Emotional Changes & Outcomes In Psychotherapy: Systematic Review

Sønderland, N. M., Solbakken, O. A., Eilertsen, D. E., Nordmo, M., & Monsen, J. T. (2024). Emotional changes and outcomes in psychotherapy: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 92(9), 654–670. https://doi.org/10.1037/ccp0000814

Rationale

This systematic review and meta-analysis aimed to synthesize current knowledge on emotional change processes and mechanisms and their relationship with outcomes in psychotherapy.

The rationale for conducting this study was based on several factors:

1. Increasing focus on identifying processes and mechanisms that make psychotherapeutic interventions effective (Crits-Christoph et al., 2013; Elliott, 2010; Kazdin, 2009).
2. Recognition of emotional processes as particularly promising in understanding therapeutic change (Gross, 2013; Whelton, 2004).
3. The central role of emotions in both healthy adaptive functioning and psychopathology (Aldao et al., 2010; Power & Dalgleish, 2015).
4. The development of various interventions across different therapeutic approaches to increase adaptive emotional functioning (e.g., Foa et al., 2006; Greenberg, 2012; McCullough, 2003).
5. The need for a comprehensive review of emotional change processes and mechanisms across different therapeutic modalities and client populations.
6. The importance of assessing the methodological quality of existing studies to guide future research in this field.

By synthesizing and meta-analyzing the complete existing research on emotional change processes and mechanisms and their relationship to outcomes in psychotherapy for adult clients, this study aimed to provide a comprehensive overview of the field and identify areas for future research and clinical practice improvement.

Method

The authors conducted a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

The study was preregistered at the International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD42016035961.

Search strategy and terms:

The authors conducted a comprehensive search in the electronic databases APA PsycInfo (Ovid), MEDLINE (Ovid), and Web of Science.

The initial search was conducted on March 11, 2016, with updated searches on June 15, 2018, April 8, 2019, and May 26, 2021.

The search strategy combined variations of keywords related to psychotherapy, process, outcome, and emotion.

Inclusion criteria:

1. Quantified emotional process/change mechanism measured during therapy
2. Statistical relationship to a later outcome (at minimum at the next session)
3. Clinical sample of therapy-seeking adult clients (18 years or older)
4. Individual psychological therapy
5. Sample size of at least four clients
6. Published in a peer-reviewed journal
7. Written in English

Exclusion criteria:

1. Non-individual therapy formats (group, couples, or family therapy)
2. Non-clinical samples
3. Child or adolescent populations
4. Constructs with an emotional component but primarily referring to another domain of mind and behavior (e.g., therapeutic alliance)

Results

The authors organized the results according to Doss’s (2004) multiphase model for programmatic change research, which includes therapy change processes, client change processes, and change mechanisms.

1. Overall effect:

The meta-analysis of 130 effect sizes found a moderately strong association (r = .31) between emotional change variables and therapy outcomes.

Substantial heterogeneity (62%) necessitated a random effects model.

Moderator analyses revealed that the type of emotional process significantly moderated the effect, explaining 24% of variability.

This led to further analyses of specific emotional process variables, summarized in Table 3 and Figure 3, along with methodological characteristics of included studies.

2. Therapy change processes:

The study identified two types of therapy change processes: (1) therapists’ emotion-focused interventions and (2) productive emotional interaction between clients and therapists.

Therapists’ emotion-focused interventions showed a weak overall effect (r = .19), but treatment modality was a significant moderator.

In psychodynamic therapy, therapist emotion focus had a moderate effect (r = .31), while in CBT, it had no significant effect (r = .03).

Productive emotional interaction showed a moderately strong association with outcome (r = .34).

3. Client change processes:

Nine types of client change processes were identified and organized into three categories:

a) Emotional processing of fear:

• Fear arousal: Weak but statistically significant effect (r = .17)
• Fear habituation within sessions: Moderate effect (r = .24)
• Fear habituation across sessions: Strong effect (r = .38)

b) Experiencing and transformation of emotion schemes:

• Experiencing: Large effect (r = .44)
• Emotion schemes: Moderate effect (r = .30)
• Emotional arousal: Moderate effect (r = .35)
• Narrative emotion: Non-significant effect (r = .20)

c) Positive and negative emotions:

• Positive emotions: Non-significant effect (r = .15)
• Negative emotions: Weak effect (r = .20)

4. Change mechanisms:

Two classes of change mechanisms were identified:

• Emotion regulation: Strong association with outcome (r = .37)
• Positive and negative emotions: Non-significant associations (r = .12 and r = .13, respectively)

5. Study quality:

There was no moderating effect of study quality.

The average quality score as measured with the Psychotherapy Outcome Study Methodology Rating Form (POMRF) was 17.5 (SD = 8.2), ranging from well below to well above average.

Insight

This comprehensive review and meta-analysis provide several key insights into emotional change processes and mechanisms in psychotherapy:

Fear habituation, emotion regulation, and experiencing emerged as the most robust predictors of therapeutic improvement, with effect sizes in the moderate to large range.

These findings suggest that a common denominator across effective psychotherapies is the reorganization of maladaptive emotional perception, involving improved differentiation between emotional stimuli and responses, increased tolerance for emotional activation, and enhanced capacity for adaptive meaning-making.

The study highlights the importance of examining emotional processes across different therapeutic modalities and mental health conditions, as well as the need for more differentiated approaches to studying emotions in psychotherapy research.

The findings extend previous research by providing a comprehensive overview of emotional change processes and mechanisms across various therapeutic approaches and client populations, updating and expanding on previous meta-analyses focused on specific processes.

Future research should focus on:

• Examining a broader range of differentiated emotions beyond fear and global categories
• Emphasizing the expressive and interpersonal dimensions of emotions
• Addressing methodological issues in process-outcome research, such as establishing time precedence and disentangling within-client and between-client effects
• Investigating the impact of emotional change processes on broader psychosocial outcomes, including interpersonal functioning

Implications

The results of this study have significant implications for clinical psychology practice and research:

Clinical practice:

Therapists should focus on facilitating emotional change processes such as fear habituation, emotion regulation, and experiencing across different therapeutic modalities.

Interventions that promote the reorganization of maladaptive emotional perception and increase emotional differentiation may be particularly effective.

Clinicians should consider incorporating techniques that enhance clients’ ability to distinguish between emotional stimuli and their own responses, as well as improve tolerance for emotional activation.

Research:

Future studies should adopt more rigorous methodologies to address critical issues in process-outcome research, such as establishing time precedence and examining within-client effects.

Researchers should expand their focus to include a broader range of differentiated emotions and emphasize the expressive and interpersonal dimensions of emotions.

Investigation of the impact of emotional change processes on broader psychosocial outcomes, including interpersonal functioning, is needed.

Theory development:

Integration of findings across different therapeutic approaches may lead to more comprehensive models of emotional change in psychotherapy.

Refinement of existing theories to incorporate a more differentiated view of emotions and their role in psychopathology and therapeutic change.

Training and education:

Emphasis on teaching therapists-in-training about the importance of emotional change processes and how to facilitate them effectively.

Development of training programs that focus on enhancing therapists’ ability to work with a range of differentiated emotions and promote adaptive emotional processing.

Policy:

Funding agencies should prioritize research that addresses the methodological limitations identified in this review and focuses on expanding our understanding of emotional change processes in psychotherapy.

Clinical guidelines may need to be updated to reflect the importance of targeting specific emotional change processes across different therapeutic modalities and mental health conditions.

Strengths

The study had many methodological strengths, including:

1. Comprehensive search strategy across multiple databases
2. Adherence to PRISMA guidelines and preregistration of the study protocol
3. Inclusion of a wide range of emotional change processes and mechanisms across different therapeutic modalities and client populations
4. Use of rigorous statistical methods, including random-effects models and examination of heterogeneity and publication bias
5. Systematic assessment of methodological quality of included studies
6. Clear organization of findings using Doss’s (2004) multiphase model for programmatic change research
7. Integration of findings with existing theoretical frameworks and identification of areas for future research

Limitations

1. Geographical: The study was limited to English-language publications, potentially excluding relevant research from non-English speaking countries.
2. Demographical: The review focused on adult populations, excluding research on children and adolescents.
3. Methodological:
   • Only included studies published in peer-reviewed journals, potentially leading to publication bias
   • Limited to individual therapy formats, excluding group, family, and couples therapy
   • Did not systematically search reference lists of included studies
   • Relied on a single reviewer for initial screening of articles
   • Excluded qualitative studies and case studies, which could provide valuable insights into complex emotional processes in psychotherapy

These limitations may impact the generalizability of the findings to non-English speaking populations, younger age groups, and alternative therapy formats.

Additionally, the potential for publication bias and the exclusion of qualitative research may limit the comprehensiveness of the review.

References

Primary reference

Sønderland, N. M., Solbakken, O. A., Eilertsen, D. E., Nordmo, M., & Monsen, J. T. (2024). Emotional changes and outcomes in psychotherapy: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 92(9), 654–670. https://doi.org/10.1037/ccp0000814

Other references

Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2), 217-237.

Citkowicz, M., & Vevea, J. L. (2017). A parsimonious weight function for modeling publication bias. Psychological Methods, 22(1), 28-41.

Crits-Christoph, P., Connolly Gibbons, M. B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 298-340). Wiley.

Doss, B. D. (2004). Changing the way we study change in psychotherapy. Clinical Psychology: Science and Practice, 11(4), 368-386.

Elliott, R. (2010). Psychotherapy change process research: Realizing the promise. Psychotherapy Research, 20(2), 123-135.

Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory: An update. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 3-24). Guilford Press.

Greenberg, L. S. (2012). Emotions, the great captains of our lives: Their role in the process of change in psychotherapy. American Psychologist, 67(8), 697-707.

Gross, J. J. (2013). Emotion regulation: Taking stock and moving forward. Emotion, 13(3), 359-365.

Kazdin, A. E. (2009). Understanding how and why psychotherapy leads to change. Psychotherapy Research, 19(4-5), 418-428.

McCullough, L. (Ed.). (2003). Treating affect phobia: A manual for short-term dynamic psychotherapy. Guilford Press.

Power, M., & Dalgleish, T. (2015). Cognition and emotion: From order to disorder (3rd ed.). Psychology Press.

Whelton, W. J. (2004). Emotional processes in psychotherapy: Evidence across therapeutic modalities. Clinical Psychology & Psychotherapy, 11(1), 58-71.

Keep Learning

Socratic questions for a college class to discuss this paper:

1. How might the findings of this study inform the development of more integrative approaches to psychotherapy that incorporate emotional change processes from different therapeutic modalities?
2. What are the potential implications of focusing on a more differentiated view of emotions in psychotherapy research and practice? How might this change our understanding of psychopathology and treatment?
3. How can we address the methodological limitations identified in this review to improve the quality and validity of future process-outcome research in psychotherapy?
4. What are the ethical considerations in studying emotional change processes in psychotherapy, particularly when it comes to inducing or working with intense emotions in clinical settings?
5. How might cultural differences in emotional expression and regulation impact the generalizability of these findings across diverse populations? How can future research address this issue?
6. What are the potential challenges and benefits of translating these research findings into clinical practice? How can we bridge the gap between research and practice in this area?
7. How might advances in technology and neuroimaging contribute to our understanding of emotional change processes in psychotherapy? What are the potential limitations and ethical considerations of such approaches?
8. Given the importance of emotional change processes across different therapeutic modalities, how might this influence the training of future psychotherapists? What skills and competencies should be emphasized?
9. How do the findings of this study relate to broader theories of emotion and emotional intelligence? What implications might this have for understanding emotional processes beyond the context of psychotherapy?
10. What are the potential long-term implications of focusing on emotional change processes in psychotherapy for mental health prevention and promotion strategies at a societal level?