Sønderland, N. M., Solbakken, et al. (2024).
Journal of Consulting and Clinical Psychology,
92(9), 654–670.
Abstract
Objective: This systematic review and meta-analysis summarize current knowledge on emotional change processes and mechanisms and their relationship with outcomes in psychotherapy. Method: We reviewed the main change processes and mechanisms in the literature and conducted meta-analyses of process/mechanism–outcome associations whenever methodologically feasible. Results: A total of 121 studies, based on 92 unique samples, met criteria for inclusion. Of these, 85 studies could be subjected to meta-analysis. The emotional change processes and mechanisms most robustly related to improvement were fear habituation across sessions in exposure-based treatment of anxiety disorders (r = .38), experiencing in psychotherapy for depression (r = .44), and emotion regulation in psychotherapies for patients with various anxiety disorders (r = .37). Common methodological problems were that studies often did not ascertain representative estimates of the processes under investigation, determine if changes in processes and mechanisms temporally preceded outcomes, disentangle effects at the within- and between-client levels, or assess contributions of therapists and clients to a given process. Conclusions: The present study has identified a number of emotional processes and mechanisms associated with outcome in psychotherapy, most notably fear habituation, emotion regulation, and experiencing. A common denominator between these appears to be the habitual reorganization of maladaptive emotional perception. We view this as a central pan-theoretical change mechanism, the essence of which appears to be increased differentiation between external triggers and one’s own affective responses, which facilitates tolerance for affective arousals and leads to improved capacity for adaptive meaning-making in emotion-eliciting situations.
Impact Statement
This review demonstrates that helping clients differentiate between emotion-eliciting stimuli and their associated affective responses is essential across theoretical approaches. Increased affective differentiation presumably leads to reorganization of perceptual processes, improves tolerance of emotional activation, and fosters openness to the informational value of emotions, thus leading to therapeutic improvement. Findings also indicate that psychotherapy models focusing on emotional processes would profit from more systematically differentiating between different emotions (e.g., anxiety, sadness, anger, contempt, disgust, shame, guilt, interest, joy, and tenderness) and more explicitly focusing on helping clients adaptively express such emotions.
Here are some thoughts:
This systematic review and meta-analysis comprehensively examines emotional change processes and mechanisms in individual psychotherapy for adults, marking a significant contribution to the field by covering various aspects not previously included in meta-analyses. The review synthesizes findings from 121 studies, with 85 suitable for meta-analysis, focusing on key emotional processes such as emotion regulation, emotional arousal, and the dynamics of positive and negative emotions. The analysis categorizes emotional changes into therapy change processes—changes occurring within the therapeutic setting—and client change mechanisms that manifest outside of therapy. The overall relationship between therapy change processes and outcomes was moderately strong (r = .28), with productive emotional interaction emerging as a robust predictor of therapeutic success.
The review highlights several critical client change processes, particularly fear arousal and habituation, which are essential for exposure therapy. Experiencing, a well-researched process related to the transformation of emotion schemes, demonstrated a strong association with improvement (r = .44). Additionally, adaptive emotion regulation strategies were linked to positive outcomes (r = .37), while positive and negative emotions showed weaker associations. The findings suggest that enhancing clients' ability to differentiate between emotional stimuli and their responses is crucial across therapeutic models. However, methodological limitations were noted, including insufficient attention to causality and a lack of focus on broader psychosocial outcomes beyond diagnostic symptoms. The authors advocate for future research to adopt more differentiated views of emotions and emphasize the expressive dimension of emotional utilization to enhance therapeutic efficacy. Overall, this review underscores the importance of emotional processing in psychotherapy and suggests directions for future research to improve treatment outcomes.
