed in order to eliminate systemic error outside the control of the researcher due to the non-random sampling method. Cronbach’s alpha coefficient was used to determine the reliability of instruments. All statistical tests were two-sided, and a P-value of less than 0.05 was considered statistically significant.
Results General characteristics and homogeneity The demographic characteristics and homogeneity of the experimental and control groups prior to the experiment are presented in Table 2. Among the participants, there © 2015 John Wiley & Sons Ltd
Narrative therapy with emotional approach
Table 2 General characteristic and homogeneity test (n = 50)
Characteristics Gender Male Female Education level Above high school graduate Below high school graduate Employment1 Unemployed Employed Martial statues Married Unmarried Age Disease duration Medication period
Total (n = 50) n (%) Mean ± SD
ExP. (n = 24) n (%) Mean ± SD
Cont. (n = 26) n (%) Mean ± SD
χ2
t
P
23 (46.0) 27 (54.0)
8 (16.0) 16 (32.0)
15 (30.0) 11 (22.0)
2.98
0.098
23 (46.0) 27 (54.0)
9 (18.0) 15 (30.0)
14 (28.0) 12 (24.0)
0.15
0.763
44 (88.0) 6 (12.0)
23 (46.0) 1 (2.0)
21 (42.0) 5 (10.0)
2.68
0.192
2.07
0.211
14 (28.0) 36 (72.0) 43.14 ± 9.76 12.26 ± 8.83 12.66 ± 10.56
9 (18.0) 15 (30.0) 43.92 ± 10.09 10.13 ± 9.21 10.13 ± 9.41
5 (10.0) 21 (42.0) 42.42 ± 9.58 14.23 ± 8.15 15.00 ± 11.20
0.54 −1.67 −1.66
0.594 0.101 0.104
Cont, control group; ExP, experimental group; SD, standard deviation. 1 An exact test was done on this chi-square with one person in the cell, and it was 0.99.
were 23 (46.0%) males and 27 (54.0%) females. The average age of the participants was 43.14 [standard deviation (SD) = 9.76] years. In terms of education level, 23 (46.0%) had an education higher than high school, and 27 (54.0%) had a below-high school education. Of the participants, 44 (88.0%) were employed and 6 (12.0%) were unemployed. Those married totalled 14 (28.0%), and there were 36 (72.0%) unmarried participants. The mean disease duration was 10.13 (SD = 9.21) years and 14.23 (SD = 8.15) years, for the experimental and control groups, respectively; the medication period was 10.13 (SD = 9.41) years and 15.0 (SD = 11.20) years, respectively. There were no significant differences in demographic characteristics between the experimental and control groups, such as gender (χ2 = 2.98, P = 0.098), age (t = 0.54, P = 0.594), education level (χ2 = 0.15, P = 0.763), employment (χ2 = 2.68, P = 0.192), marital status (χ2 = 2.07, P = 0.211), disease duration (t = −1.67, P = 0.101) and medication period (t = −1.66, P = 0.104).
Homogeneity of the groups regarding the test variables Table 3 indicates that prior to the experiment; there were no significant differences between the experimental group and the control group with respect to the variables of self-awareness, hope, positive emotion, negative emotion and depression.
Table 3 Homogeneity of variables (n = 50) Variables
ExP. (n = 24) Mean ± SD
Cont. (n = 26) Mean ± SD
t
P
Self-awareness Hope Positive emotion Negative emotion Depression
58.20 ± 6.45 76.42 ± 12.66 23.29 ± 7.73 37.95 ± 8.01 51.54 ± 16.03
58.96 ± 5.78 81.35 ± 21.16 24.46 ± 10.04 28.28 ± 10.81 46.35 ± 15.62
0.03 −0.99 −0.46 1.08 1.16
0.973 0.328 0.649 0.240 0.251
Cont, control group; ExP, experimental group; SD, standard deviation.
Table 4. Shapiro–Wilk test was used to confirm the normality of the data distribution. As seen in Table 3, we wanted to see the differences in the results while leaving the pretest scores of all variables as covariate. Therefore, we tried to exclude the discrepancy between the pre- and post-test scores, although the pre and post scores of each variable were significantly homogeneous. There were significant differences between the experimental and control groups in the post-test scores of hope, positive emotion, negative emotion and depression. Interestingly, selfawareness did not significantly change after the experiment (F = 3.71, df = 1, P = 0.060). However, hope (F = 42.57, df = 1, P < 0.001), positive emotion (F = 10.41, df = 1, P = 0.002), negative emotion (F = 7.16, df = 1, P = 0.010) and depression (F = 20.65, df = 1, P < 0.001) were significantly improved after the experiment.
Discussion Comparison of the mean scores in variables between the two groups The mean scores and SD of the study variables, as well as the results of the one-way ANCOVA, are presented in © 2015 John Wiley & Sons Ltd
This study evaluated the use of NTEA for people with depression. NTEA improved the depression symptoms of the participants and produced significant cognitiveemotional outcomes, including increased hope and positive 385
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Table 4 Comparison of the mean scores in variables between two groups (n = 50) ExP. (n = 24)
Self-awareness Hope Positive emotion Negative emotion Depression
Cont. (n = 26)
Pretest Mean ± SD
Post-test Mean ± SD
Pretest Mean ± SD
Post-test Mean ± SD
F1
P
58.20 ± 6.45 76.42 ± 12.66 23.29 ± 7.73 37.95 ± 8.01 51.54 ± 16.03
58.96 ± 5.78 92.96 ± 14.65 28.50 ± 8.13 25.42 ± 10.36 37.46 ± 11.99
58.12 ± 11.91 81.35 ± 21.16 24.46 ± 10.04 28.28 ± 10.81 46.35 ± 15.62
58.62 ± 6.65 79.65 ± 23.03 24.04 ± 9.25 26.92 ± 9.80 45.04 ± 16.53
3.71 42.57 10.41 7.16 20.65
0.060
Narrative therapy with an emotional approach for people with depression: Improved symptom and cognitive-emotional outcomes M . S E O 1 Ph D S. M. CHAE4
RN,
H. S. KANG2
Ph D
Ph D
RN,
Y. J . L E E 3
Ph D
RN
&
RN
1
Associate Professor, Department of Counseling, Dankook University, Seoul, 2Professor, Red Cross College of Nursing, Chung-Ang University, 4Associate Professor, College of Nursing, Seoul National University, Seoul, and 3 Assistant Professor, Department of Nursing, Daegu Health College, Daegu, Korea
Keywords: depression, emotional
Accessible summary
approach, hope, narrative therapy, self-awareness
•
Correspondence: M. Seo Counseling Dankook University
•
126 Jukjeon-dong, Kyounggi-do Yongin City Korea
•
E-mail: [email protected] Accepted for publication: 5 January 2015 doi: 10.1111/jpm.12200
Narrative therapy is a useful approach in the treatment of depression that allows that person to ‘re-author’ his/her life stories by focusing on positive interpretations, and such focus on positive emotions is a crucial component of treatment for depression. This paper evaluates narrative therapy with an emotional approach (NTEA) as a therapeutic modality that could be used by nurses for persons with depression. A nurse-administered NTEA intervention for people with depression appears effective in increasing cognitive-emotional outcomes, such as hope, positive emotions and decreasing symptoms of depression. Thus, NTEA can be a useful nursing intervention strategy for people with depression.
Abstract Narrative therapy, which allows a person to ‘re-author’ his/her life stories by focusing on positive interpretations, and emotion-focused therapy, which enables the person to realize his/her emotions, are useful approaches in the treatment of depression. Narrative therapy with an emotional approach (NTEA) aims to create new positive life narratives that focus on alternative stories instead of negative stories. The purpose of this study was to evaluate the effects of the NTEA programme on people with depression utilizing a quasi-experimental design. A total of 50 patients (experimental 24, control 26) participated in the study. The experimental group completed eight sessions of the NTEA programme. The effects of the programme were measured using a self-awareness scale, the Nowotny Hope Scale, the Positive Affect and Negative Affect Scale, and the Center for Epidemiological Studies-Depression Scale. The two groups were homogeneous. There were significant differences in hope, positive and negative emotions, and depression between the experimental and control group. The results established that NTEA can be a useful nursing intervention strategy for people with depression by focusing on positive experiences and by helping depressed patients develop a positive identity through authoring affirmative life stories.
Introduction People with depression may experience negative interpretations of their lives and of themselves, and decreased © 2015 John Wiley & Sons Ltd
interest in participating in their usual activities. They might exhibit bleak, pessimistic views of the future and discouraged future-directed thinking, anxiety about upcoming events, and inability to look forward to future positive 379
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events (Feeser et al. 2013). Their negative thoughts reinforce dysfunctional beliefs, thereby consolidating the emotion of depression. Depressogenic schemata in Beck’s cognitive theory of depression provides access to a complex system of negative themes and cognitions that contribute to the onset of a pattern of negative self-referent information processing characterized by systematic errors in thinking (Abela & D’Alessandro 2002). Engaging in such cognitive processing increases the likelihood that individuals will develop a negative cognitive triad, such as a negative view of the self, negative awareness of the world and negative perceptions of the future. The negative cognitive triad is a sufficient cause of depression and is responsible for the onset of depressive symptoms (Beck 1967). The abundance of these negative stories leads people with depression to overly identify with problematic life narratives (White & Epston 1990), from which they need to be separated. In the modern biomedical model, a therapist is an expert with special knowledge that allows him/ her to observe, assess, diagnose and treat (Weingarten 1998). However, when the patient with depression needs to possess a positive outlook on himself/herself and the world around him/her, it is desirable to put the patient at the centre of the narrative. That is, the patient should become the narrator rather than the listener. Postmodernism relies on the notion that the outcome of one’s own experience will necessarily be relative, rather than certain and universal. Postmodernism is a shared state of mind for individuals to interpret according to their own personal inclination. It assumes that there is no single truth that must be favoured, according to one scale or another. Instead of finding the truth, it sees what is in front of our eyes, is enthralled by it, and interprets it in one way or another. Instead of standard moral judgement, postmodernism suggests the individual consideration of each specific occurrence and seeks a departure from rigid patterns for a place of subjectivity and collapsed boundaries (Weinblatt & Avrech-Bar 2001). According to the postmodern theorist Foucault, power and knowledge cannot be separated from each other (Glazer 2004). In Foucault’s theory, discourse functions as knowledge, which is constructed by an author, or narrator. The author of a narrative produces and controls the discursive field. The equivalence of power (of a narrative author) and knowledge (that a narrative contains) is secured in this way. Foucault’s notion of power/knowledge can help us understand the relationship between the narrative author and the act of narration. Traditionally, the therapist is the powerful author who controls the patients. In particular, psychoanalysts see the patient in a clinical problematic context as sick, suffering and inferior, rather than seeing the patient’s point of view as a person like himself or herself (Van Wyk 380
2008). Therefore, when a patient’s expression of lived experience becomes a therapeutic concern to the nurse, the roles of the therapist as a talker and the patient as a listener are reversed. The patient comes to have the authoritative power as narrator. Narrative therapy is based on the postmodernist view of clients as having the power to create new meaning and to overcome a medical model that sees disabled people as the problem through retelling stories that contribute to their problems. It involves ways of re-authoring the stories of people’s lives, which are considered pivotal to an understanding of the individual (White & Epston 1990, Morgan 2000). All people, including persons with depression, create meaning through their narratives. Dominant stories tend to prevent the infiltration of alternative experiences, hopes and capabilities. It is the aim of narrative therapy to liberate and empower individuals to break free from the dominant problem-centred story and separate their identity from the problem (Freeman et al. 1997). Narrative therapists take the role of supporting patients in order to help them find positive identities. They begin with the premise that the problem is not the person, but is the problem itself. Thus, the problem should be separated from the client (White & Epston 1990). In this context, people with depression dissemble their negative stories and attempt to live their lives according to what they see as their strengths (Drewery & Winslade 1997). Narrative therapists listen to the negative stories of people with depression and search for unique outcomes and experiences in which patients successfully solved problems in the past. Through the therapy process, the narrative therapist helps people with depression to ‘re-author’ their stories by focusing on positive interpretations. This can help patients develop alternative, more positive life narratives. Thus, narrative therapy can be a useful approach in the treatment of depression. Emotional approach is a crucial component of treatment for people with depression. As a part of therapy sessions, these interventions can decrease patients’ depressive moods because emotion is a central force in maintaining old patterns and learning new, more adaptive ones (Magnavita 2006). More emotionally intense therapeutic approaches might facilitate more active learning and lead to new selfrepresentations (Grigsby & Stevens 2000). The dominant emotions of people with depression are sadness, anxiety, helplessness, horror and fear (Davidson 2000). These negative emotions seriously affect one’s mental health and psychological resilience (Cohn et al. 2009). Negative emotions lead to negative thoughts and behaviours (Greenberg & Paivio 2008). Thus, the negative emotions of people with depression might lead to negative thoughts about the self and the world, as well as to isolation and avoidance of © 2015 John Wiley & Sons Ltd
Narrative therapy with emotional approach
social interactions. In consequence, stories of people with depression can be dominated by problems, and stories of the future are often negative stories with little hope. Hope provides the motivational power to overcome the harshness of life; it helps one make the necessary steps towards a better life. People with depression, however, might have decreased motivation to live in the present moment and to make a better future. At the same time, not only can hope motivate a positive change in the present, but positive emotions also buffer the deleterious effects of negative emotions (Cohn et al. 2009). Additionally, positive emotions serve to expand a person’s cognition. The more people have hope, the more they experience positive emotions and enjoy social interactions (Snyder 2002). Some people with depression may lack the ability to have positive emotions due to the symptoms of depression itself. In therapy for people with depression, it is necessary to intentionally find positivity through focusing on positive experiences, events and emotions. These positive experiences, events and emotions can form a basis for new life stories that focus on positivity instead of negativity. For this reason, the narrative therapy with an emotional approach (NTEA) programme, which is narrative therapy (White & Epston 1990) combined with skills of emotion-focused therapy (Johnson 2004), is provided for people with depression in this study in order to test its effectiveness. Narrative therapy has not been commonly used in nursing, although it has been widely used in the realms of counselling, family therapy and social work. Previous nursing studies on people with depression have focused on cognitive behaviour therapy (CBT) (Grey et al. 2000, Gellatly et al. 2007, Sudak 2012, Fiellin et al. 2013), a guided self-help programme based on computerized cognitive behavioural therapy (National Institute for Health and Clinical Excellence 2014), group cognitive therapy (Watt & Cappeliez 2000), problem-solving therapy (Alexopoulos et al. 2003, D’zurilla & Nezu 2007) and mindfulness therapy (Day & Horton-Deutsch 2004). However, no rigorous empirical support exists for narrative therapy (Vromans & Schweitzer 2011). Although CBT, which is problem-focused, is well known as an effective intervention for reducing symptoms, including depression, there exists a need for a more humanistic and holistic approach to clients (Sierpina et al. 2007) because it did not help create a comprehensive view of the self (Wampold 2012). Postmodern critiques of CBT address the importance of separating the problem from the person, valuing the meaning of individual’s experience, acknowledging that individuals are embedded within a social context and giving clients a central role as authors who construct stories (White & Epston 1990). © 2015 John Wiley & Sons Ltd
The NTEA, which reflects these views, has the potential to help clients and nurses as well. The client may benefit from externalizing him/herself to view himself/herself as separate from the problem. This can also give clients an opportunity to identify problem-dominant stories about their lives and to actively engage in the creation of selfenabling stories about their lives. This latter kind of story can help patients deal with their problems. This approach helps nurses view people with depression in a holistic way so that nurses do not equate patients with their problems nor blame them for those problems (Bacon 2007). This method can also help nurses understand each individual’s unique lived experience and its meaning by giving them the opportunity to listen to their patients’ life stories. By utilizing NTEA, nurses can help people with depression separate negative thoughts and emotions from themselves, change their self-perceptions and their problems, and explore alternative stories that connect to future options (White & Epston 1990). This new self-recognition could help patients have hope for the future.
Purpose of the study The purpose of the study was to identify the effects of NTEA on self-awareness, hope, positive emotion, negative emotion and depression in people with depression.
Hypothesis The hypothesis is that the intervention group will have significantly higher scores of self-awareness, hope and positive emotion and lower scores of negative emotion, and depression than those of the control group following eight sessions of the NTEA programme.
Intervention programme The NTEA programme consisted of a total of eight sessions (Table 1) based on White and Epston’s narrative therapy (1990) and Johnson’s emotion-focused therapy (2004). White (2007) proposed steps to deconstruct problems, promote externalization, dissemble unique outcomes, construct alternative stories and culminate in a definitional ceremony with new position statements. Through these steps, patients can have new perspectives of life and of themselves rather than focusing on their problems. During the narrative therapy programme, emotion-focused therapy was used as an additional technique to help people with depression express themselves well; they would realize their inherent inner emotions when they told their stories, and this experience helped them express their emotions better. Johnson’s (2004) emotion-focused therapy skills, 381
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Table 1 Intervention programme Session
Subjects
Goals
Programme contents
Emotional approach
1
Orientation for programme
Understanding the programme
Careful listening, validation
2
Deconstruction of the problems
To have better understanding of the problem
3
Externalization of the problems
To separate person and problem
4
Exploring unique outcomes
To have positive identity
5
Construction of an alternative story
To have alternative stories
6
Building new story
To recognize storylines in lives
7
Definitional ceremony
To reinforce positive identity
8
New position statement and closing
To take root unique outcome and summarization
To have rapport with participants To introduce each other To express each participant’s expectancy To explain goals and programme contents of each session To identify problems in experience-near To explore consequences of the problem To explore influence of the problem To produce evidence of the evaluation To give a name to the problem To make the naming problems with clay To see the difference when problems separate from self To feel true self without problems To recall the time when they were not overwhelmed by problems To talk about stories without problems To know the differences between stories with problems and without problems To find out their original identity To have participants know their intentional state To know the value in alternative stories To give meaning to the alternative story To tell their goals, dreams and vision To think about precious things in their life To have rich positive stories To present new stories to members as a witness To validate the participants’ new story To retell group members’ thoughts To reinforce the participants’ value of life To tell the influence of a unique outcome To tell changes of life before and after the programme To tell changes of their stories before and after the programme To share feelings and thoughts about the programme
such as empathic response, validation, reflection, evocation, reframing and restructuring, were used during all sessions. Sessions 1 and 2 included introductions, a discussion regarding the aims of the programme, and a discussion aimed at the development of a therapeutic relationship. Participants’ dominant negative stories, the influence of recent problems on their lives and the reasons for the negative evaluation of problems were stated and explored. Sessions 3 and 4 focused on externalizing depression by separating the depression from the person. Depression was regarded as a problem to be separated from the self rather than a pathology that needed to be removed. Depression was externalized. In order to have a positive identity, participants explored unique outcomes. The emotional approach, which calls for validation, reflection, reframing 382
Empathic response, validation
Validation, reflection
Evocation, reframing
Validation, empathy, reframing, heightening Validation
Validation, reflection
Validation, reflection
and evocative questioning, was used in the process of expression to reshift focus to positive feelings and thoughts. Sessions 5 and 6 focused on constructing alternative stories that were contrasted with the problem stories. Participants were encouraged to explore the personal meaning of past events, which were related to depression, preferred ways of living and hope. The therapist validated and heightened the patients’ positive identities. Sessions 7 and 8 comprised a definitional ceremony and a new position statement. Participants presented and shared their new positive stories in the definitional ceremony within the people-with-depression community. Participants resolved to live a new life once again and were also affirmed in their excitement about their new lives. The differences in their lives before and after the programme were shared in the group. © 2015 John Wiley & Sons Ltd
Narrative therapy with emotional approach
Approved community mental health centres A/B/C/D
Methods Study design and data collection
Drawing lots
This study was a quasi-experimental design with two randomized study groups using a pre- and post-test design. Practicability and feasibility are the strengths of a quasiexperimental study (Polit & Hungler 1999). Prior to the study, a letter explaining the purpose of the study and selection criteria of the study population was sent to the directors of 15 community mental health centres in Seoul, Korea. Four community mental health centres in South Korea took part in the study. The centres were similar in size, number of users and programme offerings. In Korea, all community mental health centres offer similar programmes. In this case, the four centres provide similar rehabilitation programmes, such as social skills training to improve social performance and reduce social situation-associated stress (Pilling et al. 2002), art therapy to experience rather than verbalize feelings and to produce tangible evidence of the emotional progress (Withrow 2004), and education on medication. Two centres were randomly picked and assigned to the experimental group, and two additional centres were assigned to the control group. All study participants received medical treatment regularly and took antidepressants. The research team visited each institution, and explained the purpose and the process of the research to the potential subjects/patients. Written consent was received from those who wished to participate in the programme. The selection criteria for participants were the following: (1) adults from ages 18–65, (2) have been diagnosed with depression and (3) have scored over 25 points on the Mini Mental State Examination (MMSE; Yeo et al. 1998). The MMSE was conducted to check if the candidates had any isolated cognitive impairment. A total of 51 participants, 25 in the experimental group and 26 in the control group, agreed to participate in the study. To minimize intentional or unconscious bias, data were collected by one member of our research team who is not an NTEA therapist. The data collector was blinded to the control and experimental condition. A pretest was conducted 1 week prior to the first NTEA session. A post-test was performed 1 week after the completion of the final NTEA session, and it took approximately 20 min. Data were collected from 4 September 2011 to 30 October 2011. NTEA was held for the same period at two community mental health centres, which were included as the experimental group. Each session ran for 90 min, with two sessions per week during the 4 weeks. The NTEA was conducted by the primary investigator of this research, who is a practitioner of NTEA as well as a professor of family © 2015 John Wiley & Sons Ltd
Control group B and C
Experimental group A and D Selection criteria Adults in ages 18–65 Diagnosed with depression Scored more than 25 in MMSE Signed the agreement
n = 24 Pretest (4 September 2011) Provide NTEA Post-test (30 October 2011)
n = 26 Pretest (4 September 2011) No NTEA provided Post-test (30 October 2011)
Data analysis
Figure 1 Process of data collection
counselling. One participant from the experimental group dropped out of the programme, however, to accept a new job. Finally, a total of 50 people with depression, 24 individuals in the experimental group and 26 in the control group, completed the programme. These 50 participants met the requirements for the sufficient sample size by power 0.95, effect size 0.5, and P-value 0.05 of the G-power programme. Figure 1 shows the process of data collection. The most important part of this experiment is the equivalency of the experimental group and the control group. To ensure the homogeneity of both groups, and to clarify that the effects of the experiment were not caused by the intervention of additional variables, but by NTEA, we verified that patients in both groups had similar durations and severity of depression. They have also participated in similar programmes, such as social skill training, art therapy and medication group at institutions. Importantly, we made sure that both groups had taken similar medication in order to clarify that the effects of the experiment were not caused by medications taken at any point. In other words, both the experimental group and the control group had chronic depression and had taken the lowest dose of antidepressants once or twice a day for over 10 years. During the experiment, there was no change to the medication dose caused by symptom relapse. Every patient received case management to ensure that he/she regularly took his/her medication.
Instruments Self-awareness Self-awareness was measured using the Korean version of the rating of self and other scales, originally developed by 383
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Lee et al. (2001), with the authors’ permission. This measure is composed of a total of 10 positive selfawareness questions, such as ‘I am more reliable than others’ or ‘I am a more warm-hearted person than others’; and 10 negative self-recognitions, such as ‘I am a cooler person than others’ or ‘I am more selfish than others’. A 5-point Likert scale, ranging from 1 (not at all) to 5 (always), was used. The total score was in the range of 20–100, with higher scores representing a greater positive self-recognition. Cronbach’s alpha was 0.75 in the original study (Lee et al. 2001) but 0.68 in the current study. Hope Hope was measured using the Korean version of Nowotny Hope Scale, originally developed by Nowotny (1989), which was translated by Choi (1990). The questionnaire is composed of 29 items and consists of six subscales: confidence, possibility of a future, relates to others, spiritual beliefs, comes from within and active involvement. A 4-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree), was used. The total score was in the range of 29–116, with higher scores representing higher hope. Cronbach’s alpha was 0.90 in the original study (Nowotny 1989) and 0.93 in the current study. Positive and negative emotions Positive and negative emotions were measured using the Korean version of the Positive Affect and Negative Affect Scale, originally developed by Watson et al. (1988), which was translated by Lee et al. (2003). This scale is composed of a total of 10 positive adjectives, such as ‘passionate’ and ‘vitality’, and 10 negative adjectives, such as ‘painful’ and ‘aghast’, representing emotions. Each item is rated on a 5-point scale ranging from 1 (very slightly or not at all) to 5 (extremely) in order to indicate the extent to which the respondent has felt this way in the indicated time frame. The total score was in the range of 10–50 in each positive and negative emotion, where higher scores represented higher positive and negative emotions. The Cronbach’s alphas of the positive emotion and negative emotion were 0.88 and 0.87, respectively, in the original study (Watson et al. 1988), and were 0.73 and 0.73, respectively, in the current study. Depression Depression was measured using the Korean version of the Center for Epidemiological Studies-Depression Scale (CESD). This scale was originally developed by Radloff (1977) and was subsequently translated by Cho & Kim (1993). It has been shown that the CES-D scale is a valid instrument that can be useful for assessing depression in clinical settings and for the screening of depressive disorders in the 384
context of epidemiological studies (Morin et al. 2011, Ruiz-Grosso et al. 2012). It was used to measure degree of depressive symptoms in this study. The questionnaire is composed of 20 items, and each item is rated on a 4-point Likert scale, ranging from 0 (not at all) to 3 (always). The total score was in the range of 0–60, where higher scores represented more depressive symptoms. A score of 16 or higher was used as the cut-off point for higher depressive symptoms (Radloff 1977). Cronbach’s alpha was 0.87 in the original study and 0.90 for the current study.
Ethical consideration Members were assured that their participation was voluntary and anonymous. All participants received a small gift, equivalent to $10, upon completion of the programme. While NTEA was ongoing in the experimental group, the control group was going through their regular programme, such as physical exercise and ceramics programme, at their community mental health centres. With ethical consideration, the NTEA was provided to the control group after the completion of the experiment. The Ethical Committee of the Dankook University Hospital (DKUH-IRB-2011-100371) approved the study.
Data analysis Data were analysed using SPSS-PC (version 18.0 for Windows; SPSS, Chicago, IL, USA). χ2 test and t-test were used to test the homogeneity of demographic characteristics and dependent variables between the experimental and control groups. Shapiro–Wilk test was used to test the normal distribution of variables. For testing the differences between the experimental and control groups after the experiment, one-way analysis of the covariance (ANCOVA) test was conducted using the pretest scores of all the variables as the covariants. A covariate analysis was performed in order to eliminate systemic error outside the control of the researcher due to the non-random sampling method. Cronbach’s alpha coefficient was used to determine the reliability of instruments. All statistical tests were two-sided, and a P-value of less than 0.05 was considered statistically significant.
Results General characteristics and homogeneity The demographic characteristics and homogeneity of the experimental and control groups prior to the experiment are presented in Table 2. Among the participants, there © 2015 John Wiley & Sons Ltd
Narrative therapy with emotional approach
Table 2 General characteristic and homogeneity test (n = 50)
Characteristics Gender Male Female Education level Above high school graduate Below high school graduate Employment1 Unemployed Employed Martial statues Married Unmarried Age Disease duration Medication period
Total (n = 50) n (%) Mean ± SD
ExP. (n = 24) n (%) Mean ± SD
Cont. (n = 26) n (%) Mean ± SD
χ2
t
P
23 (46.0) 27 (54.0)
8 (16.0) 16 (32.0)
15 (30.0) 11 (22.0)
2.98
0.098
23 (46.0) 27 (54.0)
9 (18.0) 15 (30.0)
14 (28.0) 12 (24.0)
0.15
0.763
44 (88.0) 6 (12.0)
23 (46.0) 1 (2.0)
21 (42.0) 5 (10.0)
2.68
0.192
2.07
0.211
14 (28.0) 36 (72.0) 43.14 ± 9.76 12.26 ± 8.83 12.66 ± 10.56
9 (18.0) 15 (30.0) 43.92 ± 10.09 10.13 ± 9.21 10.13 ± 9.41
5 (10.0) 21 (42.0) 42.42 ± 9.58 14.23 ± 8.15 15.00 ± 11.20
0.54 −1.67 −1.66
0.594 0.101 0.104
Cont, control group; ExP, experimental group; SD, standard deviation. 1 An exact test was done on this chi-square with one person in the cell, and it was 0.99.
were 23 (46.0%) males and 27 (54.0%) females. The average age of the participants was 43.14 [standard deviation (SD) = 9.76] years. In terms of education level, 23 (46.0%) had an education higher than high school, and 27 (54.0%) had a below-high school education. Of the participants, 44 (88.0%) were employed and 6 (12.0%) were unemployed. Those married totalled 14 (28.0%), and there were 36 (72.0%) unmarried participants. The mean disease duration was 10.13 (SD = 9.21) years and 14.23 (SD = 8.15) years, for the experimental and control groups, respectively; the medication period was 10.13 (SD = 9.41) years and 15.0 (SD = 11.20) years, respectively. There were no significant differences in demographic characteristics between the experimental and control groups, such as gender (χ2 = 2.98, P = 0.098), age (t = 0.54, P = 0.594), education level (χ2 = 0.15, P = 0.763), employment (χ2 = 2.68, P = 0.192), marital status (χ2 = 2.07, P = 0.211), disease duration (t = −1.67, P = 0.101) and medication period (t = −1.66, P = 0.104).
Homogeneity of the groups regarding the test variables Table 3 indicates that prior to the experiment; there were no significant differences between the experimental group and the control group with respect to the variables of self-awareness, hope, positive emotion, negative emotion and depression.
Table 3 Homogeneity of variables (n = 50) Variables
ExP. (n = 24) Mean ± SD
Cont. (n = 26) Mean ± SD
t
P
Self-awareness Hope Positive emotion Negative emotion Depression
58.20 ± 6.45 76.42 ± 12.66 23.29 ± 7.73 37.95 ± 8.01 51.54 ± 16.03
58.96 ± 5.78 81.35 ± 21.16 24.46 ± 10.04 28.28 ± 10.81 46.35 ± 15.62
0.03 −0.99 −0.46 1.08 1.16
0.973 0.328 0.649 0.240 0.251
Cont, control group; ExP, experimental group; SD, standard deviation.
Table 4. Shapiro–Wilk test was used to confirm the normality of the data distribution. As seen in Table 3, we wanted to see the differences in the results while leaving the pretest scores of all variables as covariate. Therefore, we tried to exclude the discrepancy between the pre- and post-test scores, although the pre and post scores of each variable were significantly homogeneous. There were significant differences between the experimental and control groups in the post-test scores of hope, positive emotion, negative emotion and depression. Interestingly, selfawareness did not significantly change after the experiment (F = 3.71, df = 1, P = 0.060). However, hope (F = 42.57, df = 1, P < 0.001), positive emotion (F = 10.41, df = 1, P = 0.002), negative emotion (F = 7.16, df = 1, P = 0.010) and depression (F = 20.65, df = 1, P < 0.001) were significantly improved after the experiment.
Discussion Comparison of the mean scores in variables between the two groups The mean scores and SD of the study variables, as well as the results of the one-way ANCOVA, are presented in © 2015 John Wiley & Sons Ltd
This study evaluated the use of NTEA for people with depression. NTEA improved the depression symptoms of the participants and produced significant cognitiveemotional outcomes, including increased hope and positive 385
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Table 4 Comparison of the mean scores in variables between two groups (n = 50) ExP. (n = 24)
Self-awareness Hope Positive emotion Negative emotion Depression
Cont. (n = 26)
Pretest Mean ± SD
Post-test Mean ± SD
Pretest Mean ± SD
Post-test Mean ± SD
F1
P
58.20 ± 6.45 76.42 ± 12.66 23.29 ± 7.73 37.95 ± 8.01 51.54 ± 16.03
58.96 ± 5.78 92.96 ± 14.65 28.50 ± 8.13 25.42 ± 10.36 37.46 ± 11.99
58.12 ± 11.91 81.35 ± 21.16 24.46 ± 10.04 28.28 ± 10.81 46.35 ± 15.62
58.62 ± 6.65 79.65 ± 23.03 24.04 ± 9.25 26.92 ± 9.80 45.04 ± 16.53
3.71 42.57 10.41 7.16 20.65
0.060
