CPA Award for Distinguished Contributions to Psychology as a Profession – 2007Prix de la SCP pour contribution remarquable a la psychologie comme profession – 2007

Emotion and Cognition in Psychotherapy: The TransformingPower of Affect

LESLIE GREENBERGYork University

AbstractTheory and research on emotion in bothpsychology and psychotherapy are re-viewed to demonstrate the importance ofemotion in human functioning and psy-chotherapeutic change. A proposal is made for the importanceof integrating empirically supported emotion-focused changeprocesses into psychotherapeutic work. Five principles ofchange in the emotion domain—emotion awareness; expression;regulation; reflection on emotion; and the more novel principleof emotion transformation, by which emotion is changed byemotion—are offered as processes of change that are rapidlygathering empirical support. The result of emotion coming ofage will be the expansion of theories of dysfunction and oftreatment to include emotion-focused coping and emotional pro-cesses of change.

Keywords: emotion, emotion-focused therapy, awareness, reg-ulation transformation

This article reviews both the evolving understanding of the roleof emotion in human functioning and the evidence for the importantrole of emotion in psychotherapy, and a set of empirically groundedprinciples of emotional change is proposed. Given that emotion nowis seen as information, as signalling the significance of the situation toa person’s well being, and given that affect regulation is seen as a keyhuman motivation, it has become clear that emotion needs to befocused on, accepted and worked with directly in therapy to promoteemotional change. (Foa, Riggs, Massie, & Yarczower, 1995; Fosha,2000; Greenberg, 2002; Goldman, Greenberg, & Angus, in press;Linehan et al., 2002; Samoilov & Goldfried, 2000). The idea thataccessing and exploring painful emotions, within the context of asecure therapeutic relationship, leads to therapeutic change has been

widely held by several schools of psychotherapy (Bowlby, 1980;Kohut, 1977; Rogers, 1951; Perls, 1969) but has been difficult toprove. However over the past decade, newer therapeutic approachesthat treat affect as a primary target of intervention, within the contextof an empathic relationship, have been developed, tested, and shownto be effective in the treatment of affective disorders, personalitydisorders, 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 function-ing, 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 ofemotion, or its avoidance, does not ensure health or happiness. Alarge volume of research has now been collected on the debilitat-ing physiological effects of not expressing deeply felt emotions(Traue & Pennebaker, 1993). It appears that inhibiting the expres-sion of emotion can lead to impaired immune system function andpoorer health on a variety of indices. In addition, there is increas-ing evidence on the importance of emotion knowledge and emo-tional intelligence in enhancing social competence and healthydevelopment (Mayer & Salovey, 1997).

Emotions are a fundamentally adaptive resource because theyinvolve a meaning system that informs people of the significanceof events to their well-being, and they organise people for rapidadaptive action (Frijda, 1986; Izard, 1991; Oatley & Jenkins, 1992;Tomkins, 1963). From birth onward, emotion also is a primarysignalling system that communicates intentions and regulates in-teraction (Sroufe, 1996). Emotion thus regulates self and other andgives life much of its meaning. With the advent of a view ofemotion as an adaptive resource, the understanding of its relation-ship with cognition and its role in human functioning and psycho-therapy has changed. This new look has begun to set a new agendafor psychological research—to determine the conditions underwhich emotions play a determining role in human experience andhow this occurs.

Neurological Evidence on Affective Primacy

Research emerging from the arena of affective neurosciencesupports the conceptualisation of emotion and cognition as sepa-rate but interacting mental functions mediated by separate but

Correspondence concerning this article should be addressed to LeslieGreenberg, Department of Psychology, York University, 228 BehaviouralScience Building, 4700 Keele Street, Toronto, Ontario M3J 1P3 Canada.E-mail: lgrnberg@yorku.ca

Canadian Psychology Copyright 2008 by the Canadian Psychological Association2008, Vol. 49, No. 1, 49–59 0708-5591/08/$12.00 DOI: 10.1037/0708-5591.49.1.49

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interacting brain systems. LeDoux’s (1996) research on the emo-tional brain has demonstrated that it is possible for our brains toregister the emotional meaning of a stimulus before that stimulushas been fully processed by the perceptual system. He suggeststhat there are two different paths for producing emotion. What heterms the low road is when the amygdala senses danger andbroadcasts an emergency distress signal to brain and body, and theslower high road is when the same information is carried throughthe thalamus to the neocortex. Because the shorter amygdalapathway transmits signals more than twice as fast as the neocortexroute, the thinking brain often cannot intervene in time to stopemotional responses. Thus, the automatic emotional response hasalready occurred before one can stop it, be it jumping back from asnake, snapping at an inconsiderate spouse, or yelling at a dis-obedient child. The neocortex, however, also has been found tohave fibers leading back to the amygdala and provides a path forcognitive feedback to the emotional systems. This is the path bywhich deliberate conscious cognitive processes can be used to helpregulate emotion. LeDoux noted, however, that the initial “pre-cognitive,” perceptual, emotional processing of the low road, fun-damentally, is highly adaptive because it allows people to respondquickly to important events before complex and time-consumingprocessing has taken place.

Functional brain imaging studies have provided evidence consis-tent with LeDoux’s view that the amygdala can perform its role in theprocessing of emotional stimuli nonconsciously. Using functionalMRI, Whalen et al. (1998) demonstrated amygdala activation inresponse to emotional stimuli (facial expressions), even when con-scious awareness of the stimuli is experimentally prevented. In addi-tion, autonomic physiological and motoric aspects of emotion havebeen shown to occur in response to an emotional stimulus that is notconsciously recognised or is outside of attentional focus (Ohman &Soares, 1994). It should be noted that, in these studies, that lack ofawareness of the emotionally salient stimulus does not necessarilyprevent the person from being aware of emotional experience inresponse to the nonconsciously processed stimulus.

More recently Tucker et al. (2003) have shown that an evalua-tive decision begins by recruiting motivational and semantic in-fluences within limbic networks, and these influences appear toshape the development of decisions in various neocortical areas ofthe brain. Affect, by being so densely interconnected with otherbrain areas, has a significant influence on decision making. Ulti-mately, cognition and emotion are inextricably linked so thatcognition often works in the service of affective goals, whereasemotion often is a response to cognition. Emotions thus set a basicmode of processing in motion, orienting consciousness to differ-entially analyse situations for loss, danger, intrusion, violation,novelty, or pleasure. Emotion, in essence, sets problems for reasonto solve (Greenberg, 2002; Greenberg & Pascual Leone, 2001).Emotion moves us and reason guides us.

An important consequence of this method of functioning is thatpeople can respond emotionally without thought, as a situation isperceived to fit the category it activates. Damasio (1994), in his studyof the neurology of emotion, explained that the tacit experiential levelof functioning involves the development of systematic connectionsbetween categories of objects and situations and primary emotions. Ascertain images are stored in memory, they are marked with “somaticinformation.” As these images—an argument with a boss, for exam-ple, or a moment of tenderness with a spouse—are stored, the feelings

experienced in those moments also are stored. These emotions arethen restored when the image is recalled. This produces an emotionalexperience without an actual train of thought. Memories are thusmarked to set off the emotional responses that were set off by theoriginal event. The next time something is recalled, the person willfeel the same way unless the emotion-schematic memory and asso-ciations linked to it are revised. This can be facilitated therapeuticallyby re-experiencing the emotion-laden memory, thereby making itamenable to new input.

Psychological Processes in Emotion Generation

Association, appraisal, and degree of goal attainment have allbeen proposed as important psychological processes in under-standing how emotion is generated. Association is the most fun-damental process of which Bower’s (1981) original associativenetwork theory of emotion is a good example. Although he em-phasised semantic associations, the principle of association appliesto other types of associations, such as external stimuli previouslyassociated with emotional arousal, posture, and facial expression(Berkowitz, 1999). Association helps explains some of the non-cognitive and automatic aspects of emotional experience. Peoplethus may become angry or sad by means of associative processeswithout knowing how situational stimuli are affecting them. How-ever, not all emotions are produced associatively. Appraisal theoryproposes that some form of cognitive evaluation is fundamental.Here, emotions are elicited and differentiated on the basis of aperson’s subjective evaluation or appraisal of the personal signif-icance of a situation. In this view, anger, for example, is generatedonly with appraisals of blame; or sadness, only with appraisals ofloss. Appraisals have, however, been found only to account forabout 40% of emotions (Averill, 1983; Frijda, Kuipers, & terSchure, 1989), suggesting that there is more to emotion generationthan appraisal alone. A third type of theory emphasises desires tomaintain or attain a certain desired state or goal. Here, for example,goal frustration can lead to anger without any attribution of wrong-doing or appraisal of blame. Rather, the anger is motivated by adesire to change undesirable situations, reinstate goals, or protectboundaries. This process involves a different form of evalua-tion—a match or mismatch with a desired endstate. Emotions thus,at times, appear to involve some form of appraisal, but these maybe out of awareness. Emotion, however, often is thoughtless andmay be purely associative. Determining under what conditionsemotion is and is not governed by cognitive processes remains acentral task for psychological research in the coming decades.

More encompassing multilevel theories of emotion that attemptto integrate a variety of different emotion generation processeshave arisen to deal with this complexity. Leventhal (1984) was thefirst to suggest that sensorimotor, schematic, and conceptual levelswere all involved in generating emotions, and Greenberg andSafran (1987) adapted this model to psychotherapy. Teasdale andBarnard (1996) more recently suggested a nine-level model start-ing out at a sensory level moving through a conscious proposi-tional level one level lower than a final tacit implicational level ofprocessing at the top of the hierarchy. Greenberg and PascualLeone (1995, 2001) proposed a dynamic model of emotion con-struction by synthesis rather than a hierarchical model to explainhow change occurs. In this type of model, the dynamic, dialectical

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synthesis of different components is the focus, rather than thehierarchical structuring of levels.

The type of functioning suggested by these models, in whichseparate but interacting mental functions are mediated by separatebut interacting brain systems, appears to be crucial in understand-ing a variety of areas of human functioning; for example, theoperation of two types of memory (one, factual; the other, emo-tional), as well as two kinds of learning (one, a more conceptual,logical form of learning; the other, a more perceptual and emo-tionally, associative one; Pascual-Leone, 1987, 1991). These mod-els help explain the difference between two ways of knowing: one,more conceptual; and the other, more experiential. The importanceof accessing and working with the more tacit, procedural means ofgenerating affective experience rather than more conscious declar-ative processes has been noted by a number of writers (Bohart &Wugalter, 1991; Buck, 1988; Epstein, 1994; Greenberg, Rice, &Elliott, 1993).

In this emotion-focused view of functioning, individuals areseen as consciously making sense of an independent source ofaffective experience that has to be organised by consciousness toconstruct meaning. Meaning results from the dialectical synthesisof emotion and reason. Without emotion, there is no motivation toaction, but without conscious organisation, there is no coherence.The depth, range, and complexity of emotion cannot developbeyond its instinctual origins without conscious articulation.

The process of experiencing an emotion thus involves construc-tion (Neimeyer & Mahoney, 1995). Emotional expression is itselfclearly an elaborate cognitive-processing task, in which data areintegrated from many sources in the brain (often in milliseconds),and this occurs, in the main, outside awareness. The consciousnarrative flow of evaluations, interpretations, and explanations ofexperience—the reported story of the emotion—often only comesafterward. The narrative account is significant as a record inmemory of experience but often is only peripherally related to theprocess of generating ongoing emotion. Human beings thus areseen as actively constructing their sense of reality, acting asdynamic self-organising systems that synthesise many types andlevels of information to create their experience (Greenberg & vanBalen, 1998; Mahoney, 1991).

Convergence in Psychotherapeutic Views

All therapeutic approaches now appear to be converging on ashared view of emotion as a rapid-action, adaptive, control systemthat orients people to the relevance that events in their environmenthave to their well-being. All agree that emotion produces tenden-cies to act in specific ways in response to those events, sets a basicmode of information processing in motion, and plays an indepen-dent role in functioning and can affect cognition. There is alsoconsensus that emotion and cognition are automatically and inti-mately connected in higher order meaning making, that people areconstantly explaining their experience to themselves, and that howthey make sense of their experience influences their experience. Inaddition, a striking point of agreement across approaches appearsto be the shared view that, at automatic or unconscious levels,emotional and cognitive structures are highly integrated and thatthese affective–cognitive, or cognitive–affective, structures are theimportant targets of treatment. Another striking point of agreementis the importance of the meaning construction process. All views

are converging on the view that there are emotional “qualia,” buthow people make sense of their experience is as crucial as whatthey experience, and both are important in intervention.

In addition to agreeing on emotion-laden core structures as thetarget of change, the approaches appear to agree on a number ofother specific points of practice. All approaches recognise thatawareness of emotion and acceptance of and attention to it intherapy are important to access the information in emotion. Allagree that desynchronies or incongruence between cognition andemotion and physiology occur and need to be overcome. Anotherpoint of agreement is that emotion often needs to be aroused toaccess the core structures generating it and that the experiencegenerated by these need to be further processed in therapy topromote change. The final point of agreement is that in therapy itis important to promote emotional experience, as well as emotionregulation.

Thus, we have a picture in which emotion in therapy needs to beattended to, aroused, accepted, and processed, as well as regulatedand changed when necessary. Crucial therapeutic questions thenbecome: When should emotions be regulated, and when shouldthey be facilitated or phrased differently? When should people bechanged by their emotions (i.e., accept or be guided by them), andwhen should they change them?

Emotion in Psychotherapy

In discussing emotion in psychotherapy, it is important to recog-nise that not all emotions serve the same function both in and outof therapy and that therapists need to intervene differentially withdifferent types of emotional processes. Therapists do not simplyhelp clients regulate all emotions or become aware of or express allfeelings. Rather, they distinguish clinically among different typesof emotions to guide their interventions. Problems of overregula-tion are discriminated from problems of underregulation, andemotions that are a sign of distress are distinguished from emo-tions that are a sign of working through distress. Therapists inter-vene differentially with clients depending on their assessment ofthe in-session emotional state, helping them to accept and integratecertain emotions; to acknowledge some and bypass others; toregulate disruptive emotions; to express those that will enhancerelationships; to contain and soothe painful emotions; and toexplore and transform maladaptive emotions. This approach todifferential intervention with emotions is based on the premise thatsome types of emotional expression are more productive thanothers, in and outside of therapy, and that emotional arousal ofproductive emotions relates to outcome in psychotherapy (Green-berg, Auszra, & Herrmann, 2007; Pos, Greenberg, Goldman, &Korman, 2003). In this view, primary emotions are the person’smost fundamental, immediate reaction to a situation, whereassecondary emotions are a person’s emotional reactions to theirown emotional responses to a stimulus, rather than to the situationitself (Greenberg, 2002; Greenberg & Safran, 1987). For example,anger may be a reaction to a feeling of fear of abandonment, whichitself may be adaptive or maladaptive depending on the function itserves in the situation. Primary emotions, the person’s first, gut-level, emotional response to the situation, need to be accessed fortheir adaptive information and capacity to organise action. Mal-adaptive emotions, on the other hand, are learned responses thatare no longer adaptive and need to be regulated and transformed.

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Secondary emotions may be defenses against feelings such asshame at one’s sadness, hopelessness when angry, or reactions tonegative thoughts. Secondary emotions need to be explored toaccess their more primary cognitive or emotional generators. Fi-nally, instrumental emotions are those emotions that are usedconsciously or unconsciously to achieve an aim, such as crying“crocodile tears.”

Primary emotions need to be accessed for their adaptive infor-mation and capacity to organise action, whereas maladaptive emo-tions need to be regulated and transformed. Secondary maladaptiveemotions need to be reduced by exploring them to access theirmore primary cognitive or emotional generators. With this moredifferentiated perspective, we see that not only do we want to helpclients down-regulate unproductive dysregulated secondary andprimary maladaptive emotions, but at different times we may wantto help them access productive primary emotions.

Principles of Working With Emotion

Outcome and process research findings point toward emotionalprocesses as centrally important to good therapy, but what is goodprocessing remains to be elucidated (Greenberg & Pascual Leone,2006). Emotional insight, catharsis, awareness, and exposure have allbeen put forward as explanations of the role of emotion in change, butthere is still not a comprehensive, empirically based understanding ofhow emotion and its processing lead to change. The following fiveprinciples provide an empirically based understanding of emotionalchange processes in clinical change: (a) increasing awareness ofemotion, (b) expressing emotion, (c) enhancing emotion regulation,(d) reflecting on emotion, and (e) transforming emotion (Greenberg,2002; Greenberg & Watson, 2005).

Emotion Awareness

The first and most general goal of emotional change is thepromotion of emotional awareness. The goal is for clients tobecome aware of their emotions and, more specifically, theirprimary adaptive emotions. Becoming aware of and symbolizingcore emotional experience in words provides access both to theadaptive information and action tendency in the emotion. Label-ling emotions often is a first step in problem definition. It isimportant to note that emotional awareness is not thinking aboutfeeling, it involves feeling the feeling in awareness. Only whenemotion is felt does its articulation in language become an impor-tant component of its awareness. The therapist thus needs to helpclients approach, tolerate, and accept their emotions. Acceptanceof emotional experience as opposed to its avoidance is the first stepin emotion work.

Emotion awareness has been grounded in a measure of levels ofemotional awareness developed by Lane and associates (Lane &Schwartz, 1992). Five levels of emotional awareness can be mea-sured. In ascending order, these are physical sensations, action ten-dencies, single emotions, blends of emotion, and blends of blends ofemotional experience (the capacity to appreciate complexity in theexperiences of self and other). Levels of emotional awareness corre-late significantly with self-restraint and impulse control, indicatingthat greater emotional awareness is associated with greater self-reported impulse control. Individual differences in emotion awarenesshave also been found to predict recovery of positive mood and

decrements in ruminative thoughts after a distressing stimulus(Salovey, Mayer, Golman, Turvey, & Palfai, 1995).

Awareness of emotion also involves overcoming the avoidanceof emotional experience. Leahy (2002) noted that there are twofundamental coping pathways for dealing with emotion: One path-way involves attending to and labelling emotions in a manner thataccepts and normalises them, and the other pathway pathologisessome emotional experiences leading to attempts to distort or avoidthem, initiating guilt, frantic efforts at control, obsessive rumina-tion, and so forth. To overcome emotion avoidance, clients mustfirst be helped to approach emotion by attending to their emotionalexperience.

Emotional Arousal and Expression

Emotional expression mobilises the affect system, changesphysiology and neurochemistry, overcomes inhibition, andchanges interpersonal interaction. Emotional expression has re-cently been shown to be a unique therapeutic aspect of emotionalprocessing that predicts adjustment to breast cancer (Stanton et al.,2000) and resolving interpersonal problems (Greenberg & Mal-colm, 2002). Results from a variety of studies also support thatemotional engagement with trauma memories in early sessions(Paivio, Hall, Holowaty, Jellis, & Tran, 2001; Paivio & Nieuwen-huis, 2001) during the first exposure and habituation (reduceddistress) during exposure (Foa & Jaycox, 1999; Jaycox, Foa, &Morral, 1998) over the course of therapy predict better outcome.There is a long line of evidence on the effectiveness of arousal ofand exposure to previously avoided feelings as a mechanism ofchange, such as in exposure treatments for anxiety in youth andadults (Kendall & Hedtke, 2006).

There, however, can be no universal rule about the effectivenessof arousing emotion or evoking emotional expression. Emotionalarousal and expression, although helpful, are not always useful intherapy or in life. Recently, for example, Greenberg et al. (2007)found that the degree of productivity of processing of arousedemotions, rather than arousal alone, distinguished good from pooroutcome cases in which productivity was defined in terms ofdegree of regulation, agency, and processing of the emotion.Arousal appears to be necessary but is not necessarily sufficient forcertain types of therapeutic progress.

Emotion Regulation

The provision of a safe, validating, supportive, and empathicenvironment is the first level of intervention that helps soothe andregulate automatically generated underregulated distress (Bohart& Greenberg, 1997). Linehan et al. (2002) found evidence for theeffectiveness of emotional validation and soothing as part of thetreatment for borderline personality disorder. Empathy from an-other person seems to be important in learning to self-soothe andrestore emotional equilibrium and help strengthen the self (Green-berg et al., 2007). Important issues in any treatment are whatemotions are to be regulated and how these emotions are to beregulated. Clients with underregulated affect have been shown tobenefit both from validation and from the learning of emotionregulation and distress tolerance skills (Linehan, 1993). Undercon-trolled secondary emotions and maladaptive emotions are whatneed to be regulated.

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Regulation of underregulated emotion involves getting somedistance from despair and hopelessness and/or developing self-soothing capacities to calm and comfort core anxieties and humil-iation. Emotion self-regulation skills that involve such things asidentifying and labelling emotions, allowing and tolerating emo-tions, establishing a working distance, increasing positive emo-tions, reducing vulnerability to negative emotions, self-soothing,breathing, and distraction also have been found to help withtolerance of high distress (Linehan, 1993).

Forms of meditative practice and self-acceptance often are mosthelpful in achieving a working distance from overwhelming coreemotions (Teasdale et al., 2000). These can be learned deliberatelyand with practice. Emotion, in addition, can be down-regulated bydeveloping tolerance and soothing at a variety of different levels ofprocessing. Physiological soothing involves activation of the para-sympathetic nervous system to regulate heart rate, breathing, andother sympathetic functions that speed up under stress.

In clinical work, a number of theorists, therapists, and research-ers, however, believe that emotion regulation is not easily achievedthrough the cognitive system alone (Campos, Frankel, & Camras,2004; Fosha, 2000; Hunt, 1998; Linehan, 1993; Schore, 2003).Problems in vulnerable personalities arise most often from deficitsin the more implicit forms of regulation of emotion and its inten-sity. Although deliberate behavioural and cognitive forms of reg-ulation—more left hemispheric process—are useful for peoplewho feel out of control, over time, the building of implicit orautomatic emotion regulation capacities is important for enduringchange, especially for personality-disordered clients. Implicitforms of regulation often cannot be trained or learned as a voli-tional skill. People with underregulated affect have been shown tobenefit both from interpersonal validation and from the learning ofemotion regulation and distress tolerance skills (Greenberg &Watson, 1998; Linehan, 1993; Linehan et al., 2002). Here, regu-lation is seen as an aspect of emotion generation.

Clinical work that views dysfunction as resulting from faultylearning and skill deficit also sees emotion regulation as followingemotion generation and has focused on teaching skills and chang-ing the cognitive system to regulate emotion (Beck, 1976). Inviews of emotion regulation in which regulation is seen as coter-minous with generation, rather than emotion control, the facilita-tion of adaptive emotions is seen as necessary, and clinical workfocuses on clarifying which emotions one allows into awareness.Here, emotion regulation is viewed as having the desired emotionsat adaptive levels at the right time, and therapy is based on theacceptance or facilitation of particular emotions. An issue of majorclinical significance, then, is generating theory and research tohelp understand the extent to which automatic emotion processescan be changed through (a) deliberate regulation processes and (b)more implicit regulation processes based on new emotional and/orrelational experiences.

Reflection on Emotion

The role in psychotherapy of the human capacity for consciousawareness of the processes and contents of their own mind, and forreason and insight to shed light on unconscious motivations, hasbeen substantial, from the beginnings of psychoanalysis right up tothe present day. In addition, many therapists have written on theimportance of changing people’s assumptive frameworks in ther-

apy (Frank, 1974). In addition to the value of emotional awarenessas a source of information, symbolizing emotion in awarenesspromotes reflection on experience to create new meaning, and thishelps clients develop new narratives to explain their experience(Greenberg & Angus, 2004; Greenberg & Pascual-Leone, 1997;Guidano, 1995; Pennebaker, 1990). What we make of our emo-tional experience makes us who we are. Understanding an emo-tional experience always involves putting it into narrative form. Aswitnessed in therapy, as well as in literature, all emotions occur inthe context of significant stories, and all stories involve significantemotions (Greenberg & Angus, 2004). Therapy thus involveschange in both emotional experience and change in the narrativesin which they are embedded.

This principle applies to all types of emotion: secondary, pri-mary, adaptive, or maladaptive. For example, understanding thatone is prone to get angry at one’s partner because one feelsabandoned, and understanding that this relates to one’s past historyof abandonment, is very therapeutic. Alternately being able tosymbolise and explain traumatic emotional memories in wordshelps promote their assimilation into one’s ongoing self-narrative(Van der Kolk, 1995). This form of putting emotion into wordsallows previously unsymbolised experience in emotion memory tobe assimilated into conscious, conceptual understandings of selfand world, where it can be organised into a coherent story. Pen-nebaker and colleagues have shown the positive effects of writingabout emotional experience on autonomic nervous system activity,immune functioning, and physical and emotional health (e.g.,Pennebaker, 1995). Through language, individuals are able toorganise, structure, and ultimately assimilate both their emotionalexperiences and the events that may have provoked the emotions.In addition, once emotions are put into words, people are able toreflect on what they are feeling, create new meanings, evaluatetheir own emotional experience, and share their experience withothers (Pennebaker, 1995; Rime, Finkenauer, Luminet, Zech, &Philippot, 1998). There also is a vast empirical literature on theinfluence of attributions and cognition on emotion in general, andon depression in particular (Clarke & Blake, 1997), that attests tothe importance of reflecting on emotion to create meaning.

Emotion Transformation

The final, most novel, and probably most fundamental principleof emotional change involves the transformation of one emotionby another. This applies most specifically to transforming primarymaladaptive emotions by contact with more adaptive emotions.Although the more traditional ways of transforming emotion—either through exposure, experience, expression, and completion orthrough reflection on them—do occur, another process appears tobe more important. This is a process of changing emotion withemotion (Greenberg, 2002). This novel principle suggests that amaladaptive emotional state can be transformed best by undoing itwith another more adaptive emotion. In time, the co-activation ofthe more adaptive emotion along with or in response to themaladaptive emotion helps transform the maladaptive emotion.Rather than reason with emotion, one can transform one emotionwith another. Whereas thinking usually changes thoughts, feelingusually changes emotions.

Spinoza (1967) was the first to note that emotion is needed tochange emotion. He proposed that “An emotion cannot be re-

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strained nor removed unless by an opposed and stronger emotion”(1967, p.195). Reason clearly is seldom sufficient to change au-tomatic emergency-based emotional responses. Rather than reasonwith emotion, one needs to transform one emotion by accessinganother emotion. In an interesting line of investigation, positiveemotions have been found to undo lingering negative emotions(Frederickson, 2001). The basic observation is that key compo-nents of positive emotions are incompatible with negative emo-tions. Frederickson (2001) suggested that, by broadening a per-son’s momentary thought action repertoire, a positive emotion mayloosen the hold that a negative emotion has on a person’s mind.The experience of joy and contentment were found to producefaster cardiovascular recovery from negative emotions than a neu-tral experience. Frederickson, Mancuso, Branigan, and Tugade(2000) found that resilient individuals cope by recruiting positiveemotions to regulate negative emotional experiences. They foundthat these individuals manifested a physiological bounce back thathelped them to return to cardiovascular baseline more quickly.

Thus, it appears that bad feelings can be transformed by happyfeelings, not in a simple manner, such as by trying to look on thebright side, but through the evocation of meaningfully embodiedalternate experience to undo the negative feeling. For example, ingrief, laughter has been found to be a predictor of recovery. Beingable to remember the happy times and to experience joy helps asan antidote to sadness (Bonanno & Keltner, 1997). Warmth andaffection are similarly often an antidote to anxiety. In depression,a protest-filled, submissive sense of worthlessness can be trans-formed therapeutically by guiding people to the desire that drivestheir protest—a desire to be free of their cages and to access theirfeelings of joy and excitement for life. According to Isen (1999),it has been hypothesised that at least some of the positive effect ofhappy feelings depends on the neurotransmitter’s effect, in theexperiencing of joy, on specific parts of the brain that influencepurposive thinking. Mild positive affect has been found to facili-tate problem solving. These studies together indicate that emotioncan be used to change emotion.

However it is not only that unpleasant feelings are transformedby pleasant ones. Davidson (2000) suggested that the right hemi-spheric withdrawal-related negative affect system can be trans-formed by activation of the approach system in the left prefrontalcortex. In addition, both clinical and research observations showthat many different emotions can change distressing emotions. Forexample, in a study of self-criticism, Whelton and Greenberg(2004) found that people who were less vulnerable to depressionwere able to recruit emotional resources such as self-assertiveanger to combat depressogenic contempt and shame. Empoweringanger in therapy changes depressive hopelessness and shame, aswell as the anxiety and fear in anxiety disorders. Sadness, love, andforgiveness have also been observed to change anger (Malcolm,Warwar, & Greenberg, 2004).

It is important to note that the process of changing emotion withemotion goes beyond ideas of catharsis or completion, exposure,extinction or habituation, in that the maladaptive feeling is not purged,nor does it simply attenuate by the person feeling it. Rather, anotherfeeling is used to transform or undo it. Although exposure to emotion,at times, may be helpful to overcome affect phobia in many situationsin therapy, change also occurs because one emotion is transformed byanother emotion rather than simply attenuating. In these instances,emotional change occurs by the activation of an incompatible, more

adaptive, experience that undoes or transforms the old response. Thisinvolves more than simply feeling or facing the feeling, leading it todiminish. Rather, emotional change occurs by the activation of anincompatible, more adaptive experience that replaces or transformsthe old response.

Clinical observation and research suggests that emotional trans-formation occurs by a process of dialectical synthesis of opposingschemes. When opposing schemes are co-activated, they synthe-sise compatible elements from the co-activated schemes to formnew higher level schemes, just as in development when schemesfor standing and falling, in a toddler, are dynamically synthesisedinto a higher level scheme for walking (Greenberg & Pascual-Leone, 1995; Pascual-Leone, 1991). Schemes of different emo-tional states similarly are synthesised to form new integrations.Thus, in therapy, maladaptive fear, once aroused, can be trans-formed into security by the more boundary-establishing emotionsof adaptive anger or disgust or by evoking the softer feelings ofcompassion or forgiveness. Similarly, maladaptive anger can beundone by adaptive sadness. Maladaptive shame can be trans-formed by accessing both anger at violation and self-comfortingfeelings and by accessing pride and self-worth. Thus, the tendencyto shrink into the ground in shame is transformed by the thrusting-forward tendency in newly accessed anger at violation. With-drawal emotions from one side of the brain are replaced withapproach emotions from another part of the brain, or vice versa(Davidson, 2000). Once the alternate emotion has been accessed,it transforms or undoes the original state, and a new state is forged.

Applications of the Principles to Treatment

Working with these principles involves first differentiating be-tween emotional experiences that are adaptive or maladaptive andemotions that are primary or secondary. Primary emotions need tobe accessed in awareness for their adaptive information and ca-pacity to organise action. In contrast, maladaptive emotions needto be accessed to be transformed, which occurs by exposing themto new experience, thereby creating new meaning. Secondaryemotions need to be bypassed to get to more primary emotions.Emotion-focused therapy (EFT) suggests that it is important to beaware of and reflect on primary emotions and to regulate andtransform maladaptive emotions. A two-step therapeutic process isrecommended when the core emotion avoided is adaptive. First,the symptomatic secondary emotions (e.g., feeling upset, despair-ing, and hopeless) are evoked in therapy, then the core primaryadaptive emotion that is being interrupted (e.g., sadness of grief orempowering anger are accessed and validated). A three-step se-quence, however, is required to transform maladaptive core emo-tion. In this sequence, first the secondary emotion is evoked, andthen core maladaptive emotions being avoided (e.g., shame, fear,or anger) are accessed. These are then transformed by accessingadaptive emotions such as anger, sadness, and compassion. Whenadaptive emotions finally are evoked, they are incorporated intonew views of self and used to transform personal narratives.

The Therapeutic Relationship

In addition to the principles of emotional change, the therapeuticrelationship is the crucible of emotional processing. The linkbetween both therapeutic alliance and empathy and outcome are

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widely recognised (Greenberg, Elliott, Watson, & Bohart, 2001),and there is reason to believe that a good alliance is a prerequisiteto productive emotional processing. In studies across several typesof psychotherapy, the role of emotional arousal has been found tobe mediated by the working alliance (Beutler, Clarkin, & Bongar,2000), so that high arousal predicted good session outcome, butonly when there was a strong alliance (Iwakabe, Rogan, & Stali-kas, 2000). If the client feels overwhelmed and emotion is dys-regulated, the relationship is soothing, validating, and regulating(Greenberg, 2002; Linehan, 1993). On the other hand, if theclient’s level of arousal is unproductively low (e.g., avoidance,worry intellectualization), the relationship can be empathicallyevocative, focusing, and supportive, thereby heightening emo-tional activity (Gendlin, 1996; Greenberg, 2002; Perls, Hefferline,& Goodman, 1951).

Evidence-Based Treatment

In addition to the aforementioned theoretical and empiricaldevelopments, a number of approaches focused on working di-rectly with emotion have been demonstrated to be effective inrandomised clinical trials (Elliott, Greenberg, & Lietaer, 2004;Greenberg & Pascual-Leone, 2006; Whelton, 2004), providingempirical support for the importance of focusing on painful emo-tion in therapy.

EFTs have shown to be effective in both individual and couplestherapy in a number of randomised clinical trials (Elliott et al.,2004; Johnson, Hunsley, Greenberg, & Schlindler, 1999). A manu-alised form of EFT of depression, process–experiential (PE) ther-apy (in which specific emotion activation methods are used withinthe context of an empathic relationship), has been found to behighly effective in treating depression in three separate studies(Goldman et al., in press; Greenberg & Watson, 1998; Watson,Gordon, Stermac, Kalogerakos, & Steckley, 2003). The EFT treat-ment added the use of specific tasks to the client-centered (CC)therapy—in particular, systematic evocative unfolding, focusing,two chair, and empty chair dialogue. In the York II DepressionStudy, Goldman et al. (in press) replicated the York I study bycomparing the effects of CC and PE therapy on 38 clients withmajor depressive disorder; they obtained a comparative effect sizeof .71 in favour of PE therapy. They then combined the York I andII samples to increase power of detecting differences betweentreatment groups, particularly at follow-up. Statistically significantdifferences among treatments were found on all indices of changefor the combined sample, with differences maintained at 6- and18-month follow-ups. This provides evidence that the addition ofPE emotion-focused interventions to the foundation of a CC rela-tionship improves outcome.

In a later study, Watson et al. (2003) carried out a randomisedclinical trial comparing PE therapy and cognitive–behaviouraltherapy (CBT) in the treatment of major depression. Sixty-sixclients participated in 16 sessions of weekly psychotherapy. Therewere no significant differences in outcome on depression betweengroups. Both treatments were effective in improving clients’ levelof depression, self-esteem, general symptom distress, and dysfunc-tional attitudes. However, clients in PE therapy were significantlymore self-assertive and less overly accommodating at the end oftreatment than clients in CBT. At the end of treatment, clients inboth groups developed significantly more emotional reflection for

solving distressing problems. In these studies, EFT for depressionwas found to be equally or more effective on some measures thanboth a purely relational empathic treatment and a cognitive–behavioural treatment.

EFT for adult survivors of childhood abuse (EFT-AS), whichuses empathy plus empty-chair work and involves arousal andprocessing of painful emotions, has been found to be effective intreating abuse (Paivio & Nieuwenhuis, 2001). Emotionally fo-cused couples therapy (Greenberg & Johnson, 1988) that involvespartners revealing their underlying attachment and identity-relatedvulnerable feelings to each other has been found to be effective intreating couples’ distress (Johnson, Hunsley, Greenberg, & Schin-dler, 1999).

Short-term dynamic therapy (STDP) that works on overcomingdefenses and treats affect phobia by exposure to dreaded emotionhas garnered empirical support in the treatment of cluster C per-sonality disorders when compared with CBT, pure cognitive ther-apy, and brief supportive psychotherapy (Svartberg et al. 2004;Winston et al., 1994). A convincing amount of outcome researchalso supports the efficacy of STDP in the treatment of complicatedAxis I disorders (Winston et al., 1994; Winston et al., 1991).

In addition, CBTs based on exposure to imaginal stimuli have along history of demonstrated effectiveness for trauma and otheranxiety-related disorders (Borkovec, Alcaine, & Behar, 2004; Sha-piro, 1999). Outcome research supports the efficacy of exposure-based therapies with diverse traumatised populations, includingsurvivors of child abuse (e.g., Foa, Rothbuam, & Furr, 2003;Paivio & Nieuwenhuis, 2001; Shapiro, 1999). More recently, anavoidance theory of generalized anxiety disorder, in which worryis understood as a cognitive response that orients individuals to athreat while insulating them from the immediacy of their emo-tional experience, has gained support (Borkovec et al., 2004).

The Process of Change

In addition to clinical trials, empirical research on the indepen-dent role of emotion in therapeutic change is growing. Processresearch has consistently demonstrated a relationship betweenin-session emotional activation and outcome. Jones and Pulos(1993) found that the strategies of evocation of affect and thebringing of troublesome feelings into awareness were correlatedpositively with outcome in both dynamic treatment and CBT in theNational Institute of Mental Health Treatment of Depression Col-laborative Research Program. A more recent study (Coombs,Coleman, & Jones, 2002) examining therapists’ stance on inter-personal therapy and CBT for depression showed the importanceof focusing on emotion, regardless of orientation. This study foundthat collaborative emotional exploration, which occurred signifi-cantly more frequently in interpersonal therapy, was found torelate positively to outcome in both forms of therapy, whereaseducative/directive process, utilised more frequently in CBT, hadno relationship to outcome. Helping people overcome their avoid-ance of emotion, focusing collaboratively on emotions, and ex-ploring them in therapy appears to be important in therapeuticchange, regardless of therapeutic orientation.

The importance of facilitating in-session emotional experienceto promote change has become increasingly recognised (Green-berg, 2002; Samoilov & Goldfried, 2000). Reviews of pastprocess–outcome studies testing these claims show a strong rela-

55EMOTION AND COGNITION IN PSYCHOTHERAPY

tionship between in-session emotional experiencing, as measuredby the Experiencing Scale (Klein, Mathieu, Kiesler, & Gendlin,1969) and therapeutic gain in dynamic, cognitive, and experientialtherapies (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996;Goldman, Greenberg, & Pos, 2005; Orlinsky & Howard, 1986;Silberschatz, Fretter, & Curtis, 1986). These findings suggest thatprocessing one’s bodily felt experience and deepening this intherapy may well be a core ingredient of change in psychotherapy,regardless of approach.

The recipe for emotional processing from the perspective ofbehaviour therapy is arousal plus habituation to the distressingstimulus and exposure to new information: In short, it is theexperience of old distress in the presence of new informationaccrued experientially in the moment. From an experiential ther-apy perspective, however, approach, arousal, acceptance, and tol-erance of emotional experience are necessary but not sufficient forchange. In addition, optimum emotional processing involves theintegration of cognition and affect (Greenberg, 2002; Greenberg &Pascual-Leone, 1995). Once contact with emotional experience isachieved, clients must also cognitively orient to that experience asinformation, explore, reflect on, and make sense of it; they alsomust access other internal emotional resources to help transformthe maladaptive state.

Supporting the first aspect of this hypothesis, process–outcomeresearch on EFT for depression has shown that both higher emo-tional arousal at midtreatment, coupled with reflection on thearoused emotion (Warwar & Greenberg, 1999), and deeper emo-tional processing late in therapy (Pos et al., 2003) predicted goodtreatment outcomes. High emotional arousal plus high reflectionon aroused emotion distinguished good and poor outcome cases,indicating the importance of combining arousal and meaning con-struction (Missirlian, Toukmanian, Warwar, & Greenberg, 2005;Warwar, 2003). EFT thus appears to work by enhancing the typeof emotional processing that involves helping people experienceand accept their emotions and make sense of them.

A client’s individual capacity for emotional processing early intherapy also predicted outcome, but the increase in degree ofemotional processing from early to mid-, or early to late, phases oftreatment was found to be a better predictor of outcome than earlylevel of processing or than the early alliance (Pos et al., 2003).Early capacity for emotional processing thus does not guaranteegood outcome, nor does entering therapy without this capacityguarantee poor outcome. Although likely an advantage, earlyemotional-processing skill appears not to be as critical as theability to acquire and/or increase depth of emotional processingthroughout therapy. Therapists’ interventions that focused moredeeply on client’s experience were also shown to deepen clients’experience and to predict outcome (Adams & Greenberg, 1996).

Studies of the behavioural treatment of anxiety disorders haslong demonstrated that clients who profited most from systematicdesensitization (Borkovec & Stiles, 1979; Lang, Melamed, & Hart,1970) and flooding (Watson & Marks, 1971) exhibited higherlevels of physiological arousal during exposure. More recently,methods that increase arousal have also been found to be effectivein treating panic (Clarke, 1996; Mineka & Thomas, 1999). Theseand other findings suggest that the arousal of the fear-activatedphobic memory structures is important for change.

Research on couples therapy also supports the role of emotionalawareness and expression in a satisfying relationships and change

in therapy. Emotionally focused couples therapy (Greenberg &Johnson, 1988) that helps partners access and express underlyingattachment-oriented emotions, has been found to be effective inincreasing marital satisfaction (Johnson & Greenberg, 1985; John-son et al., 1999). In addition, couples who showed higher levels ofemotional experiencing in therapy, which accompanied the soft-ening in the blaming-partners stance, were found to interact moreaffiliatively and ended therapy more satisfied than couples whoshowed lower experiencing (Greenberg, Ford, Alden, & Johnson,1993; Johnson & Greenberg, 1985; Makinen & Johnson, 2006). Asimilar effect of the expression of underlying emotion was foundin resolving family conflict (Diamond & Liddle, 1996).

The evidence from psychotherapy research indicates that certaintypes of therapeutically facilitated emotional awareness andarousal, when expressed in supportive relational contexts and inconjunction with some sort of conscious cognitive processing ofthe emotional experience, is important for therapeutic change withregard to certain classes of people and problems. Emotion also hasbeen shown to be both adaptive and maladaptive. In therapy,emotions sometimes need to be accessed and used as guides and atother times regulated and modified. The role of the cognitiveprocessing of emotion in therapy has been found to be twofold,either to help make sense of the emotion or to help regulate it.

Conclusion

The emotion/motivation, cognitive, and behavioural systems areall important in therapeutic work. Privileging one system fortherapeutic attention over the others leads to a narrowing ofperspective. Understanding the conditions under which it is opti-mal to intervene therapeutically with a specific system is crucial.In this article, a number of principles for working with emotionhave been suggested to promote the inclusion of emotion-focusedwork into an ultimate empirically based, integrative, emotion-focused cognitive behavioural therapy for the new millennium.

Resume

Le document traite des theories et des recherche relatives auxemotions, relevees dans les domaines de la psychologie et de lapsychotherapie, en vue de montrer l’importance de ces etats af-fectifs dans le fonctionnement humain et le changement psycho-therapeutique. L’integration de processus de changement axes surles emotions, soutenus empiriquement, dans l’exercice psycho-therapeutique est fortement suggeree. On propose cinq principesde changement dans le domaine des emotions : la reconnaissance,l’expression, la regulation et la reflexion sur les emotions ainsi quele principe novateur de la transformation de ces dernieres, selonlequel une emotion peut changer une emotion. Il s’agit de proces-sus de changement qui se meritent un soutien empirique grandis-sant. L‘etude des emotions en pleine evolution se traduira par lestheories de la dysfonction et du traitement connexe, qui inclurontla reponse de l’individu face aux emotions et les processus emo-tionnels du changement.

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Received September 19, 2007Accepted September 21, 2007 �

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