Clinical Psychology and Psychotherapy Clin. Psychol. Psychother.

11, 5871 (2004)

Emotional Processes in Psychotherapy: Evidence Across Therapeutic Modalities

William J. Whelton*
University of Alberta, Edmonton, Alberta, Canada This article briey reviews recent process research on emotion in humanistic, cognitive, behavioural and psychodynamic psychotherapies. Cognitive therapy has traditionally shown less interest in emotional processes than the other therapies, but the interest of the others has not always borne fruit in empirical research. At the present time there is an interest in emotion research in therapy that cuts across all therapeutic modalities. Emotional processing and depth of experiencing, two heavily-researched emotion process categories of the behaviourists and humanists respectively, have been shown to have a robust association with outcome. There is accumulating evidence that both the in-session activation of specic, relevant emotions and the cognitive exploration and elaboration of the signicance and meaning of these emotions are important for therapeutic change. Further research on emotional processes in psychotherapy is required. Copyright 2004 John Wiley & Sons, Ltd.

INTRODUCTION
Emotions are both the means and the measure of ones engagement with the world (Frijda, 1986) and emotional distress is usually what brings people to therapy. As Damasio (1994) so tellingly demonstrated in his analysis of specic brain lesions, without emotion human life lacks the organizing power of motivated choice and goal-directed activity. It stands to reason that psychotherapy, a process in which people attempt to recollect, explore, understand and change themselves, is infused with emotion. This paper will present a brief overview of the research that has been carried out on emotional processes in psychotherapy, concentrating especially on the recent past.

* Correspondence to: Dr William Whelton, 6-123 Education North Building, University of Alberta, Edmonton, Alberta, Canada T6G 2G5. E-mail: william.whelton@ualberta.ca

This review will begin by examining research in the humanistic-experiential therapies, in which attention to emotion has become more rened and empirically grounded (e.g. Greenberg & Safran, 1987). The initial focus will be on experiencing, a widely-studied construct with a venerable humanistic tradition (Gendlin, 1996; Rogers, 1959). It will then move to a review of some of the extensive research on the construct of emotional processing, a construct from the behavioural tradition (e.g. Foa & Kozak, 1986). Both types of research highlight a central fact about emotion and change in therapy: that emotional events are processes, and that it is in facilitating these processes through structured sequences of a particular type at a particular time for a particular disorder that change is produced. A number of sections will follow presenting the available research on emotion in therapy from psychodynamic and cognitive therapy and health psychology. A central integrative nding is that when emotions are regulated sufciently to be facilitated and processed, it is the combination of their arousal and processing and a more cognitive

Copyright 2004 John Wiley & Sons, Ltd.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.392

Emotional Processes reection on their meaning that produces the deepest therapeutic transformation.

59 in a more rened and differentiated way. For example, depth of experiencing has been examined in relation to core themes (Goldman, 1997; Goldman & Greenberg, 2003) and to emotion episodes (Pos, Greenberg, Goldman, & Korman, 2003) in therapy. Arguing that it was a shift in experiencing in relation to core themes that would have the greatest impact, Goldman (1997) selected and coded passages from therapy process focused on those themes. She found that changes in depth of experiencing from early to late in therapy in relation to core themes predicted outcome even better than the working alliance. A method of rating emotion episodes (EE) was developed to track shifts in the emotional states of depressed clients over the course of experiential therapy (Greenberg & Korman, 1993; Korman, 1998). This method (Greenberg & Korman, 1993) is derived from conceptualizations of the structure, components and function of emotions as developed in basic emotion research (e.g. Frijda, 1986). An emotion episode refers to a designated section of transcribed therapy process in which most or all of the basic components of an emotion are present. There are four typical components: the situation, the emotion or its action tendency, the appraisal and the personal concern associated with the emotion. Korman (1998) examined all the emotion episodes in the rst and last three sessions of 12 depressed clients with good and 12 depressed clients with bad outcomes in experiential therapy. The clients with good outcomes had more overall changes in their emotional states from early to late in therapy and the degree of change had a signicant positive correlation with therapeutic outcome. As mentioned earlier, emotion episodes have also been studied in relation to depth of experiencing. Pos et al. (2003) studied a sample of 34 clients who received experiential therapy for depression. All emotion episodes were examined from the second (early) and second last (late) sessions of therapy and were coded for depth of experiencing. Hierarchical multiple regression analyses showed that early depth of experiencing predicted outcome suggesting that some clients arrive at therapy with a greater capacity to process and verbalize emotion. But with the addition of late experiencing, early experiencing was no longer a signicant predictor and late experiencing was the sole independent predictor of outcome. Clearly, clients can learn over the course of therapy to attend to and process their emotions and to do so predicts an increase in self-esteem and a reduction
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HUMANISTIC AND EXPERIENTIAL THERAPY

Humanistic and experiential therapies emphasize the expansion of an individuals awareness of both conscious and tacit experience and the responsibility to discover and create meaning from this awareness. In this approach, emotion has always been valued and researched as a core organizing process (Greenberg, Korman, & Paivio, 2002). One of the most robust and consistent ndings in psychotherapy process research is that depth of experiencing is positively related to outcome (Orlinsky & Howard, 1978). The concepts of experiencing and depth of experiencing, usually measured with the Experiencing Scale, originated in Person-Centred therapy and the majority of early research was on Client-Centred (CC) therapy. The observer-rated scale goes from a low score at level 1, an emotionless account of the clients experience from an impersonal point of view, to level 4, in which clients are internally focused and processing their feelings and the meaning of signicant personal events, to a level 6, which indicates that readily accessible feelings are being synthesized to form new meaning and solve problems (Klein, Mathieu-Coughlan, & Kiesler, 1986). Depth of experiencing has been researched extensively and it has consistently been shown to have a positive relationship with outcome in therapy (Klein et al., 1986; Orlinsky & Howard, 1978). Much of this research was done on PersonCentred therapy, but the Experiencing Scale has now been investigated in other forms of therapy with similar results. Castonguay, Goldfried, Wiser, Raue and Hayes (1996) found that the clients emotional engagement in the therapy process, as measured by the Experiencing Scale, was a signicant predictor of outcome in the cognitive therapy of depression, suggesting that emotional processes are an essential aspect of therapeutic change regardless of therapeutic theory or technique. This impression was strengthened by Silberschatz, Fretter and Curtis (1986) who demonstrated that experiencing was related to outcome in psychodynamic therapy. Experiencing, a process long posited by experiential therapies to be a core change process, appears to apply across therapeutic orientations. Recent research has begun to look at depth of experiencing in the process of experiential therapy
Copyright 2004 John Wiley & Sons, Ltd.

60 in depressive symptomology. When the working alliance is added to the equation it predicts outcome but less so than late experiencing. Curiously, whether the emotion episodes related to core themes was not a factor in this study. It was depth of experiencing on late emotion episodes that best predicted outcome. One of the most difcult and longstanding quandaries in emotional research in psychotherapy relates to the issues connoted by the word catharsis. The conventional wisdom in some forms of dynamic and humanistic therapy was that intense emotional arousal and expression was usually therapeutically benecial. Such a perspective is now widely held to be inaccurate (Kennedy-Moore & Watson, 1999) and in experiential therapy it has ceded to a more complex taxonomy of emotional processes in therapy (e.g. Greenberg et al., 2002). Emotions are important in experiential therapy, but there can be no general principle about the effectiveness of arousing and expressing an emotion: it depends on what the emotion is, how it is expressed, by whom, to whom, when, under what conditions, what the underlying therapeutic issue is, how the expression is followed up and all the panopoly of relevant circumstantial detail (Greenberg, 2002; Kennedy-Moore & Watson, 1999). A simple example of this necessary differentiation would be that emotion can in a given instance be primarily a social signal of distress and in another instance a psychological process of change (Kennedy-Moore & Watson, 1999). Prolonging the arousal of a signal of distress would not have therapeutic value. Experiential researchers would agree with Wiser and Arnow (2001) when they suggest that there are times in therapy when emotional experience and expression should be facilitated and other times when they should be regulated and controlled. Fully experiencing an emotion involves both allowing the subjective physiological and psychological processes accompanying the emotion to take their course and making a conscious attempt to understand and articulate the meaning of the emotion, this whole process together producing transformation and change (Gendlin, 1996; Greenberg, 2002). There is a growing body of empirical evidence in experiential therapy to support the notion that both parts of this process are indispensable: that emotion needs to be aroused and felt and also to have its meaning be consciously examined and articulated to bring about therapeutic change. In a series of counselling analogue studies on catharsis and anger, Bohart (1977, 1980) discovCopyright 2004 John Wiley & Sons, Ltd.

W. J. Whelton ered that the arousal and cathartic discharge of anger did not lead to the angers reduction or resolution. On the contrary, it led to an increase in aggression. A purely cognitive and rational analysis of the provocation and ones anger did little to help either. What helped to resolve the anger was an arousal and expression of anger in conjunction with a cognitive exploration of its meaning. Transformation involved cognition and emotion. A subsequent study using a similar analogue paradigm found that cathartic hitting of a pillow was less effective in reducing anger than role-play or nondirective counselling. Bohart (1980), in advancing a cognitive theory of catharsis, proposed that the emotional expression when coupled with a cognitive reection produced either a better ability to cope with the provocative situation or a change in self-perception. S. Warwar and L. Greenberg (paper presented at the International Society for Psychotherapy Research Annual Meeting, Chicago, IL, June 2000) recently showed that good outcome clients in the experiential therapy of depression showed both higher emotional arousal and more levels ve and six, in depth of experiencing on emotion episodes. This indicated that emotional arousal plus making sense of this arousal distinguished good and poor outcomes although contrary to expectation it was found that arousal alone was a unique predictor of outcome. Watson (1996) studied experiential therapy for Problematic Reaction Points (PRP) and found that those clients who offered the most vivid verbal descriptions of these problematic past events thereby aroused the most intense emotions and then deepened their reective experiencing and resolved their PRPs. Once again, there were complex but orderly stages in the interaction between emotional arousal and cognitive meaning-making in the process of therapeutic change. Stalikas and Fitzpatrick (1995) showed that in session change was related to both higher levels of reection and strength of feeling. Honos-Webb, Surko, Stiles and Greenberg (1999) recently found that change in therapy occurred by replacing a dominant, maladaptive, emotionally-based voice in the personality with a more adaptive emotionally-based one. These studies indicate that emotion needs to be both aroused and transformed. The effect of emotional arousal in therapy also depends on the quality of the working alliance. Beutler, Clarkin and Bongar (2000) studied several therapies, including experiential therapy, in an attempt to match patient variables with treatments. Across modalities, session emotional intensity was
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Emotional Processes a strong predictor of outcome but this effect was mediated by the working alliance. Likewise, Iwakabe, Rogan and Stalikas (2000) documented that high arousal predicted good session outcome only when there was a strong alliance. Researchers in Rochester (Pierce, Nichols, & DuBrin, 1983) found some support for the cathartic expression of feeling in therapy but only with certain people under specied circumstantial conditions. Catharsis was not helpful all the time. Evidence has been found supporting the effectiveness of arousing and expressing anger in the treatment of depression (Beutler et al., 1991). Van Velsor and Cox (2001) have also documented that anger can be a means for survivors of sexual abuse to develop self-efcacy, heal memories and correctly attribute blame. Any benets believed to accrue from the cathartic expression of emotion were generally predicated on the clients overregulation (overcontrol) of emotion, but it is apparent that for some individuals, psychological disorders and situations, emotions are under- or dysregulated (Greenberg & Bolger, 2001; Greenberg et al., 2002; Gross, 1999). Learning to adequately contain and regulate strong emotions is central to adaptive emotional arousal and expression and these skills are often lacking. The ability to regulate emotion is believed to emerge from early attachment experiences of validation, soothing and safety and involves attending to emotions and dampening or expressing them as appropriate (Paivio & Laurent, 2001). The emotional validation and empathy of the therapist seem to be particularly important in allowing clients with dysregulated emotions to learn to self-soothe and restore emotional equilibrium (Greenberg, 2002; Paivio & Laurent, 2001) and these attributes have been central characteristics of many of the humanistic and experiential therapies (e.g. Rogers, 1959). What is clear is that emotional arousal and expression is not always helpful or appropriate in therapy or in life and that, for some clients, training in the capacity for emotional regulation must precede or accompany it (Greenberg, 2002). Some other studies have examined aspects of emotional processing in experiential group work. Moore and Haverkamp (1989) found that a structured, multi-modal group intervention over 10 weeks could help men in mid-life become more emotionally aware and expressive than controls. Rosner (1996), in a project that was a corollary to Beutler et al. (1991), studied emotion change processes in groups which used 20 sessions of
Copyright 2004 John Wiley & Sons, Ltd.

61 either Cognitive therapy or Focused-Expressive therapy to treat clients who were clinically depressed. Focused-Expressive therapy (Daldrup, Beutler, Engle, & Greenberg, 1988) is a manualized version of Gestalt therapy which asserts that the arousal and expression of suppressed anger indirectly facilitates recovery from depression while cognitive therapy seeks to reduce emotional intensity, particularly of negative emotions. Some evidence was found that for individual group members in their respective groups these hypothesized emotional processes occurred as predicted, but several hypotheses about emotional processing were rejected (Rosner, 1996). In particular, there was no evidence of emotional contagion (Rosner, Beutler, & Daldrup, 2000). Those group members who were observing currently active group members did not display a similar emotion or emotional intensity to them as might have been predicted by theories of social or vicarious learning. Emotional processes have been studied both in the resolution of interpersonal problems in experiential therapy and in Emotion-Focused couples therapy. In a well-controlled study of therapy for unnished business with a signicant other, the degree of emotional arousal during imagined dialogues with the other was signicantly related to outcome and engaging in these emotionallycharged dialogues led to better outcomes than did psychoeducational groups (Paivio & Greenberg, 1995). In a further study of these therapeutic unnished business dialogues, emotional arousal and depth of emotional processing were signicantly related to the expression of needs and shift in selfother schemas that discriminated resolvers and nonresolvers (Greenberg & Malcolm, 2002). Emotionally-focused couples therapy is based on fundamental attachment principles: that all people need safe, secure, responsive relationships, that for most adults intimate partnerships are crucial in meeting these needs and, that these needs and bonds are largely organized and expressed by emotions (Greenberg & Johnson, 1988). The therapy involves changing the couples communication cycles by helping them access, experience and express their attachment-oriented and vulnerable feelings and needs. A substantial body of research has established this therapy as empirically-supported while delineating its affective change mechanisms (Johnson & Talitman, 1997; Johnson, Hunsley, Greenberg, & Schindler, 1999) and further research is rening and extending its range of application (Johnson, 2002).
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62

W. J. Whelton Rothbaum and Schwartz (2002) reviewed the empirical evidence related to exposure treatments of PTSD and concluded that the emotional processing hypothesis, that therapeutic effectiveness is achieved by the activation of the fear structure while providing new information, seems to be a sound interpretation of the available data, but that effective outcomes can be sabotaged by failure to apply the treatment with sufcient clinical skill and discipline. Foa and Franklin (2000) provide similar evidence for emotional processing in a review of exposure plus response prevention as a treatment for OCD. Foa, Zoellner, Feeny, Hembree and Alvarez-Conrad (2002) have shown that imaginal exposure, which arouses strong emotion, can exacerbate symptoms in some clients, but that it does this in relatively few clients and, even then, does not impede a long-term positive outcome. GilboaSchechtman and Foa (2001) studied patterns of recovery in sexual and non-sexual assault victims and found that, in general, long-term recovery was prolonged if the indispensable emotional engagement with traumatic material was delayed. Foa, Rothbaum and Furr (2003) have found in a meta-analytic review of the literature that exposure therapy is the most effective treatment for PTSD, and that its effectiveness, based on emotional processing, is only diminished when it is combined with cognitive or other additional techniques. Behavioural methods, in clinical and empirical development for 50 years, have established a solid basis for understanding the emotional processing required for therapeutic change when treating fear and anxiety. Hunt (1998), while acknowledging the benets of emotional processing for difculties related to anxiety, sought to discover whether this would hold true for individuals after a depressive event. She found that emotional processing entailed a greater short-term attention to negative feelings thereby inducing short-term emotional pain, but that those who went through this pain felt better in the long run than individuals who problem-solved or avoided after the depressive event. This benet was mediated by emotional arousal, suggesting again that emotions must be up and running and experienced for benecial emotional processing to occur. In a timely review of research literature related to the benets and dangers of re-experiencing painful emotion in therapy, Littrell (1998) concluded that when therapy is designed so as to allow for the planned restructuring of painful memories, the re-experience of pain in therapy has been demonstrated to be benecial and therapeutic.
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EMOTIONAL PROCESSING AND EXPOSURE THERAPY

Behaviour therapy has also extensively examined the role of emotional processing in the process of effective therapy (Foa & Kozak, 1986; Lang, 1977, 1979; Rachman, 1980; Wolpe, 1982). This research originated in the 1950s with clinical studies undertaken by Wolpe (1982) on counterconditioning, in which he found that an anxious, fearful state could be therapeutically replaced by an incompatible state. This early work by Wolpe was followed by seminal papers by Lang (1977, 1979), Rachman (1980), and Foa and Kosak (1986), each extending and elaborating the core idea that emotional processing is vital to produce change in numerous disorders. In this model three basic signs of emotional processing in therapy presage positive outcomes: fear is activated physiologically as well as by verbal self-report, there is a gradual reduction of these reactions through exposure to fearful stimuli and, there is a reduction across sessions of the level of the initial reaction to these stimuli (Foa & Kozak, 1998). Several studies document support for key aspects of these hypothesized emotional processing principles. In a study of exposure and response prevention therapy with obsessive compulsives, emotional processes were assessed using selfreport measures and cardiac and electrodermal responses (Kozak, Foa, & Steketee, 1988). The degree to which anxiety was activated predicted outcome on all measures and there were also either group or individual difference indicators that habituation during and across sessions predicted outcome. In a study related to the treatment of PTSD, Foa, Riggs, Massie and Yarczower (1995) demonstrated that it is crucial to activate the underlying fear structures if they are to be successfully restructured. The clients facial expressions were observed during exposure (telling the stories of their trauma) and these indicated emotional processing and predicted outcome. In another study, cluster analysis revealed three patterns of self-reported distress among clients over the course of a therapy that included an imaginal re-experiencing of their trauma each session: high distress in session 1 with gradual tapering off over therapy, high distress in session 1 and all subsequent sessions and, moderate distress in session 1 and all subsequent sessions (Jaycox, Foa, & Morral, 1998). Those in the rst group recovered much better than the others. Both the activation of the fear structure and a process of habituation are needed to produce change.
Copyright 2004 John Wiley & Sons, Ltd.

Emotional Processes

63 with behaviour therapy, in which, as described earlier, emotional processing has a prominent role. One might say that the level of emotional processing has been inversely proportional to the prevalence of C over B in CBT. The tide appears to be gradually turning. Some cognitive theorists are beginning to contend that emotion is more than the product of cognition (for an interesting review of empirical evidence on the complexity of this relationship in relation to depression, see Scott & Ingram, 1998) and that emotion is sometimes a source of meaning and a type of information processing as well as being the result of these (e.g. Safran, 1998). Samoilov and Goldfried (2000) provide a range of psychological and neuroscientic evidence for recognizing emotion as a source of tacit meaning which serves an important organizing function for the semantic networks in memory (cf. Guidano, 1993; Mahoney, 1991). Samoilov and Goldfried (2000) offer a range of suggestions for ways in which emotion and emotional arousal can be used as an ally in reorganizing these tacit meanings in therapy. Teasdale and Barnard (1993) have developed the Interacting Cognitive Subsystems theory, which posits two types of meaning, one registered in propositional code and the other in implicational code. The former is deliberate and straightforward while the latter is inchoate, bodily-felt and metaphoric, a highly emotional form of meaning. Both are valid and important ways of representing and processing information. Beck (1996) has also tried to conceptually represent an immediate, multi-system, organismic reaction to a highly-charged stimulus. At the core of his recent thinking is the concept of the primal mode, which is a more basic, and more physical, emotional and motivational, form of information processing than the schema. Researchers found that suicidal patients displayed better problem-solving skills and attitudes in treatment when in positive moods, showing that emotion and cognition can interact in diverse ways (Joiner et al., 2001). Wells and Carter (2001) found support for a cognitive model of Generalized Anxiety Disorder that is characterized by Type 2 worry, that is perseverative worry about the harmful consequences of ones already frequent worrying. This meta-worry is a form of metacognition. Cognitive thinkers are making metacognition a much more central aspect of their models of disorders and treatments. Metacognition not only refers to beliefs about thoughts and thought processes but to beliefs about a range of internal processes, including
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EMOTION AND COGNITIVE THERAPY

Cognitive therapy has tended to view emotion in psychotherapy as troublesome and symptomatic (Samoilov & Goldfried, 2000), something, if negative, to be tamed and brought within the purview of rational control, but a chorus of cognitive voices have recently protested that cognitive practice would benet from a more complex and differentiated view of the relation between cognition and emotion (e.g. Kanfer, 1996; Mahoney, 1991; Rachman, 1980; Safran,1998; Samoilov & Goldfried, 2000; Teasdale & Barnard, 1993). Wiser and Goldfried (1993) found that when CBT therapists were compared with PsychodynamicInterpersonal (PI) therapists, the former believed that improvement in therapy would come from a lowering of emotional experiencing, whereas the latter believed that it needed to be intensied. Stiles et al. (1996) studied therapists intentions and found that emotional awareness and expression were prominent foci for PI therapists but not CBT therapists. Goldfried, Castonguay, Hayes, Drozd and Shapiro (1997) also compared sessions from CBT and PI therapies and, although they used a different methodology, they concluded with virtually identical results in relation to emotion: it was a prominent component of therapy in PI therapy but not in CBT therapy. In another study comparing helpful sessions of CBT and PI therapy, Mackay, Barkham, Stiles and Goldfried (2002) found that CBT therapy tended to be more instructional and less exploratory than PI therapy, that emotion in PI therapy was, on average, less pleasant and more painful than in CBT therapy, and that whereas emotional arousal followed a U pattern in CBT therapy with the middle of the session being calmest, in PI therapy it involved an inverted U, with arousal of painful affect being highest in the middle of the session and then dropping off. Coombs, Coleman and Jones (2002) studied the therapists stance toward client emotion in 128 sessions of CBT and IPT for depression. The two largest factors they identied in a categorization of these passages were Collaborative Emotional Exploration and Educative/Directive Process. The former was signicantly more frequent in IPT than CBT but was positively related to outcome in both forms of therapy. The latter was more frequent in CBT than IPT and had no relation to outcome in either form of therapy. These ndings suggest that emotional processing has not traditionally been a big part of cognitive therapy in theory or practice despite its alliance
Copyright 2004 John Wiley & Sons, Ltd.

64 emotion. Blackledge and Hayes (2001) describe the rst step of Acceptance and Commitment Therapy as choosing to allow and accept rather than fear and avoid negative emotions. Teasdale et al. (2002) have found empirical support for a MindfulnessBased cognitive therapy of depression, demonstrating in particular that it helps to prevent depressive relapse. Mindfulness, as they describe it, is a type of awareness of internal processes that allows one to gain distance and perspective on them, accepting painful and depressive emotions (for example) as normal and passing phenomena rather than as a cause for fear and catastrophizing (cf. Perls, Hefferline, & Goodman, 1951). There is an important place for beliefs about emotions in much recent cognitive thinking. Leahy (2002) conceptualized and studied a cognitive model of emotional schemas. He contrasted his view of emotional schemas with the view advanced in Emotion-Focused Therapy (EFT) by Greenberg (2002), but ultimately he saw these as related and complementary models and he found evidence in support of both. Leahy observed that EFT conceptualizes emotional schemas as organizing emotional structures that, when activated, confer access to relevant tacit meanings and cognitions. By way of contrast, he dened emotional schemas as cognitive structures that frame the interpretation of emotional experience and guide the strategies used in coping with emotion. Leahy noted that there are two fundamental coping pathways: one pathway involves attending to and labelling emotions in a manner that accepts and normalizes them, while the other pathway pathologizes some emotional experiences leading to attempts to distort or avoid them, initiating guilt, frantic efforts at control, obsessive rumination and so forth. Leahy devised the Leahy Emotional Schemas Scale (LESS) and gave it to 53 psychiatric outpatients in a CBT clinic along with the Beck Depression Inventory and the Beck Anxiety Inventory. The LESS has 50 items measuring emotional schemas on 14 dimensions including validation, comprehensibility, numbness, control and rumination. Depression and anxiety scores were related to guilt about emotions, the perception of emotions as incomprehensible and out of control, and rumination. In general, the acceptance and validation of emotion resulted in less guilt and rumination, greater understanding and control, less concern with the duration of emotions and a less simplistic view of emotional experience. Leahy concluded that the complex cognitive processing of emotion is important for treating anxiety and depression.
Copyright 2004 John Wiley & Sons, Ltd.

W. J. Whelton The dysregulation of emotion and its contribution to psychological disorders has become a topic of considerable interest in cognitive-behavioural therapy (Gross, 1999; Southam-Gerow & Kendall, 2002). Abnormalities in processing and regulating emotions can be related to disorders such as psychopathy (Hare, 1998) but more frequently the dysregulation of emotion is seen in BPD and PTSD and conditions and disorders related to trauma, attachment difculties and various forms of abuse (Wolfsdorf & Zlotnick, 2001). The disruptive effects of dysregulated emotions have been clinically well documented and, when triggered, they are frequently overwhelming and both cognitively and behaviourally disorganizing. Emotional distress in certain populations such as parasuicides or addicts, leads to self-destructive behaviors (Linehan, 1993) while the expression of facial contempt and fear in quarrelling couples predicts divorce (Gottman & Levenson, 1992). Linehan (1993) has found strong evidence for the effectiveness of emotional validation and soothing as part of the treatment for BPD and empathy seems to be particularly important in learning to self-soothe and restore emotional equilibrium. Shapiro (1989) has developed EMDR (Eye Movement Desensitization and Reprocessing) as a method of reprocessing traumatic fears, memories and beliefs. While the method is still controversial, partly because the therapeutic mechanisms underlying any changes are so unclear, she has offered some evidence that manipulations of the eyes under specied conditions have allowed traumatic negative affects to be accessed, assimilated and replaced by healthier emotions. Some researchers are now contending that even anxiety disorders are best understood as disorders of emotional regulation (Mennin, Heimberg, Turk, & Fresco, 2002).

EMOTION AND PSYCHOANALYTIC THERAPY

In recent decades, emotion has become theoretically central to a whole range of psychoanalytic thinkers (Eagle, 1984), although there is still a relative paucity of empirical investigation in this area. One form of short-term psychodynamic therapy (Kuhn & McCullough, 2002) posits that dynamic conicts are basically affect phobias, structured fear and shame-based defences against deeper feelings, and there is growing evidence for the effectiveness of this therapy which integrates dynamic and behavioural techniques (e.g. Winston
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Emotional Processes et al., 1994). Fosha (2001) has developed Accelerated ExperientialDynamic Psychotherapy from an integration of basic emotion research, experiential therapy and the short-term dynamic therapy just described. It is based on a developmental model of affective growth and focuses on the dyadic regulation of affect in the therapy relationship. Optimal support in this relationship allows core affective experiences to be acknowledged and integrated, freeing adaptive emotional resources. What quickly becomes apparent in these newer dynamic therapies is that feelings are no longer viewed as drive derivatives, but as a sort of musical counterpoint expressing a complex, ambivalent and conicted inner motivational and relational world which must be acknowledged, faced and tolerated with help from the intersubjective medium of therapy (Greenberg & Mitchell, 1983; Sandler & Sandler, 1978; Stein, 1991; Westen & Gabbard, 1999). There is some psychodynamic therapy process research on emotion. Dahl and his group are continuing to develop and validate FRAMES (it stands for Fundamental, Repetitive and Maladaptive Emotion Structures) which is a form of narrative analysis that identies invariant and repetitive structures in the emotional aspects of the stories that clients tell (Dahl & Teller, 1994). This research is progressing and recent ndings (Siegel, Sammons, & Dahl, 2002) offer a new, streamlined methodology for identifying core emotion structures, one based on tracking narrative sequences according to eight basic emotion codes, and also provide solid evidence for the interrater reliability of FRAMES. Psychodynamically-oriented studies of emotion processes in therapy often involve intensive analyses of individual cases. There are a number of recent efforts to base these analyses on objective observations and quantitative measurements. Lecours, Bouchard, St-Amand and Perry (2000) analysed 14 sessions of a single, prematurelyterminated, psychodynamic therapy to test the Verbal Elaboration of Affect Scale (acronym GEVA in the original French). This scale tracks two separate channels by which affect is mentalizedthe processes by which the elementary physiological and experiential bases of affect become transformed into images and words. These two channels are affect expression and affect tolerance and abstraction. The study showed acceptable levels of interrater reliability over a range of coding tasks. The two channels were not orthogonal which went against prediction but some support was found for
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65 the hypothesis that positive affects would be more frequently mentalized than negative affects, as these latter painful feelings are more difcult to tolerate and express. In another study, facial affect was tracked in the client and the therapist over 11 sessions of an unsuccessful therapy, allowing their emotional interaction to be studied and correlated with measures of emotional experience, beliefs, therapy outcome and perceptions of the success or failure of the therapy on various dimensions (Dreher, Mengele, Krause, & Kammerer, 2001). This research was theoretically premised on the belief that emotional interactions with caretakers early in life lead to the establishment of largely automatic and unconscious patterns of emotional exchange in relationships that may be adaptive or dysfunctional. Successful therapy requires that the therapist in certain essential respects not be responsive to some of the maladaptive, but completely unconscious, overtures of the client, which are initiated in part by facial affect. The study revealed a large discordance between facially expressed affect and consciously experienced feelings, particularly on the part of the client, as well as a frequent display of the facial blends of different emotions that are regarded as signs of conict and masking. The authors interpret these results as supportive of the idea that the client was unconsciously structuring a relationship in which contempt would play a large part, which she had said was her lifelong pattern, though she disclaimed any awareness of contempt on the part of either herself or the therapist in this relationship. In this particular client, the more diversely expressive her face was, the more unreective and undifferentiated her verbal, emotional experience. The authors interpreted both her and the therapists increasingly frequent, automatic smiles as a defence against negative affect, although unlike the client, the therapist knew that she was feeling more and more contempt for the client. However interpreted, these data exemplify the various, sometimes seriously disconnected, components of emotion and the complex difference between having and nonverbally expressing emotions out of awareness and the awareness that leads to verbal expression and reection upon feelings. In a close analysis of a clients anger event in psychodynamicinterpersonal therapy Mackay, Barkham and Stiles (1998) concluded that staying with the feeling, as coached by the therapist, was helpful for reasons that corresponded better to an experiential than psychodynamic interpretation. They argued that
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66 continuing to stay with the anger helped to reorganize the clients anger schema, letting go of elements of depression and hopelessness to allow the adaptive, primary feeling of anger to emerge and be truly experienced. A study of high and low verbalized affect segments from the third session of 32 clients in shortterm psychodynamic therapy yielded a range of information about the therapists use of language in general and in good and bad outcome cases (Anderson, Bein, Rinnell, & Strupp, 1999). This is one of a number of recent studies in which lexical software was used to analyse the use of language in psychotherapy. Anderson et al. found that while, in general, therapists had more highly efcient and differentiated forms of speech than clients, in poor outcome cases they used more cognitive verbs during the high affect segments of the session, thus appearing to subtly direct attention away from the emotion being expressed. Mergenthaler (1996), in a computer-assisted study of verbal patterns in psychodynamic therapy, showed that in the key moments in therapy in which substantial shifts happened there was a frequent co-occurrence of high emotion tone (emotional arousal) and high abstraction (a reection on this emotional process), a benecial co-occurrence that he called a connection. It seemed to be the timely conjunction of emotional arousal and a thoughtful exploration of the emotions meaning that generated change.

W. J. Whelton robust across gender, culture, class and personality type (Pennebaker & Seagal, 1999). Benets shown to accrue to emotional processing in this research include improved health and immune function, problem-solving and mood. A related nding suggests that these benets extend to trauma survivors who write about an imaginary experience of a trauma which they have not experienced in reality (Greenberg, Wortman, & Stone, 1996). Interestingly, in two recent longitudinal studies of bereavement, emotional disclosure and a Pennebaker writing task focused either on emotions or on problems related to adjustment to loss, did not hasten recovery or the reduction of physical and psychological symptoms of grief for spouses recovering from the loss of a partner (Stroebe, Stroebe, Schut, Zech, & van den Bout, 2002). The authors speculate that there is a natural process of healing in uncomplicated grief and that additional interventions cannot hasten or circumvent this process for most people. Alexythymia is considered to be a decit in cognitive, particularly verbal, functioning in relation to emotion. The word alexythymia literally means the inability to nd words to describe or express emotions and alexythymic individuals can suffer from a range of bodily tensions which they are unable to differentiate and articulate (Bouman, Eifert, & Lejuez, 1999). Research on alexythymia lends considerable support to the idea that emotional awareness and expression are integral to physical and psychological health (Taylor, 1994). Alexythymia has also been associated in the literature with posttraumatic stress disorder, eating disorders, psychosomatic complaints, panic disorders, substance abuse disorders, anxiety and depression (Bagby, Taylor, & Atkinson, 1988; Bagby, Taylor, & Ryan, 1986; Haviland, Shaw, MacMurray, & Cummings, 1988; Sifneos, 1988; Taylor, Parker, Bagby, & Acklin, 1992; Wise, Jani, Kass, Sonnenschein, & Mann, 1988). In traditional formulations of coping with stress, emotion-focused coping has often been viewed as problematic and unhelpful, unlike, for example, problem-solving coping (e.g. Endler & Parker, 1990). Stanton and her associates have challenged this view by contending that traditional measures of emotion-focused coping have been contaminated by items which overlap with symptoms of distress (e.g. I feel anxious about not being able to cope from Endler & Parker, 1990). Stanton, Kirk, Danoff-Burg and Cameron (2000), in an attempt to rectify this situation, developed and validated a scale which measured a style of coping that involved approaching the emotions and this scale
Clin. Psychol. Psychother. 11, 5871 (2004)

EMOTIONAL AWARENESS AND EXPRESSION AND HEALTH ISSUES IN THERAPY

Emotions are constituted in part by all the physiological changes which underlie action tendencies (Frijda, 1986). Because bodily responses form such a key component of emotions it is not at all surprising that emotion is very closely related to physical health. Empirical ndings are beginning to abound attesting to the health benets of attending to emotions and the harmful consequences of suppressing and denying them. Pennebaker and his associates have shown a range of benets to physical and psychological health deriving from the exploration and written expression of ones pain, loss and trauma (Booth & Pennebaker, 2000; Pennebaker, 1997). Conversely, to bury the trauma in silence leads to a range of negative outcomes. The act of ordering the inchoate complexity of emotional experience into coherent and meaningful narratives is instrumental in producing these health improvements which are
Copyright 2004 John Wiley & Sons, Ltd.

Emotional Processes had two factors: emotional processing (e.g. I take time to gure out what Im really feeling) and emotional expression (e.g. I let my feelings come out freely). In a study of 92 women diagnosed with breast cancer (Stanton et al., 2000) emotionally expressive coping, but not emotional processing, predicted decreased distress, increased vigor, improved self-perceived health and fewer cancerrelated trips to doctors and medical facilities over a 3-month period. Contrary to hypothesis, emotional processing appeared to predict increased distress and was unrelated to other dependent variables. The signicant relationship with distress occurred in analyses where emotional expression was controlled statistically, which may indicate that when processing leads to expression it is adaptive, but when it does not it resembles an unhealthy rumination. Along similar lines, Giese-Davis et al. (2002) found that women suffering from metastatic breast cancer who received supportiveexpressive group therapy showed more effective emotion-regulation strategies than controls. Ninety-seven women with breast cancer were randomly assigned to either a weekly supportiveexpressive (emotion-focussed) group intervention or a psychoeducational control. Those receiving treatment decreased the amount to which they bottled-up and suppressed feelings of fear, sadness and anger but increased the amount to which they restrained aggression, controlled impulses, considered the feelings of others and were responsible in their behaviour. An increase in the free expression of primary, adaptive negative emotions in a supportive environment appeared to alleviate any tendency to the irresponsible expression of hostile impulses. Yet again, it is evident that the expression of feelings is not a unitary construct, but must be differentiated: the expression of primary emotions is not to be equated with the willy-nilly expression of hostility. Indeed, doing the former appears to decrease the latter.

67 ties. Second, the cathartic idea, the idea that emotional expression, by itself, is always inherently good, is now viewed as an incomplete and inadequate perspective. The value of emotional expression depends on several contextual variables and on the availability of support to process, explore and articulate the experience. Emotional arousal and expression can lead to constructive change for some clients and problems. Third, the acceptance of emotional experience is generally benecial and the avoidance of emotional experience is generally harmful, even when the emotions are painful and negative. Fourth, when the client is productively engaged in therapy and is processing information in an experiential manner successful outcomes can be predicted. Fifth, exposure to difcult and fearful stimuli while emotionally aroused in a safe, supportive environment will restructure expectancies and reduce anxiety and symptoms of trauma. Finally, emotional engagement and arousal facilitates effective therapy but lasting personal change also requires cognitive reection and the construction of new meaning. It is worth remembering as well that the bedrock of all therapy is the development of a relationship and emotional responsiveness is at the heart of this unique form of personal and professional intimacy.

REFERENCES
Anderson, T., Bein, E., Pinnell, B.J., & Strupp, H.H. (1999). Linguistic analysis of affective speech in psychotherapy: A case grammar approach. Psychotherapy Research, 9, 8899. Bagby, R.M., Taylor, G.J., & Atkinson, L. (1988). Alexithymia: a comparative study of the three self-report measures. Psychosomatic Research, 32, 107116. Bagby, R.M., Taylor, G.J., & Ryan, D.P. (1986). Toronto Alexithymia Scale: relationship with personality and psychopathology measures. Psychotherapy and Psychosomatics, 45, 207215. Beck, A.T. (1996). Beyond belief: a theory of modes, personality, and psychopathology. In P.M. Salkovskis (Ed.), Frontiers of cognitive therapy (pp. 125). New York: Guilford Press. Beutler, L.E., Clarkin, J.F., & Bongar, B. (2000). Guidelines for the systematic treatment of the depressed patient. York: Oxford University Press. Beutler, L., Engle, D., Mohr, D., Daldrup, R., Bergan, M., & Merry, W. (1991). Predictors of differential response to cognitive, experiential and self-directed psychotherapeutic procedures. Journal of Consulting and Clinical Psychology, 59, 333340. Blackledge, J.T., & Hayes, S.C. (2001). Emotion regulation in acceptance and commitment therapy. In Session: Psychotherapy in Practice, 57, 243255.

CONCLUSION
There has been a paucity of research on emotion in the process of psychotherapy but this has started to change. Most of the research being carried out is coloured by the theoretical commitments of the researchers, but the outline of a few general, empirically-grounded principles appears to be taking shape on the horizon. First, emotion and emotional processing are now widely perceived to be vital dimensions of therapy in all therapeutic modali-

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Clin. Psychol. Psychother. 11, 5871 (2004)

68
Bohart, A. (1977). Role playing and interpersonal-conict reduction. Journal of Counseling Psychology, 24, 1524. Bohart, A. (1980). Toward a cognitive theory of catharsis. Psychotherapy: Theory, Research and Practice, 17, 192 201. Booth, R.J., & Pennebaker, J.W. (2000). Emotions and immunity. In M. Lewis, & J.M. Haviland-Jones (Eds), Handbook of emotions (2nd ed., pp. 558570). New York: Guilford. Bouman, T.K., Eifert, G.H., & Lejeuz, C.W. (1999). Somatoform disorders. In T. Millon, T.H. Blaney, & R.D. Davis (Eds), Oxford textbook of psychopathology (pp. 444465). New York: Oxford University Press. Castonguay, L.G., Goldfried, M.R., Wiser, S., Raue, P.J., & Hayes, A.M. (1996). Predicting the effect of cognitive therapy for depression: a study of unique and common factors. Journal of Consulting and Clinical Psychology, 64, 497504. Coombs, M.M., Coleman, D., & Jones, E.E. (2002). Working with feelings: the importance of emotion in both cognitive-behavioral and interpersonal therapy in the NIMH treatment of depression collaborative research program. Psychotherapy: Theory, Research, Practice, Training, 39, 233244. Dahl, H., & Teller, V. (1994). The characteristics, identication, and applications of frames. Psychotherapy Research, 4, 253276. Daldrup, R.J., Beutler, L.E., Engle, D., & Greenberg, L.S. (1988). Focused expressive psychotherapy: Freeing the overcontrolled patient. New York: Guilford. Damasio, A. (1994). Descartes error: Emotion, reason, and the human brain. New York: Putnam. Dreher, M., Mengele, U., Krause, R., & Kammerer, A. (2001). Affective indicators of the psychotherapeutic process: An empirical case study. Psychotherapy Research, 11, 99117. Eagle, M. (1984). Recent developments in psychoanalysis: A critical evaluation. Cambridge, MA: Harvard University Press. Endler, N.S., & Parker, J.D.A. (1990). CISS: Coping Inventory for Stressful Situations manual. Toronto, Canada: Multi-Health Systems. Foa, E.B., & Franklin, M.E. (2000). Psychotherapies for obsessive-compulsive disorder: A review. In M. Maj, N. Sartorius, A. Okasha, & J. Zohar (Eds), Obsessivecompulsive disorder (pp. 93115). New York: J. Wiley and Sons. Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: exposure to corrective information. Psychological Bulletin, 99, 2035. Foa, E.B., & Kozak, M. (1998). Clinical applications of bioinformational theory: understanding anxiety and its treatment. Behavior Therapy, 29, 675690. Foa, E.B., Riggs, D.S., Massie, E.D., & Yarczower, M. (1995). The impact of fear activation and anger on the efcacy of exposure treatment for PTSD. Behavior Therapy, 26, 487499. Foa, E.B., Rothbaum, B.O., & Furr, J.M. (2003). Augmenting exposure therapy with other CBT procedures. Psychiatric Annals, 33, 4753. Foa, E.B., Zoellner, L.A., Feeny, N.C., Hembree, E.A., & Alvarez-Conrad, J. (2002). Does imaginal exposure

W. J. Whelton
exacerbate PTSD symptoms? Journal of Consulting and Clinical Psychology, 70, 10221028. Fosha, D. (2001). The dyadic regulation of affect. In Session, 57, 227242. Frijda, N.H. (1986). The emotions. Cambridge, England: Cambridge University Press. Gendlin, E.T. (1996). Focusing-oriented psychotherapy: A manual of the experiential method. New York: Guilford Press. Giese-Davis, J., Koopman, C., Fobair, P., Butler, L.D., Classen, C., Cordova, M., Benson, J., Kraemer, H.C., & Spiegel, D. (2002). Change in emotion-regulation strategy for women with metastatic breast cancer following supportive-expressive group therapy. Journal of Consulting and Clinical Psychology, 70, 916925. Gilboa-Schechtman, E., & Foa, E.B. (2001). Patterns of recovery from trauma: the use of intraindividual analysis. Journal of Abnormal Psychology, 110, 392400. Goldfried, M.R., Castonguay, L.G., Hayes, A.M., Drozd, J.F., & Shapiro, D.A. (1997). A comparative analysis of the therapeutic focus in cognitive-behavioural and psychodynamic-interpersonal sessions. Journal of Consulting and Clinical Psychology, 65, 740748. Goldman, R.N. (1997). Theme-related depth of experiencing and change in experiential psychotherapy with depressed clients. Unpublished doctoral dissertation. Toronto, Ontario, Canada: York University. Goldman, R.N., & Greenberg, L.S. (2003). Core themes, experiencing and change in experiential therapy. Psychotherapy Research (in press). Gottman, J.M., & Levenson, R.W. (1992). Marital processes predictive of later dissolution: behavior, physiology and health. Journal of Personality and Social Psychology, 63, 221223. Greenberg, J.R., & Mitchell, S.A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. Greenberg, L.S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings. Washington, DC: APA Press. Greenberg, L.S., & Bolger, E. (2001). An emotion-focused approach to the overregulation of emotion and emotional pain. In Session: Psychotherapy in Practice, 57, 197211. Greenberg, L.S., & Johnson, S.M. (1988). Emotionally focused therapy for couples. New York: Guilford. Greenberg, L.S., & Korman, L. (1993). Assimilating emotion into psychotherapy integration. Journal of Psychotherapy Integration, 3, 249265. Greenberg, L.S., & Malcolm, W. (2002). Resolving unnished business: relating process to outcome. Journal of Consulting and Clinical Psychology, 70, 406416. Greenberg, L.S., Korman, L.M. & Paivio, S.C. (2002). Emotion in humanistic therapy. In D. Cain, & J. Seeman (Eds), Handbook of humanistic psychotherapy (pp. 499530). Washington, DC: APA Press. Greenberg, L.S., & Safran, J.D. (1987). Emotion in psychotherapy. New York: Guilford. Greenberg, M.A., Wortman, C.B., & Stone, A.A. (1996). Emotional expression and physical health: revising traumatic memories or fostering self-regulation? Journal of Personality and Social Psychology, 71, 588602.

Copyright 2004 John Wiley & Sons, Ltd.

Clin. Psychol. Psychother. 11, 5871 (2004)

Emotional Processes
Gross, J.J. (1999). Emotion and emotion regulation. In L.A. Pervin, & O.P. John (Eds), Handbook of personality: Theory and research (2nd ed., pp. 525552). New York: Guilford. Guidano, V.F. (1993). The self in process. New York: Guilford Press. Hare, R.D. (1998). Psychopathy, affect, and behavior. In D.J. Cooke, A.E. Forth, & R.B. Hare (Eds), Psychopathy: Theory, research, and implications for society (pp. 105137). Dordrecht, The Netherlands: Kluwer. Haviland, M.G., Shaw, D.G., MacMurray, J.P., & Cummings, M.A. (1988). Validation of the Toronto Alexithymia Scale with substance abusers. Psychotherapy and Psychosomatics, 50, 8187. Honos-Webb, L, Surko, M., Stiles, W.B., & Greenberg, L. (1999). Assimilation of voices in psychotherapy: the case of Jan. Journal of Counseling Psychology, 46, 448460. Hunt, M.G. (1998). The only way out is through emotional processing and recovery after a depressing life event. Behaviour Research and Therapy, 36, 361 384. Iwakabe, S., Rogan, K., & Stalikas, A. (2000). The relationship between client emotional expressions, therapist interventions, and the working alliance: An exploration of eight emotional expression events. Journal of Psychotherapy Integration, 10, 375402. Jaycox, L.H., Foa, E.B., & Morral, A.R. (1998). Inuence of emotional engagement and habituation on exposure therapy for PTSD. Journal of Consulting and Clinical Psychology, 66, 185192. Johnson, S.M. (2002). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. New York: Guilford. Johnson, S.M., & Talitman, E. (1997). Predictors of success in emotionally focused marital therapy. Journal of Marital and Family Therapy, 23, 135152. Johnson, S.M., Hunsley, J., Greenberg, L.S., & Schlindler, D. (1999). Emotionally focused couples therapy: status and challenges. Clinical Psychology: Science and Practice, 6, 6779. Joiner, T.E., Pettit, J.W., Gencoz, T., Gencoz, F., Perez, M., Burns, A.B., & Rudd, M.D. (2001). Can positive emotion inuence problem-solving attitudes among suicidal adults? Professional Psychology: Research and Practice, 32, 507512. Kanfer, F.H. (1996). Motivation and emotion in behavior therapy. In K.S. Dobson, & K.D. Craig (Eds), Advances in cognitive-behavioral therapy (pp. 130). London, England: Sage. Kennedy-Moore, E., & Watson, J.C. (1999). Expressing emotion: Myths, realities, and therapeutic strategies. New York: Guilford Press. Klein, M.H., Mathieu-Coughlan, P., & Kiesler, D.J. (1986). The Experiencing Scales. In L.S. Greenberg, & W.M. Pinsof (Eds), The psychotherapeutic process: A research handbook (pp. 2171). New York: Guilford Press. Korman, L.M. (1998). Changes in clients emotion episodes in therapy. Unpublished doctoral dissertation. Toronto, Canada: York University. Kozak, M.J., Foa, E.B., & Steketee, G. (1988). Process and outcome of exposure treatment with obsessive-

69
compulsives: psychophysiological indicators of emotional processing. Behavior Therapy, 19, 157169. Kuhn, N., & McCullough, L. (2002). Short-term dynamic psychotherapy: Resolving character pathology by treating affect phobias. In S.G. Hofmann, & M.C. Tompson (Eds), Treating chronic and severe mental disorders: A handbook of empirically supported intervention (pp. 403417). New York: Guilford. Lang, P.J. (1977). Imagery in therapy: an information processing analysis of fear. Behavior Therapy, 8, 862886. Lang, P.J. (1979). A bio-informational theory of emotional imagery. Psychophysiology, 16, 495512. Leahy, R.L. (2002). A model of emotional schemas. Cognitive and Behavioral Practice, 9, 177191. Lecours, S., Bouchard, M.A., St-Amand, P., & Perry, J.C. (2000). Assessing verbal elaboration of affect in psychotherapy: a preliminary report and single case study. Psychotherapy Research, 10, 4756. Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Littrell, J. (1998). Is the reexperience of painful emotion therapeutic? Clinical Psychology Review, 18, 71102. Mackay, H.C., Barkham, M., & Stiles, W. (1998). Staying with the feeling: An anger event in psychodynamicinterpersonal therapy. Journal of Counseling Psychology, 45, 279289. Mackay, H.C., Barkham, M., Stiles, W.B., & Goldfried, M.R. (2002). Patterns of client emotion in helpful sessions of cognitive-behavioral and psychodynamicinterpersonal therapy. Journal of Counseling Psychology, 49, 376380. Mahoney, M. (1991). Human change processes. New York: Basic Books. Mennin, D.S., Heimberg, R.G., Turk, C.L., & Fresco, D.M. (2002). Applying an emotion regulation framework to integrative approaches to generalized anxiety disorder. Clinical Psychology: Science and Practice, 9, 8590. Mergenthaler, E. (1996). Emotion-abstraction patterns in verbatim protocols: a new way of describing psychotherapeutic processes. Journal of Consulting and Clinical Psychology, 64, 13061315. Moore, D., & Haverkamp, B. (1989). Measured increases in male emotional expressiveness following a structured group intervention. Journal of Counseling and Development, 67, 513517. Orlinsky, D.E., & Howard, K.I. (1978). The relation of process to outcome in psychotherapy. In S.L. Gareld, & A.E. Bergin (Eds), Handbook of psychotherapy and behavior change: An empirical analysis (2nd ed., pp. 546610). New York: Wiley. Paivio, S.C., & Greenberg, L.S. (1995). Resolving unnished business: efcacy of experiential therapy using empty-chair dialogue. Journal of Consulting and Clinical Psychology, 63, 419425. Paivio, S.C., & Laurent, C. (2001). Empathy and emotion regulation: reprocessing memories of childhood abuse. Journal of Clinical Psychology, 57, 213226. Pennebaker, J.W. (1997). Writing about emotional experiences as a therapeutic process. Psychological Science, 8, 162166.

Copyright 2004 John Wiley & Sons, Ltd.

Clin. Psychol. Psychother. 11, 5871 (2004)

70
Pennebaker, J.W., & Seagal, J.D. (1999). Forming a story: the health benets of narrative. Journal of Clinical Psychology, 55, 12431254. Perls, F., Hefferline, R.F., & Goodman, P. (1951). Gestalt therapy. New York: Dell. Pierce, R.A., Nichols, M.P., & DuBrin, J.R. (1983). Emotional expression in psychotherapy. New York: Gardner. Pos, A.E., Greenberg, L.S., Goldman, R., & Korman, L. (2003). Emotional processing during experiential treatment of depression. Journal of Consulting and Clinical Psychology (in press). Rachman, S. (1980). Emotional processing. Behaviour Research and Therapy, 18, 5160. Rogers, C.R. (1959). A theory of therapy, personality and interpersonal relationships as developed in the clientcentered framework. In S. Koch (Ed.), Psychology: A study of science: Formulations of the person and the social context (pp. 184256). New York: McGraw-Hill. Rosner, R. (1996). The relationship between emotional expression, treatment and outcome in psychotherapy: An empirical study. Frankfurt-Am-Main, Germany: Peter Lang. Rosner, R., Beutler, L.E., & Daldrup, R.J. (2000). Vicarious emotional experience and emotional expression in group psychotherapy. Journal of Clinical Psychology, 56, 110. Rothbaum, B.O., & Schwartz, A.C. (2002). Exposure therapy for posttraumatic stress disorder. American Journal of Psychotherapy, 56, 5975. Safran, J. (1998). Widening the scope of cognitive therapy: The therapeutic relationship, emotion, and the process of change. Northvale, NJ: Jason Aronson. Samoilov, A., & Goldfried, M. (2000). Role of emotion in cognitive behavior therapy. Clinical Psychology: Science & Practice, 7, 373385. Sandler, J., & Sandler, A.M. (1978). On the development of object relationships and affects. International Journal of Psycho-Analysis, 59, 285296. Scott, W.D., & Ingram, R.E. (1998). Affective inuences in depression. In W.F. Flack Jr., & J.D. Laird (Eds), Emotions in psychopathology: Theory and research (pp. 200215). New York: Oxford University Press. Shapiro, F. (1989). Eye movement desensitization and reprocessing: a new treatment for post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20, 211217. Siegel, P.F., Sammons, M., & Dahl, H. (2002). Frames: the method in action and the assessment of its reliability. Psychotherapy Research, 12, 5977. Sifneos, P.E. (1988). Alexithymia and its relationship to hemispheric specialization, affect, and creativity. Psychiatric Clinics of North America, 11, 287292. Silberschatz, G, Fretter, P.B., & Curtis, J.T. (1986). How do interpretations inuence the process of psychotherapy? Journal of Consulting and Clinical Psychology, 54, 646652. Southam-Gerow, M.A., & Kendall, P.C., (2002). Emotion regulation and understanding implications for child psychopathology and therapy. Clinical Psychology Review, 22, 189222. Stalikas, A., & Fitzpatrick, M. (1995). Client good moments: an intensive analysis of a single session. Canadian Journal of Counselling, 29, 160175.

W. J. Whelton
Stanton, A.L., Danoff-Burg, S., Twillman, R., Cameron, C.L., Bishop, M., Collins, C.A., Kirk, S.B., & Sworowski, L.A. (2000). Emotionally expressive coping predicts psychological and physical adjustment to breast cancer. Journal of Consulting and Clinical Psychology, 68, 875882. Stanton, A.L., Kirk, S.B., Danoff-Burg, S., & Cameron, C.L. (2000). Coping through emotional approach: scale construction and validation. Journal of Personality and Social Psychology, 78, 11501169. Stein, R. (1991). Psychoanalytic theories of affect. New York, NY: Praeger. Stiles, W.B., Startup, M., Hardy, G.E., Barkham, M., Reynolds, S., Rees, A., & Shapiro, D.A. (1996). Therapist session intentions in cognitivebehavioral and psychodynamic-interpersonal psychotherapy. Journal of Counseling Psychology, 43, 402414. Stroebe, M., Stroebe, W., Scut, H., Zech, E., & van den Bout, J. (2002). Does disclosure of emotions facilitate recovery from bereavement? Evidence from two prospective studies. Journal of Consulting and Clinical Psychology, 70, 169178. Taylor, G.J. (1994). The alexithymia construct: conceptualization, validation, and relationship with basic dimensions of personality. New Trends in Experimental and Clinical Psychiatry, 10, 6174. Taylor, G.J., Parker, J.D.A., Bagby, R.M., & Acklin, M.W. (1992). Alexithymia and somatic complaints in psychiatric out-patients. Journal of Psychosomatic Research, 36, 417424. Teasdale, J.D., & Barnard, P.J. (1993). Affect, cognition, and change: Remodeling depressive thought. Hillsdale, NJ: Earlbaum. Teasdale, J.D., Moore, R.G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z.V. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology, 70, 275287. Van Velsor, P., & Cox, D.L. (2001). Anger as a vehicle in the treatment of women who are sexual abuse survivors: Reattributing responsibility and accessing personal power. Professional Psychology: Research and Practice, 32, 618625. Watson, J.C. (1996). The relationship between vivid description, emotional arousal, and in-session resolution of problematic reactions. Journal of Consulting and Clinical Psychology, 64, 459464. Wells, A., & Carter, K. (2001). Further tests of a cognitive model of generalized anxiety disorder: metacognitions and worry in GAD, panic disorder, social phobia, depression and nonpatients. Behavior Therapy, 32, 85102. Westen, D., & Gabbard, G.O. (1999). Psychoanalytic approaches to personality. In L.A. Pervin, & O.P. John (Eds), Handbook of personality: Theory and research. (pp. 57101). New York: Guilford. Winston, A., Laikin, M., Pollack, J., Samstag, L., McCullough, L., & Muran, C. (1994). Short-term psychotherapy of personality disorders: 2 year follow-up. American Journal of Psychiatry, 151, 190 194.

Copyright 2004 John Wiley & Sons, Ltd.

Clin. Psychol. Psychother. 11, 5871 (2004)

Emotional Processes
Wise, T.N., Jani, N.N., Kass, E., Sonnenschein, K., & Mann, L.S. (1988). Alexithymia: relationship to severity of medical illness and depression. Psychotherapy and Psychosomatics, 50, 6871. Wiser, S., & Arnow, B. (2001). Emotional experiencing: to facilitate or regulate. In Session: Psychotherapy In Practice, 57, 157168. Wiser, S., & Goldfried, M.R. (1993). Comparative study of emotional experiencing in psychodynamic-interper-

71
sonal and cognitive-behavioral therapies. Journal of Consulting and Clinical Psychology, 61, 892895. Wolfsdorf, B.A., & Zlotnick, C., (2001). Affect management in group therapy for women with Posttraumatic Stress Disorder and histories of childhood sexual abuse. Journal of Clinical Psychology, 57, 169181. Wolpe, J. (1982). The practice of behavior therapy (3rd ed.). New York: Pergamon.

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Clin. Psychol. Psychother. 11, 5871 (2004)

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