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Copyright 2008 by the Canadian Psychological Association 0708-5591/08/$12.00 DOI: 10.1037/0708-55220.127.116.11
CPA Award for Distinguished Contributions to Psychology as a Profession – 2007 Prix de la SCP pour contribution remarquable a ` la psychologie comme profession – 2007
Emotion and Cognition in Psychotherapy: The Transforming Power of Affect
Abstract Theory and research on emotion in both psychology and psychotherapy are reviewed to demonstrate the importance of emotion in human functioning and psychotherapeutic change. A proposal is made for the importance of integrating empirically supported emotion-focused change processes into psychotherapeutic work. Five principles of change in the emotion domain— emotion awareness; expression; regulation; reflection on emotion; and the more novel principle of emotion transformation, by which emotion is changed by emotion—are offered as processes of change that are rapidly gathering empirical support. The result of emotion coming of age will be the expansion of theories of dysfunction and of treatment to include emotion-focused coping and emotional processes of change. Keywords: emotion, emotion-focused therapy, awareness, regulation transformation
widely held by several schools of psychotherapy (Bowlby, 1980; Kohut, 1977; Rogers, 1951; Perls, 1969) but has been difficult to prove. However over the past decade, newer therapeutic approaches that treat affect as a primary target of intervention, within the context of an empathic relationship, have been developed, tested, and shown to be effective in the treatment of affective disorders, personality disorders, and trauma (Goldman et al., in press; Svartberg, Stiles, & Seltzer, 2004).
Emotions as an Adaptive Resource
Until recently, the prevalent commonsense view of emotion, endorsed by many, was that emotions were disruptive to functioning, were due to misinterpretation and were to be controlled, tempered, bypassed, or avoided (Beck, 1976). Control of emotion, however, is not always wise or adaptive, and overregulation of emotion, or its avoidance, does not ensure health or happiness. A large volume of research has now been collected on the debilitating physiological effects of not expressing deeply felt emotions (Traue & Pennebaker, 1993). It appears that inhibiting the expression of emotion can lead to impaired immune system function and poorer health on a variety of indices. In addition, there is increasing evidence on the importance of emotion knowledge and emotional intelligence in enhancing social competence and healthy development (Mayer & Salovey, 1997). Emotions are a fundamentally adaptive resource because they involve a meaning system that informs people of the significance of events to their well-being, and they organise people for rapid adaptive action (Frijda, 1986; Izard, 1991; Oatley & Jenkins, 1992; Tomkins, 1963). From birth onward, emotion also is a primary signalling system that communicates intentions and regulates interaction (Sroufe, 1996). Emotion thus regulates self and other and gives life much of its meaning. With the advent of a view of emotion as an adaptive resource, the understanding of its relationship with cognition and its role in human functioning and psychotherapy has changed. This new look has begun to set a new agenda for psychological research—to determine the conditions under which emotions play a determining role in human experience and how this occurs.
This article reviews both the evolving understanding of the role of emotion in human functioning and the evidence for the important role of emotion in psychotherapy, and a set of empirically grounded principles of emotional change is proposed. Given that emotion now is seen as information, as signalling the significance of the situation to a person’s well being, and given that affect regulation is seen as a key human motivation, it has become clear that emotion needs to be focused on, accepted and worked with directly in therapy to promote emotional change. (Foa, Riggs, Massie, & Yarczower, 1995; Fosha, 2000; Greenberg, 2002; Goldman, Greenberg, & Angus, in press; Linehan et al., 2002; Samoilov & Goldfried, 2000). The idea that accessing and exploring painful emotions, within the context of a secure therapeutic relationship, leads to therapeutic change has been
Neurological Evidence on Affective Primacy
Correspondence concerning this article should be addressed to Leslie Greenberg, Department of Psychology, York University, 228 Behavioural Science Building, 4700 Keele Street, Toronto, Ontario M3J 1P3 Canada. E-mail: email@example.com 49
Research emerging from the arena of affective neuroscience supports the conceptualisation of emotion and cognition as separate but interacting mental functions mediated by separate but
Affect. in his study of the neurology of emotion. appear to involve some form of appraisal. A third type of theory emphasises desires to maintain or attain a certain desired state or goal. Memories are thus marked to set off the emotional responses that were set off by the original event. Ultimately. More encompassing multilevel theories of emotion that attempt to integrate a variety of different emotion generation processes have arisen to deal with this complexity. Here. novelty. even when conscious awareness of the stimuli is experimentally prevented. for example. Teasdale and Barnard (1996) more recently suggested a nine-level model starting out at a sensory level moving through a conscious propositional level one level lower than a final tacit implicational level of processing at the top of the hierarchy. Emotion. be it jumping back from a snake. or sadness. the person will feel the same way unless the emotion-schematic memory and associations linked to it are revised. and the slower high road is when the same information is carried through the thalamus to the neocortex. Association helps explains some of the noncognitive and automatic aspects of emotional experience. for example. 2002. However. and conceptual levels were all involved in generating emotions. intrusion. or pleasure. autonomic physiological and motoric aspects of emotion have been shown to occur in response to an emotional stimulus that is not ¨ hman & consciously recognised or is outside of attentional focus (O Soares. Here.” As these images—an argument with a boss. An important consequence of this method of functioning is that people can respond emotionally without thought. however. that the initial “precognitive. as a situation is perceived to fit the category it activates. whereas emotion often is a response to cognition. LeDoux’s (1996) research on the emotional brain has demonstrated that it is possible for our brains to register the emotional meaning of a stimulus before that stimulus has been fully processed by the perceptual system. is generated only with appraisals of blame. Appraisals have. but these may be out of awareness. and Greenberg and Safran (1987) adapted this model to psychotherapy. It should be noted that. 1999). More recently Tucker et al. dialectical . Appraisal theory proposes that some form of cognitive evaluation is fundamental. such as external stimuli previously associated with emotional arousal. Psychological Processes in Emotion Generation Association. only with appraisals of loss. Using functional MRI. posture. is highly adaptive because it allows people to respond quickly to important events before complex and time-consuming processing has taken place. He suggests that there are two different paths for producing emotion. Damasio (1994). In addition. Kuipers. been found only to account for about 40% of emotions (Averill. emotions are elicited and differentiated on the basis of a person’s subjective evaluation or appraisal of the personal significance of a situation. This process involves a different form of evaluation—a match or mismatch with a desired endstate. The neocortex. suggesting that there is more to emotion generation than appraisal alone. thereby making it amenable to new input.” perceptual. As certain images are stored in memory. cognition and emotion are inextricably linked so that cognition often works in the service of affective goals. This is the path by which deliberate conscious cognitive processes can be used to help regulate emotion. These emotions are then restored when the image is recalled. the dynamic. not all emotions are produced associatively. in these studies. orienting consciousness to differentially analyse situations for loss. 1994). 1989). by being so densely interconnected with other brain areas. at times. Rather. Because the shorter amygdala pathway transmits signals more than twice as fast as the neocortex route. Frijda. 2001). the automatic emotional response has already occurred before one can stop it. In this type of model. reinstate goals. or yelling at a disobedient child. LeDoux noted. the principle of association applies to other types of associations. however.50 GREENBERG interacting brain systems. danger. goal frustration can lead to anger without any attribution of wrongdoing or appraisal of blame. they are marked with “somatic information. has a significant influence on decision making. Emotion. 1983. The next time something is recalled. Thus. the anger is motivated by a desire to change undesirable situations. that lack of awareness of the emotionally salient stimulus does not necessarily prevent the person from being aware of emotional experience in response to the nonconsciously processed stimulus. This can be facilitated therapeutically by re-experiencing the emotion-laden memory. also has been found to have fibers leading back to the amygdala and provides a path for cognitive feedback to the emotional systems. or protect boundaries. the thinking brain often cannot intervene in time to stop emotional responses. appraisal. often is thoughtless and may be purely associative. Greenberg & Pascual Leone. schematic. (2003) have shown that an evaluative decision begins by recruiting motivational and semantic influences within limbic networks. anger. Emotions thus. This produces an emotional experience without an actual train of thought. violation. fundamentally. Although he emphasised semantic associations. Association is the most fundamental process of which Bower’s (1981) original associative network theory of emotion is a good example. What he terms the low road is when the amygdala senses danger and broadcasts an emergency distress signal to brain and body. People thus may become angry or sad by means of associative processes without knowing how situational stimuli are affecting them. however. Emotion moves us and reason guides us. & ter Schure. Leventhal (1984) was the first to suggest that sensorimotor. In this view. snapping at an inconsiderate spouse. Emotions thus set a basic mode of processing in motion. Determining under what conditions emotion is and is not governed by cognitive processes remains a central task for psychological research in the coming decades. and facial expression (Berkowitz. explained that the tacit experiential level of functioning involves the development of systematic connections between categories of objects and situations and primary emotions. Whalen et al. sets problems for reason to solve (Greenberg. Greenberg and Pascual Leone (1995. 2001) proposed a dynamic model of emotion construction by synthesis rather than a hierarchical model to explain how change occurs. and degree of goal attainment have all been proposed as important psychological processes in understanding how emotion is generated. or a moment of tenderness with a spouse—are stored. in essence. the feelings experienced in those moments also are stored. (1998) demonstrated amygdala activation in response to emotional stimuli (facial expressions). however. Functional brain imaging studies have provided evidence consistent with LeDoux’s view that the amygdala can perform its role in the processing of emotional stimuli nonconsciously. and these influences appear to shape the development of decisions in various neocortical areas of the brain. for example. emotional processing of the low road.
The importance of accessing and working with the more tacit. Pos. All approaches recognise that awareness of emotion and acceptance of and attention to it in therapy are important to access the information in emotion. & Korman.” but how people make sense of their experience is as crucial as what they experience. and this occurs. The narrative account is significant as a record in memory of experience but often is only peripherally related to the process of generating ongoing emotion. to acknowledge some and bypass others. 1991).. and complexity of emotion cannot develop beyond its instinctual origins without conscious articulation. in and outside of therapy. Without emotion. Epstein. to express those that will enhance relationships. 2007. These models help explain the difference between two ways of knowing: one. Greenberg. and that emotional arousal of productive emotions relates to outcome in psychotherapy (Greenberg. or cognitive–affective. there is no coherence. and plays an independent role in functioning and can affect cognition. interpretations. This approach to differential intervention with emotions is based on the premise that some types of emotional expression are more productive than others. Rice. Greenberg & Safran. Another striking point of agreement is the importance of the meaning construction process. we have a picture in which emotion in therapy needs to be attended to. In addition to agreeing on emotion-laden core structures as the target of change. anger may be a reaction to a feeling of fear of abandonment. control system that orients people to the relevance that events in their environment have to their well-being. range. emotional response to the situation. & Herrmann. are learned responses that are no longer adaptive and need to be regulated and transformed. as well as two kinds of learning (one. more conceptual. logical form of learning. aroused. 2003). there is no motivation to action. and emotions that are a sign of distress are distinguished from emotions that are a sign of working through distress. rather than the hierarchical structuring of levels. Auszra. The type of functioning suggested by these models. for example. 1995). are converging on the view that there are emotional “qualia. Maladaptive emotions.EMOTION AND COGNITION IN PSYCHOTHERAPY 51 synthesis of different components is the focus. to contain and soothe painful emotions. emotional). Buck. Rather. it is important to recognise that not all emotions serve the same function both in and out of therapy and that therapists need to intervene differentially with different types of emotional processes. whereas secondary emotions are a person’s emotional reactions to their own emotional responses to a stimulus. Emotional expression is itself clearly an elaborate cognitive-processing task. 1994. that people are constantly explaining their experience to themselves. but without conscious organisation. Convergence in Psychotherapeutic Views All therapeutic approaches now appear to be converging on a shared view of emotion as a rapid-action. In this emotion-focused view of functioning. gutlevel. acting as dynamic self-organising systems that synthesise many types and levels of information to create their experience (Greenberg & van Balen. appears to be crucial in understanding a variety of areas of human functioning. Thus. adaptive. in which data are integrated from many sources in the brain (often in milliseconds). and when should they change them? Emotion in Psychotherapy In discussing emotion in psychotherapy. Crucial therapeutic questions then become: When should emotions be regulated. a more perceptual and emotionally. For example. 1991). more experiential. which itself may be adaptive or maladaptive depending on the function it serves in the situation. a striking point of agreement across approaches appears to be the shared view that. accepted. 1998. The process of experiencing an emotion thus involves construction (Neimeyer & Mahoney. All views . There is also consensus that emotion and cognition are automatically and intimately connected in higher order meaning making. Problems of overregulation are discriminated from problems of underregulation. at automatic or unconscious levels. the other. and explanations of experience—the reported story of the emotion— often only comes afterward. emotional and cognitive structures are highly integrated and that these affective– cognitive. Human beings thus are seen as actively constructing their sense of reality. rather than to the situation itself (Greenberg. Pascual-Leone. sets a basic mode of information processing in motion. on the other hand. factual. accept or be guided by them). In addition. outside awareness. In this view. 2002. Greenberg. Therapists do not simply help clients regulate all emotions or become aware of or express all feelings. a more conceptual. 1987). in which separate but interacting mental functions are mediated by separate but interacting brain systems. as well as emotion regulation. Mahoney. primary emotions are the person’s most fundamental. Goldman. 1987. and both are important in intervention. and processed. Therapists intervene differentially with clients depending on their assessment of the in-session emotional state. 1991. Primary emotions. The conscious narrative flow of evaluations. 1988. & Elliott. the other. The depth. structures are the important targets of treatment. they distinguish clinically among different types of emotions to guide their interventions. need to be accessed for their adaptive information and capacity to organise action. helping them to accept and integrate certain emotions. as well as regulated and changed when necessary. and when should they be facilitated or phrased differently? When should people be changed by their emotions (i. All agree that emotion produces tendencies to act in specific ways in response to those events.e. immediate reaction to a situation. in the main. to regulate disruptive emotions. associative one. and to explore and transform maladaptive emotions. the operation of two types of memory (one. 1993). The final point of agreement is that in therapy it is important to promote emotional experience. and that how they make sense of their experience influences their experience. All agree that desynchronies or incongruence between cognition and emotion and physiology occur and need to be overcome. Meaning results from the dialectical synthesis of emotion and reason. the approaches appear to agree on a number of other specific points of practice. and the other. Another point of agreement is that emotion often needs to be aroused to access the core structures generating it and that the experience generated by these need to be further processed in therapy to promote change. the person’s first. individuals are seen as consciously making sense of an independent source of affective experience that has to be organised by consciousness to construct meaning. procedural means of generating affective experience rather than more conscious declarative processes has been noted by a number of writers (Bohart & Wugalter.
changes physiology and neurochemistry. 2007). and empathic environment is the first level of intervention that helps soothe and regulate automatically generated underregulated distress (Bohart & Greenberg. . To overcome emotion avoidance. clients must first be helped to approach emotion by attending to their emotional experience. Secondary maladaptive emotions need to be reduced by exploring them to access their more primary cognitive or emotional generators. Holowaty. blends of emotion.. agency. Empathy from another person seems to be important in learning to self-soothe and restore emotional equilibrium and help strengthen the self (Greenberg et al. frantic efforts at control. these are physical sensations. but there is still not a comprehensive. 1993). and exposure have all been put forward as explanations of the role of emotion in change. Levels of emotional awareness correlate significantly with self-restraint and impulse control. 2001. With this more differentiated perspective. such as in exposure treatments for anxiety in youth and adults (Kendall & Hedtke. obsessive rumination. 1995). & Morral. Arousal appears to be necessary but is not necessarily sufficient for certain types of therapeutic progress. Jellis. tolerate. (d) reflecting on emotion. Individual differences in emotion awareness have also been found to predict recovery of positive mood and Emotion Regulation The provision of a safe. Recently. The following five principles provide an empirically based understanding of emotional change processes in clinical change: (a) increasing awareness of emotion. Emotional Arousal and Expression Emotional expression mobilises the affect system. Principles of Working With Emotion Outcome and process research findings point toward emotional processes as centrally important to good therapy. Jaycox. 2001) during the first exposure and habituation (reduced distress) during exposure (Foa & Jaycox. but what is good processing remains to be elucidated (Greenberg & Pascual Leone. & Tran. It is important to note that emotional awareness is not thinking about feeling. 1998) over the course of therapy predict better outcome. and changes interpersonal interaction. Undercontrolled secondary emotions and maladaptive emotions are what need to be regulated. Emotional insight.” Primary emotions need to be accessed for their adaptive information and capacity to organise action. Becoming aware of and symbolizing core emotional experience in words provides access both to the adaptive information and action tendency in the emotion. Emotional expression has recently been shown to be a unique therapeutic aspect of emotional processing that predicts adjustment to breast cancer (Stanton et al. Mayer. Emotion Awareness The first and most general goal of emotional change is the promotion of emotional awareness. instrumental emotions are those emotions that are used consciously or unconsciously to achieve an aim. overcomes inhibition. validating. Hall. but at different times we may want to help them access productive primary emotions. Clients with underregulated affect have been shown to benefit both from validation and from the learning of emotion regulation and distress tolerance skills (Linehan. There. 1999. and so forth. Emotional arousal and expression. and blends of blends of emotional experience (the capacity to appreciate complexity in the experiences of self and other). Acceptance of emotional experience as opposed to its avoidance is the first step in emotion work. however. Five levels of emotional awareness can be measured.52 GREENBERG Secondary emotions may be defenses against feelings such as shame at one’s sadness. Finally. indicating that greater emotional awareness is associated with greater selfreported impulse control. single emotions. In ascending order. initiating guilt. Only when emotion is felt does its articulation in language become an important component of its awareness. Labelling emotions often is a first step in problem definition. action tendencies. catharsis. 2002). although helpful. we see that not only do we want to help clients down-regulate unproductive dysregulated secondary and primary maladaptive emotions. Secondary emotions need to be explored to access their more primary cognitive or emotional generators. (b) expressing emotion. such as crying “crocodile tears. distinguished good from poor outcome cases in which productivity was defined in terms of degree of regulation. There is a long line of evidence on the effectiveness of arousal of and exposure to previously avoided feelings as a mechanism of change. The goal is for clients to become aware of their emotions and. rather than arousal alone. and accept their emotions. and the other pathway pathologises some emotional experiences leading to attempts to distort or avoid them. The therapist thus needs to help clients approach. and (e) transforming emotion (Greenberg. (2002) found evidence for the effectiveness of emotional validation and soothing as part of the treatment for borderline personality disorder. 2002. 1997). 2005). supportive. more specifically. Leahy (2002) noted that there are two fundamental coping pathways for dealing with emotion: One pathway involves attending to and labelling emotions in a manner that accepts and normalises them.. Paivio & Nieuwenhuis. Important issues in any treatment are what emotions are to be regulated and how these emotions are to be regulated. 2006). for example. Linehan et al. or reactions to negative thoughts. can be no universal rule about the effectiveness of arousing emotion or evoking emotional expression. (2007) found that the degree of productivity of processing of aroused emotions. Turvey. Results from a variety of studies also support that emotional engagement with trauma memories in early sessions (Paivio. Awareness of emotion also involves overcoming the avoidance of emotional experience. awareness. Greenberg et al. Emotion awareness has been grounded in a measure of levels of emotional awareness developed by Lane and associates (Lane & Schwartz. decrements in ruminative thoughts after a distressing stimulus (Salovey. Foa. & Palfai. 1992). Greenberg & Watson. empirically based understanding of how emotion and its processing lead to change. whereas maladaptive emotions need to be regulated and transformed. and processing of the emotion. are not always useful in therapy or in life. it involves feeling the feeling in awareness. hopelessness when angry. Golman. 2006). (c) enhancing emotion regulation. 2000) and resolving interpersonal problems (Greenberg & Malcolm. their primary adaptive emotions.
however. 1993. rather than emotion control. all emotions occur in the context of significant stories. the facilitation of adaptive emotions is seen as necessary. These can be learned deliberately and with practice. 1976). Guidano. & Camras. For example. primary. breathing. Alternately being able to symbolise and explain traumatic emotional memories in words helps promote their assimilation into one’s ongoing self-narrative (Van der Kolk. 2003). This form of putting emotion into words allows previously unsymbolised experience in emotion memory to be assimilated into conscious. This principle applies to all types of emotion: secondary. 2000. Although the more traditional ways of transforming emotion— either through exposure. most novel. and physical and emotional health (e. Finkenauer. especially for personality-disordered clients. Emotion. feeling usually changes emotions. Rather than reason with emotion. In addition to the value of emotional awareness as a source of information. 1997). is generating theory and research to help understand the extent to which automatic emotion processes can be changed through (a) deliberate regulation processes and (b) more implicit regulation processes based on new emotional and/or relational experiences. can be down-regulated by developing tolerance and soothing at a variety of different levels of processing. and all stories involve significant emotions (Greenberg & Angus. 1998. regulation is seen as an aspect of emotion generation. 1990). and this helps clients develop new narratives to explain their experience (Greenberg & Angus. another process appears to be more important. He proposed that “An emotion cannot be re- Reflection on Emotion The role in psychotherapy of the human capacity for conscious awareness of the processes and contents of their own mind. An issue of major clinical significance. Problems in vulnerable personalities arise most often from deficits in the more implicit forms of regulation of emotion and its intensity. There also is a vast empirical literature on the influence of attributions and cognition on emotion in general. and distraction also have been found to help with tolerance of high distress (Linehan. increasing positive emotions. allowing and tolerating emotions. Emotion Transformation The final.EMOTION AND COGNITION IN PSYCHOTHERAPY 53 Regulation of underregulated emotion involves getting some distance from despair and hopelessness and/or developing selfsoothing capacities to calm and comfort core anxieties and humiliation. and on depression in particular (Clarke & Blake. Implicit forms of regulation often cannot be trained or learned as a volitional skill. Frankel. Pennebaker and colleagues have shown the positive effects of writing about emotional experience on autonomic nervous system activity. Zech. in addition. and ultimately assimilate both their emotional experiences and the events that may have provoked the emotions. and completion or through reflection on them— do occur. People with underregulated affect have been shown to benefit both from interpersonal validation and from the learning of emotion regulation and distress tolerance skills (Greenberg & Watson. reducing vulnerability to negative emotions. As witnessed in therapy. In time. Therapy thus involves change in both emotional experience and change in the narratives in which they are embedded. Through language. the building of implicit or automatic emotion regulation capacities is important for enduring change. emotion regulation is viewed as having the desired emotions at adaptive levels at the right time. In addition. evaluate their own emotional experience. self-soothing. Linehan et al. believe that emotion regulation is not easily achieved through the cognitive system alone (Campos. and share their experience with others (Pennebaker. apy (Frank. In views of emotion regulation in which regulation is seen as coterminous with generation. Although deliberate behavioural and cognitive forms of regulation—more left hemispheric process—are useful for people who feel out of control. Schore. In addition. or maladaptive. 1998. as well as in literature. and understanding that this relates to one’s past history of abandonment. symbolizing emotion in awareness promotes reflection on experience to create new meaning. In clinical work.g. structure. Greenberg & Pascual-Leone.. 1993. therapists. Fosha. and other sympathetic functions that speed up under stress. Physiological soothing involves activation of the parasympathetic nervous system to regulate heart rate. This novel principle suggests that a maladaptive emotional state can be transformed best by undoing it with another more adaptive emotion. Here. create new meanings. 2004. 2004). understanding that one is prone to get angry at one’s partner because one feels abandoned. has been substantial. one can transform one emotion with another. Pennebaker. 2000). conceptual understandings of self and world. Spinoza (1967) was the first to note that emotion is needed to change emotion. Understanding an emotional experience always involves putting it into narrative form. 1993). experience. establishing a working distance. Here. the co-activation of the more adaptive emotion along with or in response to the maladaptive emotion helps transform the maladaptive emotion. once emotions are put into words. This applies most specifically to transforming primary maladaptive emotions by contact with more adaptive emotions. 2004. breathing. 1995. immune functioning. Whereas thinking usually changes thoughts. Pennebaker.. 1974). Emotion self-regulation skills that involve such things as identifying and labelling emotions. from the beginnings of psychoanalysis right up to the present day. 2002). and therapy is based on the acceptance or facilitation of particular emotions. and for reason and insight to shed light on unconscious motivations. Linehan. 1995. & Philippot. Clinical work that views dysfunction as resulting from faulty learning and skill deficit also sees emotion regulation as following emotion generation and has focused on teaching skills and changing the cognitive system to regulate emotion (Beck. Linehan. 2002). 1995). Rime ´ . 1998). that attests to the importance of reflecting on emotion to create meaning. is very therapeutic. over time. adaptive. people are able to reflect on what they are feeling. a number of theorists. 1997. then. many therapists have written on the importance of changing people’s assumptive frameworks in ther- . expression. and clinical work focuses on clarifying which emotions one allows into awareness. Hunt. Luminet.. This is a process of changing emotion with emotion (Greenberg. Forms of meditative practice and self-acceptance often are most helpful in achieving a working distance from overwhelming core emotions (Teasdale et al. where it can be organised into a coherent story. What we make of our emotional experience makes us who we are. individuals are able to organise. 1995). and researchers. and probably most fundamental principle of emotional change involves the transformation of one emotion by another.
These are then transformed by accessing adaptive emotions such as anger. Once the alternate emotion has been accessed. This involves more than simply feeling or facing the feeling. Although exposure to emotion. in grief. According to Isen (1999). emotional change occurs by the activation of an incompatible. The basic observation is that key components of positive emotions are incompatible with negative emotions. For example. first the secondary emotion is evoked. maladaptive emotions need to be accessed to be transformed. 1995. Branigan. in that the maladaptive feeling is not purged. more adaptive experience that replaces or transforms the old response. however. When opposing schemes are co-activated. Withdrawal emotions from one side of the brain are replaced with approach emotions from another part of the brain. Frederickson (2001) suggested that. 2000). In an interesting line of investigation. When adaptive emotions finally are evoked. are dynamically synthesised into a higher level scheme for walking (Greenberg & PascualLeone.g. Sadness. These studies together indicate that emotion can be used to change emotion. maladaptive fear. p. The link between both therapeutic alliance and empathy and outcome are . It is important to note that the process of changing emotion with emotion goes beyond ideas of catharsis or completion. Mancuso. In contrast. Whelton and Greenberg (2004) found that people who were less vulnerable to depression were able to recruit emotional resources such as self-assertive anger to combat depressogenic contempt and shame.g. shame. Being able to remember the happy times and to experience joy helps as an antidote to sadness (Bonanno & Keltner. once aroused. sadness of grief or empowering anger are accessed and validated). can be transformed into security by the more boundary-establishing emotions of adaptive anger or disgust or by evoking the softer feelings of compassion or forgiveness. Reason clearly is seldom sufficient to change automatic emergency-based emotional responses. experience that undoes or transforms the old response. more adaptive. in a toddler. despairing. it appears that bad feelings can be transformed by happy feelings. then the core primary adaptive emotion that is being interrupted (e.54 GREENBERG strained nor removed unless by an opposed and stronger emotion” (1967.. leading it to diminish. maladaptive anger can be undone by adaptive sadness. Thus. Thus. Maladaptive shame can be transformed by accessing both anger at violation and self-comforting feelings and by accessing pride and self-worth. Rather.. 1997). 2001). Warwar. 2004). Pascual-Leone. and a new state is forged.195). in a study of self-criticism. thereby creating new meaning. a protest-filled. may be helpful to overcome affect phobia in many situations in therapy. Secondary emotions need to be bypassed to get to more primary emotions. just as in development when schemes for standing and falling. For example. it transforms or undoes the original state. emotional change occurs by the activation of an incompatible. submissive sense of worthlessness can be transformed therapeutically by guiding people to the desire that drives their protest—a desire to be free of their cages and to access their feelings of joy and excitement for life. not in a simple manner. is required to transform maladaptive core emotion. and forgiveness have also been observed to change anger (Malcolm. at times. In these instances. the therapeutic relationship is the crucible of emotional processing. Davidson (2000) suggested that the right hemispheric withdrawal-related negative affect system can be transformed by activation of the approach system in the left prefrontal cortex. on specific parts of the brain that influence purposive thinking. A three-step sequence.. which occurs by exposing them to new experience. both clinical and research observations show that many different emotions can change distressing emotions. extinction or habituation. Warmth and affection are similarly often an antidote to anxiety. positive emotions have been found to undo lingering negative emotions (Frederickson. Rather. nor does it simply attenuate by the person feeling it. Applications of the Principles to Treatment Working with these principles involves first differentiating between emotional experiences that are adaptive or maladaptive and emotions that are primary or secondary. sadness. and Tugade (2000) found that resilient individuals cope by recruiting positive emotions to regulate negative emotional experiences. and then core maladaptive emotions being avoided (e. change also occurs because one emotion is transformed by another emotion rather than simply attenuating. fear. Empowering anger in therapy changes depressive hopelessness and shame. the symptomatic secondary emotions (e. such as by trying to look on the bright side. they synthesise compatible elements from the co-activated schemes to form new higher level schemes. laughter has been found to be a predictor of recovery. Rather than reason with emotion. or vice versa (Davidson. In this sequence. and compassion. love. and hopeless) are evoked in therapy. 1991). In depression. Primary emotions need to be accessed in awareness for their adaptive information and capacity to organise action. feeling upset. Mild positive affect has been found to facilitate problem solving. the tendency to shrink into the ground in shame is transformed by the thrustingforward tendency in newly accessed anger at violation. & Greenberg. The Therapeutic Relationship In addition to the principles of emotional change. The experience of joy and contentment were found to produce faster cardiovascular recovery from negative emotions than a neutral experience. it has been hypothesised that at least some of the positive effect of happy feelings depends on the neurotransmitter’s effect. Clinical observation and research suggests that emotional transformation occurs by a process of dialectical synthesis of opposing schemes. one needs to transform one emotion by accessing another emotion. they are incorporated into new views of self and used to transform personal narratives. However it is not only that unpleasant feelings are transformed by pleasant ones. Frederickson.g. as well as the anxiety and fear in anxiety disorders. by broadening a person’s momentary thought action repertoire. Similarly. A two-step therapeutic process is recommended when the core emotion avoided is adaptive. or anger) are accessed. They found that these individuals manifested a physiological bounce back that helped them to return to cardiovascular baseline more quickly. but through the evocation of meaningfully embodied alternate experience to undo the negative feeling. in therapy. Schemes of different emotional states similarly are synthesised to form new integrations. a positive emotion may loosen the hold that a negative emotion has on a person’s mind. In addition. another feeling is used to transform or undo it. First. Emotion-focused therapy (EFT) suggests that it is important to be aware of and reflect on primary emotions and to regulate and transform maladaptive emotions. Thus. exposure. in the experiencing of joy.
& Behar. Greenberg. EFT for adult survivors of childhood abuse (EFT-AS). & Stalikas. Outcome research supports the efficacy of exposurebased therapies with diverse traumatised populations. Sixty-six clients participated in 16 sessions of weekly psychotherapy. In addition. 2001). had no relationship to outcome. Greenberg.. This study found that collaborative emotional exploration. Greenberg & Pascual-Leone. EFTs have shown to be effective in both individual and couples therapy in a number of randomised clinical trials (Elliott et al. validating.. 2004. 2002. In these studies. in press. & Goodman. Watson. & Schindler.. pure cognitive therapy. and regulating (Greenberg. Short-term dynamic therapy (STDP) that works on overcoming defenses and treats affect phobia by exposure to dreaded emotion has garnered empirical support in the treatment of cluster C personality disorders when compared with CBT. Clarkin. Process research has consistently demonstrated a relationship between in-session emotional activation and outcome. Watson et al. focusing. general symptom distress.g. 1993). has been found to be highly effective in treating depression in three separate studies (Goldman et al. Hunsley. avoidance.and 18-month follow-ups. so that high arousal predicted good session outcome. This provides evidence that the addition of PE emotion-focused interventions to the foundation of a CC relationship improves outcome. Statistically significant differences among treatments were found on all indices of change for the combined sample. an avoidance theory of generalized anxiety disorder.. More recently. Reviews of past process– outcome studies testing these claims show a strong rela- . empirical research on the independent role of emotion in therapeutic change is growing. has been found to be effective in treating abuse (Paivio & Nieuwenhuis. EFT for depression was found to be equally or more effective on some measures than both a purely relational empathic treatment and a cognitive– behavioural treatment.71 in favour of PE therapy. systematic evocative unfolding. Greenberg. Elliott. In a later study. 2004. In studies across several types of psychotherapy. 2003). If the client feels overwhelmed and emotion is dysregulated. 1999). Gordon. The EFT treatment added the use of specific tasks to the client-centered (CC) therapy—in particular. 1994). 1988) that involves partners revealing their underlying attachment and identity-related vulnerable feelings to each other has been found to be effective in treating couples’ distress (Johnson. Shapiro. Rothbuam. Greenberg. 2004). Emotionally focused couples therapy (Greenberg & Johnson. thereby heightening emotional activity (Gendlin. which uses empathy plus empty-chair work and involves arousal and processing of painful emotions. & Furr. Evidence-Based Treatment In addition to the aforementioned theoretical and empirical developments. two chair. and there is reason to believe that a good alliance is a prerequisite to productive emotional processing. 2001). the relationship is soothing.EMOTION AND COGNITION IN PSYCHOTHERAPY 55 widely recognised (Greenberg. They then combined the York I and II samples to increase power of detecting differences between treatment groups. has gained support (Borkovec et al. Rogan. 1999). process– experiential (PE) therapy (in which specific emotion activation methods are used within the context of an empathic relationship). they obtained a comparative effect size of . utilised more frequently in CBT. and supportive. However. was found to relate positively to outcome in both forms of therapy. and exploring them in therapy appears to be important in therapeutic change. 1999). 2002) examining therapists’ stance on interpersonal therapy and CBT for depression showed the importance of focusing on emotion. The Process of Change In addition to clinical trials. Hefferline. Whelton. the role of emotional arousal has been found to be mediated by the working alliance (Beutler. Winston et al. if the client’s level of arousal is unproductively low (e. On the other hand. clients in both groups developed significantly more emotional reflection for solving distressing problems. focusing collaboratively on emotions. including survivors of child abuse (e. but only when there was a strong alliance (Iwakabe. clients in PE therapy were significantly more self-assertive and less overly accommodating at the end of treatment than clients in CBT. Winston et al. 2000). a number of approaches focused on working directly with emotion have been demonstrated to be effective in randomised clinical trials (Elliott. & Steckley.g. Watson. Kalogerakos. Helping people overcome their avoidance of emotion. regardless of orientation. focusing. & Jones. Stermac. Samoilov & Goldfried. Goldman et al. 1951). providing empirical support for the importance of focusing on painful emotion in therapy. 1999). and empty chair dialogue. 1994. Coleman. Shapiro. 2004. whereas educative/directive process. Greenberg & Watson. There were no significant differences in outcome on depression between groups. (2003) carried out a randomised clinical trial comparing PE therapy and cognitive– behavioural therapy (CBT) in the treatment of major depression. (in press) replicated the York I study by comparing the effects of CC and PE therapy on 38 clients with major depressive disorder. and brief supportive psychotherapy (Svartberg et al. the relationship can be empathically evocative. which occurred significantly more frequently in interpersonal therapy. self-esteem. Alcaine. & Lietaer. CBTs based on exposure to imaginal stimuli have a long history of demonstrated effectiveness for trauma and other anxiety-related disorders (Borkovec. particularly at follow-up. 2002. Both treatments were effective in improving clients’ level of depression. Johnson.. At the end of treatment. 2006. 2000).. Paivio & Nieuwenhuis. & Schlindler.. in which worry is understood as a cognitive response that orients individuals to a threat while insulating them from the immediacy of their emotional experience. A more recent study (Coombs. with differences maintained at 6. Hunsley. Foa. & Bongar. In the York II Depression Study.. Linehan. & Bohart. Perls. A manualised form of EFT of depression. 1998. worry intellectualization). regardless of therapeutic orientation. The importance of facilitating in-session emotional experience to promote change has become increasingly recognised (Greenberg. 2002. 1996. Jones and Pulos (1993) found that the strategies of evocation of affect and the bringing of troublesome feelings into awareness were correlated positively with outcome in both dynamic treatment and CBT in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. 2003. 2001. and dysfunctional attitudes. 2000). 1991). A convincing amount of outcome research also supports the efficacy of STDP in the treatment of complicated Axis I disorders (Winston et al. 2004. 2004).
qui incluront la re ´ ponse de l’individu face aux e ´ motions et les processus e ´ motionnels du changement. Supporting the first aspect of this hypothesis. Goldfried. nor does entering therapy without this capacity guarantee poor outcome. and make sense of it. Re ´ sume ´ Le document traite des the ´ ories et des recherche relatives aux e ´ motions. they also must access other internal emotional resources to help transform the maladaptive state. Kiesler. K. Early capacity for emotional processing thus does not guarantee good outcome. In this article. 1996). 1979. The recipe for emotional processing from the perspective of behaviour therapy is arousal plus habituation to the distressing stimulus and exposure to new information: In short. Mathieu. Warwar. & Gendlin. l’expression. as measured by the Experiencing Scale (Klein. L’inte ´ gration de processus de changement axe ´ s sur les e ´ motions. Studies of the behavioural treatment of anxiety disorders has long demonstrated that clients who profited most from systematic desensitization (Borkovec & Stiles. 1996). S. & Johnson. Warwar. & Curtis. The role of the cognitive processing of emotion in therapy has been found to be twofold. 2003). when expressed in supportive relational contexts and in conjunction with some sort of conscious cognitive processing of the emotional experience. 2005. & Hart. 1986). More recently. Therapists’ interventions that focused more deeply on client’s experience were also shown to deepen clients’ experience and to predict outcome (Adams & Greenberg. it is the experience of old distress in the presence of new information accrued experientially in the moment. A similar effect of the expression of underlying emotion was found in resolving family conflict (Diamond & Liddle. 1996.. A client’s individual capacity for emotional processing early in therapy also predicted outcome.. The evidence from psychotherapy research indicates that certain types of therapeutically facilitated emotional awareness and arousal. Fretter. 1999). and experiential therapies (Castonguay. 2006). process– outcome research on EFT for depression has shown that both higher emotional arousal at midtreatment. indicating the importance of combining arousal and meaning construction (Missirlian. explore. High emotional arousal plus high reflection on aroused emotion distinguished good and poor outcome cases. reflect on. In addition. Ford. From an experiential therapy perspective. EFT thus appears to work by enhancing the type of emotional processing that involves helping people experience and accept their emotions and make sense of them. 1969) and therapeutic gain in dynamic. Orlinsky & Howard. These findings suggest that processing one’s bodily felt experience and deepening this in therapy may well be a core ingredient of change in psychotherapy. Therapists’ influence of depressed clients’ therapeutic experiencing and outcome. In addition. cognitive. Silberschatz. which accompanied the softening in the blaming-partners stance. phases of treatment was found to be a better predictor of outcome than early level of processing or than the early alliance (Pos et al. were found to interact more affiliatively and ended therapy more satisfied than couples who showed lower experiencing (Greenberg. 1993. Lang. cognitive. Greenberg & Pascual-Leone.. however. Alden. Paper pre- . Toukmanian. early emotional-processing skill appears not to be as critical as the ability to acquire and/or increase depth of emotional processing throughout therapy. E. clients must also cognitively orient to that experience as information. acceptance. 1971) exhibited higher levels of physiological arousal during exposure. 1988) that helps partners access and express underlying attachment-oriented emotions. couples who showed higher levels of emotional experiencing in therapy. optimum emotional processing involves the integration of cognition and affect (Greenberg. & Greenberg. Once contact with emotional experience is achieved. 2003) predicted good treatment outcomes. la re ´ gulation et la re ´ flexion sur les e ´ motions ainsi que le principe novateur de la transformation de ces dernie ` res. 1970) and flooding (Watson & Marks. releve ´ es dans les domaines de la psychologie et de la psychothe ´ rapie. Research on couples therapy also supports the role of emotional awareness and expression in a satisfying relationships and change in therapy. 1996. or early to late. soutenus empiriquement. either to help make sense of the emotion or to help regulate it. 1986. arousal.. Johnson et al. but the increase in degree of emotional processing from early to mid-. en vue de montrer l’importance de ces e ´ tats affectifs dans le fonctionnement humain et le changement psychothe ´ rapeutique. & Pos. These and other findings suggest that the arousal of the fear-activated phobic memory structures is important for change. June).56 GREENBERG tionship between in-session emotional experiencing. Johnson & Greenberg. Emotionally focused couples therapy (Greenberg & Johnson. integrative. On propose cinq principes de changement dans le domaine des e ´ motions : la reconnaissance. Privileging one system for therapeutic attention over the others leads to a narrowing of perspective. has been found to be effective in increasing marital satisfaction (Johnson & Greenberg. Conclusion The emotion/motivation. Although likely an advantage. Raue. a number of principles for working with emotion have been suggested to promote the inclusion of emotion-focused work into an ultimate empirically based. Makinen & Johnson. and behavioural systems are all important in therapeutic work. & Greenberg. emotionfocused cognitive behavioural therapy for the new millennium. In therapy. dans l’exercice psychothe ´ rapeutique est fortement sugge ´ re ´ e. L. Greenberg. Understanding the conditions under which it is optimal to intervene therapeutically with a specific system is crucial. emotions sometimes need to be accessed and used as guides and at other times regulated and modified. coupled with reflection on the aroused emotion (Warwar & Greenberg. 1985. & Hayes. selon lequel une e ´ motion peut changer une e ´ motion. Mineka & Thomas. and tolerance of emotional experience are necessary but not sufficient for change. 2003). L‘e ´ tude des e ´ motions en pleine e ´ volution se traduira par les the ´ ories de la dysfonction et du traitement connexe. regardless of approach. Wiser. 2005. (1996. Il s’agit de processus de changement qui se me ´ ritent un soutien empirique grandissant. 1995). and deeper emotional processing late in therapy (Pos et al. 1985. 1999). methods that increase arousal have also been found to be effective in treating panic (Clarke. is important for therapeutic change with regard to certain classes of people and problems. 2002. Goldman. Melamed. 1999). References Adams. Emotion also has been shown to be both adaptive and maladaptive. approach.
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