Effects of Cognitive Behavioral Therapy, Existential Psychotherapy and Supportive Counselling on Facial Emotion Recognition Among Patients with Mild or Moderate Depression

Article information

Psychiatry Investig. 2019;16(7):491-503

Publication date (electronic) : 2019 July 25

doi : https://doi.org/10.30773/pi.2019.03.14

Onur Yılmaz, Ali Barlas Mırçık, Merve Kunduz, Müge Çombaş, Ahmet Öztürk, Erdem Deveci, İsmet Kırpınar

Department of Psychiatry, Bezmialem Foundation University Medical Faculty, İstanbul, Turkey

Correspondence: Onur Yılmaz, MD Department of Psychiatry, Bezmialem Foundation University Medical Faculty, Adnan Menderes Boulevard (Vatan Road) Fatih/İstanbul 34093 Turkey Tel: +90 533 658 0934, Fax: +90 212 253 1883, E-mail: ony1978@gmail.com

Received 2018 September 3; Revised 2018 December 19; Accepted 2019 March 14.

Abstract

INTRODUCTION

Nonverbal behaviors have a crucial role in expression of emotions [1,2]. These behaviors include facial expressions, postures, gestures and tones of voice [3]. Display of facial emotions may basically be spontaneous or controlled. Subcortical brain regions, in particular basal ganglia, and cortical regions, particularly frontal cortex are involved in both the spontaneous and controlled emotional displays. Basal ganglia and frontal cortex are reciprocally interconnected such that, damage to one of them lasts with the impairment in production of emotional expressions [4]. Frontal cortex is likely to be crucial for representing goals to either show or supress an emotional expression. The basal ganglia receive inputs from both the amygdala and other structures processing emotional information [4]. Amygdala lesions reduce the display of spontaneous fearful displays to novel objects [5], however, do not affect the production of controlled fearful or other emotional displays [6].

Researchers put forward that, information regarding the emotional expressions of other people is transported either by a subcortical (retinocollicular-pulvinar-amygdalar) or by a cortical pathway (retinogeniculostriate- extrastriate-fusiform) [7,8]. It is suggested that the subcortical pathway works fast and allows immediate automatic access of information on emotional expressions to the amygdala that can then modulate the processing of information through the cortical pathway [8,9].

Recognizing facial expressions of emotions is crucial for interpersonal relationships and constitution of functional cognitions. Depression was suggested to be associated with impaired ability to recognize facial emotions [10]. Inappropriate reactions to others’ emotions are reported to maintain or increase depression [11]. Such that, accurately identifying another person’s emotional state is an ability that may be necessary not only for patients, but also for psychotherapists to empathize with patients and that may be required for obtaining valid and reliable psychotherapy process ratings in research [12]. Impairments of facial emotion recognition (FER) were also shown among individuals suffering from other psychiatric disorders. A recent study reported that, adults with autism spectrum disorder uniquely misinterpreted happy faces as neutral, and were significantly more likely than typical volunteers to attribute negative valence to nonemotional faces [13]. Individuals with anorexia nervosa were shown to be less accurate than healthy controls in recognizing expressions of disgust [14]. Findings of another recenty study highlighted the severity and persistence of emotion recognition deficits early in the course of psychotic bipolar disorder and schizophrenia [15]. To the best of our knowledge, no previous study was performed concerning the effects of psychotherapy echoles on FER.

Cognitive behavioral therapy (CBT) is widely and successfully used for major depressive disorder (MDD). CBT is developed and put into practice firstly by Beck et al. [16] As time goes by, retrospective studies and reviews about CBT for depression have been added to literature [17,18]. CBT has enduring effects during acute phase of MDD, which is unlikely with antidepressants (AD) [19]. While traditional CBT was not beneficial enough in some cases, relatively new approaches on the field, called third wave CBT, have come to the scene. The terms acceptance and mindfulness, closely related to existential phylosophy, are widely used among third wave CBT literature and practice [20,21].

Existential philosopy focuses on meaning of life, freedom, authenticity and responsibility [22-25]. Existential psychotherapy (ExP) [1] is based on existential philosophy. The interview between the therapist and the patient in an existential psychotherapy session is based on the method called phenomenology [26]. Phenomenologic dialogue is a kind of invitation to the individual to let happenings and things to demonstrate themselves just like what actually they are [27].

Australian psychiatrist and psychotherapist Viktor Emile Frankl is generally accepted to be the first therapist working on the basis of existential philosophy. Frankl’s approach has a particular name, logotherapy (LT) [28]. The term “logos” is a Greek lexical item which implies ‘reason’ or ‘plan’ in English [29]. LT is generally understood as ‘meaning therapy’. Some other methods of existential psychotherapy are entitled as Dasein Analysis [30], Existential Group Therapy [31] and Existential Couple Therapy [32].

A group of researchers performed unstructured forms of psychotherapy which do not help through specific psychological techniques. These therapies are commonly described in the literature as counselling or supportive therapy. Though generally accepted to be less effective than other psychotherapies, they were reported to be helpful for MDD [33,34].

Since FER is reported to be poorer for MDD patients in former studies, we examined this ability throughout the study among patients, compared with healthy individuals and investigated the effects of CBT, ExP and SUP on it. We also aimed to compare the therapeutic effects of CBT, ExP and SUP for MDD. To the best of our knowledge, no studies have been performed previously concerning both these two domains.

METHODS

This study was performed at psychiatry clinics of Bezmialem Foundation University Hospital. The study protocol was approved by the local ethics committee for interventional studies (approval number: 3/21).

Subjects

95 patients in total, diagnosed with mild or moderate MDD were included throughout the study. 61 patients (64.2%) completed the whole protocol. The control group consisted of 60 healthy volunteers, matched with patient group for age, education, gender and marital status. All subjects were between 18 and 65 years old and reported that they were from Turkish etnics and Sunni muslims. Patients who had comorbid psychiatric disorders such as bipolar affective disorder (BPD), obsessive compulsive disorder (OCD), severe personality disorders, post traumatic stress disorder (PTSD) and substance related and addictive disorders and patients who had been on psychiatric medication from two months before the evaluation date for the study, were not included. Individuals hard to communicate, such as with blindness and deafness were not included either.

69 individuals were selected for healthy control group throughout the process. 9 out of them were excluded, due to axis-1 psychiatric disorders (4 individuals had depression, 2 had panic disorder, 2 had conversion disorder and 1 had somatization disorder), identified by performing SCID-1 and psychiatric examination. After making necessary explanations about the study, subjects who agreed to participate, have signed voluntary informed consent forms.

61 patients completed the whole study protocol, 21 (34.4%) of them got CBT, 20 (32.8%) got ExP and the rest 20 (32.8%) got SUP for eight consecutive weekly sessions and the following two monthly booster sessions. Selection of patients and therapy models were made by two separate psychiatrists who were not on the therapist list. The selection model was randomisation. Subjects were directed to groups one by one, in order of ExP, CBT and SUP.

Duration of sessions were 45 to 50 minutes. 11 patients selected for CBT (34.4%), 13 selected for ExP (39.4%) and 10 selected for SUP (33.3%) did not complete the whole study.

Three patients selected for CBT, five for ExP and two for SUP did not start sessions. Two patients in CBT group, three in ExP group did not continue after their first sessions. Two patients in CBT, two in ExP and two in SUP groups were excluded from the study and directed to psychiatry clinics back, because of worsening of the symptoms to the extent that the diagnosis differed to severe MDD and they were supposed to be on psychiatric medication. One patient from ExP group had to leave the city because of a jobwechsel, after he completed four weekly sessions. Four patients in SUP, two in CBT and one in ExP groups left the study from second to seventh of weekly sessions. Two patients in CBT, one in ExP and two in SUP groups completed the weekly sessions, however, did not come for boosters (Table 1).

Table 1.

Flowchart for numbers of patients detached from study, reasons of detachment and numbers of patients left

Prior to the sessions, patients received Sociodemographic Data Form prepared for the study, the Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-1), Hamilton Depression Rating Scale (HDRS) and Facial Emotion Recognition Test (FERT) [2]. The control group received Sociodemographic Data Form, SCID-1 and FERT. Each patient received HDRS and FERT also after weekly and booster sessions.

Facial Emotion Recognition Test

It contains a total of 56 black and white photographs from Ekman and Friesen’s catalogs, representing happy, surprised, fearful, sad, angry, disgusted and neutral facial emotions of 4 men and 4 women [41]. Photo images of faces were digitized on a computer presentation via a structured query language (SQL) data application in a Visual Basic NET software program (2.4 GHz and 3 MB processor, 3 GB main memory, 15.6-inch LCD screen with 1,366×768 pixel resolution). All participants seated 45 to 60 cm apart from the scene and performed the test in a silent, properly illuminated and ventilated room with no windows. There was an array of colours under each facial expression scene (Figure 1). Each expression matched with a separate certain colour on the array and a certain button on the keyboard. We sticked self adhesive notepapers on each of these buttons, coloured identical with their counterparts on the computer scene (Figure 2). Facial expressions on the first seven certain photographs were told to the participants in order to accommodate them to the test. For the resting 49 photographs, the participant chose one emotion and pressed the related key, then, the subsequent photograph automatically displayed on the scene. Participants were not told about the correct total number of any emotions. Thus, the possible tendency for a certain expression was inhibited. Likewise, participants received no feedback during their turn. Immediately after the test finished, the programme produced an excel file with records of all answers.

Figure 1.

The question in Turkish below the photograph on the scene can be translated to English as follows: “Which emotion do you think is expressed on the current scene?.” Below the question, there are coloured boxes including the names of the emotions written in Turkish. Colours of boxes and the names of the relevant emotions in English from left to right are as follows. Blue: Happy, Light Blue: Sad, Grey: Fearful, Green: Disgusted, Red: Angry, Pink: Surprised, Light Pink: Neutral.

Figure 2.

The computer screen (demonstrating the photograph, question in Turkish asking the relevant emotion and coloured boxes below the question) and the keyboard with sticked adhesive notepapers (coloured identical with their counterparts on the scene) are seen in the figure. The sequential letters on which the notepapers have been sticked are; D, F, G, H, J, K, and L.

Therapists and sessions

Before study beginned, flowcharts for ExP and CBT were prepared by participation of all therapists (Table 2 and 3). There was no flowchart for SUP. There were two therapists each for CBT and ExP an one for SUP. The durations of experience as psychotherapists and the number of patients with whom they performed and completed sessions were as follows: 2 years (10 patients) and 6 years (11 patients) for CBT therapists, 2 years (9 patients) and 5 years (11 patients) for ExP therapists and 4 years (20 patients all) for SUP therapist. Thus, we tried to reduce the possible unevenness regarding the therapy offered to patients.

Table 2.

Flowchart for CBT sessions

Table 3.

Flowchart for ExP sessions

RESULTS

All three patient groups and control group were matched in terms of age, gender, marital status and education (Table 4). SCID results and psychiatric examination revealed that, among patients who completed the whole study programme, 7 from ExP, 7 from CBT and 10 from SUP were diagnosed with mild depression while 13 from ExP, 14 from CBT and 10 from SUP group had moderate depression. Some patients who had prediagnoses of depression in psychiatry clinics and directed to evaluation for the study were not included due to the results obtained from psychiatric examination and SCID-1. 2 of them had OCD, 1 had PTSD, 1 had generalized anxiety disorder and 1 had alcohol use disorder as comorbid diseases to depression. Besides, after performing SCID-1 and detailed psychiatric examination and taking information of psychiatric history, 3 patients were found to have BPD and 1 was found to have severe major depression with psychotic signs. So, they were not included either.

Table 4.

Comparison of sociodemographic data of patient and control groups

At the end of the study, mean rank of HDRS scores demonstrated significant differences between patient groups (p<0.05) (Table 5). When the groups were compared in pairs, significant differences were found between ExP-SUP and CBT-SUP, however, the difference between ExP and CBT groups was not significant (Table 6). All patient groups were compared in themselves and were found to have lower mean scores of HDRS at the end of booster sessions than the beginning. Mean HDRS scores did not change significantly between the end of weekly and booster sessions in ExP and SUP, while CBT group demonstrated a significant decrease in this period (Table 7).

Table 5.

Comparison of mean ranks of HDRS scores between patient groups

Table 6.

Paired comparisons of mean HDRS ranks of each patient groups

Table 7.

Comparisons of mean HDRS scores for all treatment groups in themselves

There were significant differences of the ability of individuals to recognize surprised and neutral facial emotions before the sessions start, between patient and control groups (Table 7). When patient groups were compared after weekly and booster sessions, significant differences were found in sad, disgusted, angry, surprised and neutral emotions (Table 8). Subsequently, all patient groups were compared in pairs. ExP was superior to SUP in all emotions except happy and fearful, both after weekly and booster sessions. CBT was superior to SUP only for sad emotions. Crucially, ExP provided significantly more improvement than CBT, in recognition of disgusted and neutral emotions both after weekly and booster and in angry and surprised emotions after weekly sessions (Table 9). Moreover, each group has been compared in themselves. After booster sessions, ExP group enhanced their ability in recognizing all the emotions except anger, CBT group enhanced recognition of happy emotions only, however, SUP group did not demonstrate any enhancement (Table 10).

Table 8.

Comparison of mean ranks of facial emotion recognitions between all groups

Table 9.

Paired comparisons of mean ranks of facial emotion recognitions after weekly and booster sessions between patient groups

Table 10.

Comparisons of mean values of recognized facial emotions for each group in themselves

DISCUSSION

Depressive disorders relapse frequently, besides, their recurrence rate is remarkable [42]. As time progresses, the tendency to accept depression as a lifelong course is growing. Further, there are editorials supporting this approach [43]. The recurrence rate in first episode depression is reported to be 40% to 60% and after the third episode, the rate reaches up to 90% [44]. Considering the increasing morbidity and mortality by each relapse and recurrence of MDD [45], it is of critical importance to choose treatments which seem to be helpful to prevent from relapses and recurrences.

Various practices were reported about the average treatment duration in CBT. Shapiro et al. [46] conducted a major study comparing the efficacy of CBT and psychodynamic interpersonal therapy (PIT) for depression. In this study, duration of treatment was experimentally manipulated (8 sessions versus 16 sessions). At the end of treatment, CBT and PIT were equally effective. However, one year after treatment completed, patients who received 8 sessions of PIT did worse on almost all treatment measures compared with 8 session CBT, 16 session CBT and 16 session PIT. That is, no significant difference was found between 8 and 16 sessions of CBT. Ilardi and Creighead [47] reported that, symptom improvement in CBT predominantly occurs in first 4 weeks. DeRubeis and Feeley [48] measured how much time and effort CBT therapists spent on cognitive modification in different therapy sessions. They found that, therapists spent essentially the same amount of time and effort on cognitive techniques in the second session as they did in later sessions. Their findings suggested that therapists substantially started to use congitive modification techniques as early as the second session of CBT [48]. Likely, we performed our work on the assumption that, cognitive improvement starts from early sessions and we finally decided a total of 10 sessions, 8 weekly, followed by two monthly. While cognitive improvement has a close interaction with improvement in FER, we hypothesized that, we may accomplish results after weekly sessions for FER. In view of the fact that, unlike CBT, there are not certain numbers of sessions offered for ExP and SUP, we decided to take the session number of CBT as reference, in order to provide the utmost uniformity. Thus, the session numbers for ExP and SUP were same with CBT.

Classical and third wave CBT were compared with various psychotherapy models for treatment of MDD. Some researchers argued that CBT was superior to other psychotherapies [49,50]. CBT alone was once known to be superior to AD alone for treatment of MDD [51]. However, recent literature supports CBT combined with AD as first line treatment for MDD [52]. CBT alone showed only marginally better improvement than AD alone, besides, severe depression was reported to be best treated with CBT and AD together [53]. A metaanalysis reported that, CBT has lower rates of relapse and recurrence than AD after discontinuation of acute phase MDD treatment [54]. Some researchers stated that, sequential use of CBT after pharmacotherapy may improve the long term outcome in recurrent depression [55]. In a retrospective follow up of an earlier randomized controlled trial regarding residual symptoms of MDD, CBT was found to have short term but not long term benefits [56]. In a different trial assessing the duration of CBT effect upon MDD, effects in prevention of relapse were found to persist, but with weakening, until 3 years after the end of CBT, and subsequent additional CBT was suggested to be explored [57]. In the current trial, we demonstrated that, all three psychotherapy echoles led significant reductions in HDRS mean scores. However, while ExP and CBT had comparable effects on HDRS scores, they both provided more reduction than SUP group.

Taking into account all of these, while it remains unclear that CBT is superior to other psychotherapies for MDD, in addition to the comparement of final HDRS scores between groups, we hypothesized an indirect connection of preventive effect of CBT and certain other psychotherapies via FER.

As mentioned above, phenomenologic dialogue in ExP is not a directive process. It is a kind of work up for the process of openness to and looking out for experiences as a whole. ExP does not aim to reduce negative or enhance positive feelings and thoughts. Instead, ExP focuses on directing the patient to negotiate with all dimensions of experiences including feelings, thoughts, bodily senses and realities of the external world [58]. By this way, patient is encouraged to make choices, getting into the action and accepting and taking responsibility of all predictable and unpredictable outcomes [59]. In the current trial, ExP enhanced the ability for recognizing facial emotions most, particularly for disgust, anger, surprise and neutral emotions. This finding may be due to the nontarget oriented structure of existential psychotherapy sessions, which makes room for wider range of emotions to be expressed and detailed in the sessions.

Some researchers reported comparable outcomes for SUP and CBT in the treatment of depression [60]. In our trial, SUP had a relatively free content and the therapist was rather a friendly listener than a talker. When asked for an assistance concerning the choices about problems of daily life, SUP therapist answered with superficial and short comments in order to find possible choices of the patient together. At the end of the trial, difficulty to recognize facial emotions remained mostly unchanged in SUP group. Recognition of sad and angry emotions even got worse after weekly sessions with SUP (Table 8). This finding may partly be the conclusion of the friendly approach of SUP, which may have made room for patients to self justification and, so to say, passing the buck of life problems. Thus, they might have prioritized positive emotions and thoughts rather than negative ones and omit negative experiences to some extent.

In view of the information which indicates that depressed individuals have a tendency to perceive neutral stimuli as negative [61], unstructured psychotherapy approaches like SUP, even providing a nonspecific help for short term, did not seem to have a real effect on improving cognitions. Thus, we argue that, SUP might not be preventive enough against recurrences and relapses of MDD.

Understanding emotions from facial cues plays a fundamental role in the development of children’s social competence [62]. Children who understand facial emotional cues in social interactions have been found to form positive interpersonal relationships over time [63]. Even neonates were observed to respond facial emotions [64]. Certain configurations of facial features resulting from specific patterns of facial muscle movements are recognized as corresponding to particular basic emotions throughout the world [65,66].

Individuals are capable of intentionally manipulating their emotional displays. They may follow display rules, which are proscriptions of their society as to what emotion should be displayed in given circumstances and how intensely it should be displayed [67]. Children generally learn the predominant display rules of their culture over time. In a classic study concerning the development of display rules and control over emotional expressions, age-related changes were demonstrated in the ability of children to cover their dissapointment at the discovery that their gift for helping out an adult was much less interesting than the gift they had been expecting; the dissapointment of the younger children was too easier to detect [68]. Thus, the suggestion mentioned above in this paper which states the difference between spontaneous or overlearned emotional expressions to emotional stimuli in the presence of observers and controlled or posed emotional expressions as a function of display rules comes to scene again. Besides, cross-cultural studies of facial expressions performed by Ekman revealed that, certain cultural differences may have a role in facial expressions of different emotions [69]. While the images in FERT belong to people from United States (US) and the responders in our study were Turkish and Sunni Muslims who might have display rules dissimilar to US citizens, the results may have been affected from these diversities.

Educating individuals about recognition of others’ facial emotions may lead to a better mutual detection of emotions and then may provide more healthy cognitions and relationships. In turn, this education may have a preventive effect against relapse, recurrence or even the onset of MDD. Moreover, it presumably may facilitate remission.

In the current trial, patients who received ExP were found to have greater success on recognition of almost all facial emotions than beginning, while CBT group improved happy emotions only and SUP group did not improve any of them. Interenstingly, when each group were compared in themselves between weekly and booster sessions, only ExP group was found out to have a significantly greater success to recognize disgust and improvements close to statistically significance level for sad and neutral emotions. Thus, ExP seems to have a bigger improving effect on FER than other psychotherapies and this improvement seems to be ongoing. Therefore, we are arguing that, ExP might have a bigger effect on prevention of relapses and recurrences of MDD than CBT and SUP.

An unexpected outcome of this study was that, before sessions started, only surprised and neutral emotions were recognized better by healthy control group than patients. Other facial emotions, including happiness and sadness, did not differ. This finding should be detailed by trials with larger samples and may bring the classical data on cognitions of depressed patients into question.

The term “emotional intelligence (EI)” was originally conceptualised as the ability to perceive accurately, apraise and express emotion; the ability to access and/or generate feelings when they facilitate thought; the ability to understand emotion and emotional knowledge; and the ability to regulate emotions to promote emotional and intellectual growth [70]. This definition seems to include the components of individual intelligence expressed by Gardner, mostly known of which are social intelligence and intrapersonal intelligence [71]. While social intelligence can be conceptualised as the ability to perceive emotions, intentions and desires of others, intrapersonal intelligence can be described as the ability to reach own emotional environment. Here, the term alexithymia comes to the scene. We did not investigate alexithymia in the current trail, not to complexify our findings. However, alexithymic individuals were reported to have difficulty in recognizing facial emotions [72,73] and to distinguish different emotional expressions [74]. Thus, we suggest that, alexithymia might be a constitution to be searched alongside with FER in further studies.

Out of 95 patients included in the current study, 61 completed the whole protocol, and the rest 34 (35.8%) did not. A metaanalysis regarding CBT drop-out rates, drop-out was operationally defined as attendence of more than one session but failure to complete all sessions. The overall findings were that, on average, every fourth person failed to complete therapy with drop-out ranging widely from 0% to 68% [75]. A more recent metaanalysis demonstrated that, drop-out from CBT occurs even before treatment starts, rising to an even higher level during treatment, total attrition rate accross both phases reaching about 35% [76]. From this point of view, drop-out rate in the current study seems to be comparable with the rates reported until recently.

Our study has several limitations. First of all, photographs were not coloured. Coloured photographs could have had a positive effect on results of emotion recognition. Photographic films only were used for the process, but motion videos and analyses of facial muscle movements could have been a more descriptive application. CBT and ExP were performed by two therapists, while there was only one professional for SUP and this quantitative difference may be another limitation. Besides, while it had a relatively free content, we did not compose a brief manual or a flowchart for SUP, which may be seen as an additional limitation. Sample size and number of sessions were relatively small. Images belonged to US citizens while the responders were Turkish and Sunni Muslims.

In conclusion, the ability of depressive patients to recognize surprised and neutral facial emotions were lower than healthy controls. Patients who received ExP improved their ability to recognize almost all facial emotions, while difficulty to recognize emotions remained totally unchanged in SUP. CBT improved only happy emotions.

Ultimately, psychoeducation about recognizing facial emotions for individuals in risk group to undergo MDD and individuals who have MDD may be helpful for prevention, early diagnosis, treatment and follow-up. Moreover, psychoeducation of therapists about facial emotions may also provide beneficial effects.

ExP, CBT and SUP all led to a reduction in MDD. ExP and CBT had comparable effects and both were more helpful than SUP.

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