Primary objectives.

1. a. To assess the feasibility of the therapy and assessment protocol using key evaluation indicators, including recruitment rate, retention rate, and engagement rate.
2. b. To evaluate the acceptability of the therapy, considering the following indicators: treatment credibility and client outcome expectations, engagement, and satisfaction.

Secondary objective.

1. a. To explore the outcomes of EFT for the resolution of emotional injury among the study’s participants, according to forgiveness and letting go measures (primary outcomes) and depression and quality of life (secondary outcomes).

The aim of our study is to develop a methodologically sound and effective protocol that may serve as the foundation for a subsequent randomized clinical trial (RCT) to test the efficacy of EFT for the resolution of emotional injuries related to interpersonal offenses, in individuals aged 65 and older. In essence, a feasibility study such as the one proposed here, functions as a tool to assess the viability of the main trial (RCT)—specifically in terms of recruitment, retention, measurements, and other parameters—without necessarily focusing on clinical outcomes [22,27–29].

Phase I: Creating an alliance.

The initial phase of therapy emphasizes the establishment and reinforcement of the therapeutic alliance to cultivate a safe, exploratory, and empathic environment. This phase is used to validate the emotional injury reported during the initial assessment and to clarify its most challenging aspects, through an empathic attunement to painful aspects of the interpersonal offense and painful emotions [2]. The therapeutic process dynamics are presented to the client, emphasizing the focus on difficulties arising from the experienced offense. Once the client feels ready, the therapeutic relationship is sufficiently solid, and the marker of an unresolved, emotional injury related to a past interpersonal situation is identified, the empty chair task can be introduced [19,40]. This task involves the client visualizing the injurer in an empty chair, to facilitate the exploration, awareness, expression, and processing of painful, core primary emotions to address unmet needs and resolve emotional injuries [20,40]. It is a collaborative process between the therapist and the client, with a particular emphasis on transforming the primary emotions associated with the emotional injury [2,7].

Phase II: Evocation and exploration.

The second phase of therapy primarily involves accessing and addressing problematic emotional processes and the needs that may arise from them. Therapists try to identify emerging markers, namely, feelings of pain, sadness, anger, vulnerability that clients may feel when remembering what happened or what offended them [2,20]. Along with the empathic and exploratory stance of the therapeutic process, the empty chair task continues to be proposed when markers of unfinished business appear, to help participants deal with the lingering feelings of pain due to the emotional injury. The task facilitates the arousal and exploration of emotions, recognition and differentiation of feelings, and the identification of various forms of anger. It can also assist clients in identifying secondary or non-adaptive emotions while accessing primary emotions [20]. Thus, the empty chair task can facilitate clients’ connection with and expression of their unmet emotional needs [2,8].

Phase III: Self-Interruption work.

The interruption of experienced emotions is a prevalent challenge in addressing unfinished business through the empty-chair task [2,40]. Consequently, there is often a necessity to address self-interruptions during the deepening phase of the empty chair task. So, this third phase specifically aims to assist participants in recognizing markers of self-interruption, typically manifested as emotional constriction, resignation, or hopelessness [2]. To deal with self-interruptions, we employ the therapeutic task of two-chair enactment, which entails engaging in an imaginative dialogue between different parts of the self: the part that interrupts or obstructs and the experiencing self, who endures the consequences of this interruption [40]. Through this approach, clients can gain awareness and access how they self-interrupt, and through which processes self-interruptions occur, often rooted in experiential avoidance of more painful emotions. This enables to address, among other emotional processes, feelings of hopelessness and discouragement that may emerge from the self-interruption process [2].

Phase IV: Empowerment and letting go or forgiving.

This stage of the process aims to deepen emotional processing through the empty-chair task, by accessing painful, chronic (primary maladaptive) emotions, and their underlying unmet needs [20,41]. This emotional deepening process can facilitate the recognition and expression of the core pain [2,41]. Therapists aim to facilitate clients’ mourning of unmet needs, promoting opportunities to fulfill those needs, and fostering new emotional experiences (such as compassion and pride in oneself) and new perspectives on the offense and the injurer [2]. The forgiveness process usually involves experiencing new emotions (e.g., empathy towards the injurer) and changing the view of the injurer, that becomes softened, for example, through an understanding of the reasons underlying the offense. The emotional transformation of resentment can happen through an emotional response that involves compassion and love [2]. The process of resolving emotional injuries can also be achieved through letting go, which is understood as a process involving the addressing of unresolved emotional needs and feelings related to the offense and the offender. Letting go entails acknowledging and working through the emotional impact—such as pain, resentment, or anger—without necessitating the development of empathy or positive feelings toward the offender. In contrast to forgiveness, which typically involves a relational shift toward the offender, letting go focuses on internal emotional healing, aiming to alleviate distress while maintaining personal psychological boundaries [2].

Phase V: Termination.

The therapy seeks to address several key dimensions: the client’s role as an agent of their own emotions; the experience of change as a continuous process; the acceptance of separation and loss; and the prevention of potential relapses [2]. Ultimately, the therapeutic process aims to culminate in forgiveness, which involves an adjusted regulation of the expression of resentment, anger, and shame associated with the offense, alongside the promotion of compassion. Alternatively, the therapy may conclude with a process of letting go, which entails a thoughtful processing of unmet needs and feelings related to the offense and the offender, without necessarily fostering empathy or compassion toward the latter [2].

Phase I specificities.

Studies indicate that psychosocial difficulties, such as social isolation or elder abuse [17], can lead individuals to minimize interpersonal offenses and their respective emotional injuries [6]. For example, a person who is dependent upon a family member may not express their true feelings and may (superficially) forgive to avoid negative interpersonal consequences. While recognizing the importance of valuing current relationships, therapists may need to facilitate clients’ awareness of the significance of acknowledging their own suffering and the negative consequences of emotional injury, as blocking the emotional process can lead to additional problems (much like the contrast between normative versus complicated grief, as proposed by Sharbanee & Greenberg, 2023).

To address this issue, we propose that therapists undertake experiential formulation and focusing as a therapeutic strategy aimed at highlighting the importance and value of accessing avoided emotions, alongside the promotion of greater self-awareness and self-acceptance throughout the therapeutic process and beyond [20,41]. This aims to explore client difficulties in experiential terms, emphasizing therapy’s focus on personal feelings and not necessarily on changes on relationships (i.e., forgiveness does not imply reconciliation) [22]. Indeed, the intention is to allow individuals to access their experiences more freely and authentically, without necessitating behavioral changes or causing negative repercussions [18,19,41].

Phase II specificities.

Previous studies by the present authors [18,19] have identified specific difficulties (or markers) that older individuals may face in the process of forgiving. One such difficulty is avoiding painful experiences by being purely conceptual. For instance, an older person might say, “I feel neither anger nor sadness [...] Forgiving is like lifting a weight off my shoulders [...] I don’t feel the need for support or affection.” This type of narrative is often characterized by an overly intellectualized self-voice that suppresses a more vulnerable, experiential voice, which may signal the presence of self-interruption [18,20,41]. In therapy, tasks such as empathic exploration [40] and focusing [42] can be proposed to encourage grounding in the experience. Subsequently, the two-chair enactment task [43,44] can be employed to facilitate dialogue between the dominant voice and the disowned voice.

Phase III specificities.

A previous study with older people [19] showed that all participants struggled with internal conflicts in the process of forgiveness. An example narrative is: “To me, forgiving means forgetting and never dwelling on it again [...] when I forgive, I don’t forget, because the memory resurfaces, along with the hurt and sorrow.” These conflicts are characterized by a persistent divergence between two dimensions (or voices) of the self that do not communicate with each other [18]. This marker—self-conflict or negative self-treatment—can be addressed in therapy through the two-chair dialogue task, aiming for a satisfactory negotiation or understanding between the conflicting parts [7,43,45].

Another difficulty we anticipate is avoidance by suppression of the painful experience [18]. Consider the following example: “If I am shocked, it passes. I don’t think, I forget, I focus on other things. There is so much to live for [...] I can keep control.” This may reflect an automatic tendency to deny or avoid the emotional injury caused by the offense, hindering recognition of the interruption process and access to the repressed internal experience. We identify this marker as a potential process of self-interruption, often involving immersion in painful memories and a focus on other dimensions or problems [18,19]. The two-chair enactment task can be beneficial in bringing the automatically interrupted voice into action [43,44].

Another challenge we foresee is that older individuals might delegate the responsibility of forgiveness to others, including a divine entity [18]. For example: “Thinking about God helps, because it gives me peace, relieves me [...] The one who forgives is God.” In line with what has been observed in our studies [18,19], this response may indicate a collapse of the self in reaction to profound despair caused by the emotional injury [20,46]. This type of despair can be characterized by a sense of loss of agency, where one feels entirely powerless and submits to another (e.g., delegating forgiveness, justice or repair to a divine entity), demonstrating profound demobilization [18]. Considering this marker, tasks such as empathic affirmation [41] and compassionate self-soothing [47] can be beneficial.

Phase IV and Phase V specificities.

Based on our prior research [18,19], it is important to emphasize that certain emotional experiences resulting from therapy can indicate if the therapeutic process is progressing positively. These encompass physiological indicators like serenity, tranquility, and calmness; cognitive shifts such as reduced rumination, enhanced learning, and decreased negative thoughts; emotional transformation including peace, joy, and relief; behavioral adaptations towards oneself, others, and the environment; and self-transformation, characterized by satisfaction, the cultivation of new internal narratives, heightened empathy and compassion, and receptiveness to transcendence [5,13,18,19].

We anticipate that transforming the emotional difficulties associated with emotional injury and fostering self-narrative reconstruction may pose a significant challenge for this population. This age group is particularly susceptible to promoting satisfactory personal integration and enhancing positive life meaning, which are crucial developmental tasks at this stage of life [48]. Indeed, we see this as a consolidation of change, a reconciliation of the self with one’s life, necessitating specific narrative-meaning reconstruction work, as outlined in the self-narrative reconstruction task [19,20], which we consider particularly suitable for this population [6,13].

Intervention acceptability measures.

Therapy Credibility and Expectancy

We will use the Credibility/Expectancy Questionnaire (CEQ) [51,52] to measure treatment credibility and client outcome expectations. The CEQ is a self-report questionnaire composed of six items grouped into two subscales: treatment credibility and expected outcome–on a 9 item Likert scale. Credibility assesses the degree of confidence that participants have in the usefulness of therapy as treatment for their difficulties. Client outcome expectations assesses how much participants believe they can benefit from the therapy protocol that is provided [52].

Session Satisfaction Module

To evaluate participants’ assessment of each specific session of the intervention protocol, they will be asked at the end of each session to rate how beneficial they found each session and corresponding homework activity. This will be done through a simple question, with responses varying on a 5-point Likert scale [22].

Global Therapy Satisfaction

To assess participants’ satisfaction with the global intervention, we will use the Client Change Interview Protocol (CCIP) [40,53]. This semi-structured interview, comprising open-ended questions, has a duration of approximately 60 minutes and is administered at the conclusion of therapy (at t3 and t5). The CCIP explores potential processes of change experienced by clients during therapy, covering attributions, meanings, and relevance. Participants evaluate specific changes they have experienced using a 5-point scale, assessing the extent to which these changes were expected, likely without therapy, and their perceived value [54]. Any negative evaluations derived from the Session Satisfaction Module will also be examined. Consequently, these procedures are intended to facilitate necessary adjustments to the treatment protocol, thereby enhancing its feasibility and acceptability based upon client feedback.

Intervention feasibility measures.

Recruitment rates

Refers to the number of participants able to join the therapy as a result of the recruitment process.

Participation rates

Participants who completely discontinue therapy should be classified as dropouts.

Questionnaire feasibility

The feasibility of the questionnaires will be measured by evaluating the completion rates of the questionnaires including client feedback and the degree of missing data.

Homework evaluation

To assess the value of homework, an adapted version of the Homework Rating Scale (HRS) [55] will be employed, consisting of seven questions rated on a 5-point Likert scale. Participants will be asked to evaluate their level of achievement, understanding, effort, utility, relevance, satisfaction, and the impact of the exploratory tasks assigned during the therapy weeks [22].

Exploratory outcomes.

The exploratory results encompass the primary outcome variables of forgiveness and letting go, as well as the secondary outcome variables of quality of life and depression.

Enright Forgiveness Inventory

The Enright Forgiveness Inventory (EFI) [10] is a self-report measure designed to assess the level of forgiveness in response to a specific offending situation. The scale begins by asking participants to visualize the personal offense and imagine what happened. In a second phase, participants are asked to describe the offense in their own words. The EFI scale comprises 60 items organized into three 20-item subscales that measure affect, behavior, and cognition related to forgiveness, and a final 6-point Likert scale known as the Attitude Scale. Finally, the EFI concludes with a final question assessed on a 5-point Likert scale, which evaluates the extent to which clients report having forgiven their injurer.

Letting Go Measure

The Letting Go Measure [3] is a self-report assessment comprising a single item. It evaluates the extent to which individuals have let go of their negative emotions towards the injurer. Scores range on a Likert scale from 1 to 5 points.

Quality of Life

The European Portuguese World Health Organization Quality of Life Assessment in Older Adults (WHOQOL—OLD) [55,56] comprises 28 items classified on a five-point scale and encompassing seven domains: sensory, autonomy, activities, social, death, intimacy, and family life [56].

Geriatric Depression Scale–15

The Geriatric Depression Scale–15 (GDS-15) [57,58] is specifically designed for screening depressive symptoms in older adults. It consists of 15 straightforward questions, each requiring a simple Yes or No response. The scale ranges from zero (indicating no depressive symptoms) to 15 points (representing the highest severity of depressive symptoms), with each affirmative response scored as 1 point. The cut-off points are defined as follows: 0–4 for the absence of depressive symptoms, 5–8 for mild symptoms, 9–11 for moderate symptoms, and 12–15 for severe symptoms [58].

Quantitative analysis.

Quantitative data analysis will be conducted using SPSS version 29.0 for Windows [60]. Given the study’s exploratory character, particularly with regard to its secondary objective—namely, the study of treatment outcomes—the primary focus is not to test formal hypotheses but rather to provide an initial descriptive overview of the data [22,25]. Accordingly, we have chosen to employ descriptive statistics such as means, standard deviations, frequencies, and percentages to summarize the results. By prioritizing descriptive statistics, we seek to maintain methodological rigor while offering meaningful insights that may inform future, more comprehensive and definitive investigations [35,34].

The ratio of individuals who accepted the invitation to participate in the study relative to the total number of formal invitations sent will help determine the recruitment size. It is anticipated that accurately quantifying the total number of individuals reached through various channels may prove challenging. Additionally, the ratio of participants who complete therapy compared to those who initially commenced it will offer insights into retention rates. Furthermore, the completion rates of the questionnaires will serve as an indicator of their feasibility. Other measures, including assessments of acceptability and feasibility—such as the CEQ, CCIP, Session Satisfaction Module, and Homework Evaluation—will be assessed through exploratory data analysis [22,25,29,34].

To identify and quantify potential associations among the different variables for the main trial, Pearson correlations will be performed to analyze observed changes over time in the control group for all outcome variables. The calculation of the sample size for a future large-scale randomized controlled trial will be guided by the statistical power required to detect clinically meaningful effects, rather than by the provisional estimates derived from this feasibility study [35].

Qualitative analysis.

The data collected from the CCIP will be recorded. After being transcribed, it will be subject to respective analysis.