The Role of Emotion in Psychological Therapy

Abstract

This Special Issue of Clinical Psychology: Science and Practice provides a series of articles detailing efforts to consider the concepts of emotion and emotion regulation in relation to clinical assessment and psychopathology intervention efforts across the lifespan. In our commentary, we review some common themes and challenges presented in these articles to move forward the discussion of emotion’s role in psychological therapy. We discuss efforts to conceptualize the role of context in defining emotion concepts and maximizing the relevancy of such concepts to treatment. We review the importance of imbuing efforts to develop emotion-focused treatments with emphases on positive, as well as negative, emotions and flexibility in the expression of these emotions. We also highlight the relevance of a lifespan developmental approach to the accurate use of emotion and emotion regulation concepts within treatment. Finally, we discuss the application of these issues to our own treatment development and evaluation efforts regarding a unified approach to the treatment of emotional disorders in adults and adolescents.

As reflected in this Special Issue of Clinical Psychology:Science and Practice, the field of clinical psychology is clearly experiencing an “affect revolution” (Fischer & Tangney, 1995). This focus on incorporating research on emotion and its regulation into clinical assessment and treatment, topics that have been of primary interest to neuroscience, social, and developmental psychology researchers for decades, is overdue and certainly welcomed. However, the marriage of emotion topics and clinical ones is not necessarily easy, from either a conceptual or practical perspective. Particularly, issues of emotional variability and accessibility across context and development may make such constructs difficult to measure or apply with accuracy or consistency in a clinical setting. The articles contained within this Special Issue begin the long road toward mapping the relationships between emotion and psychopathology and its treatment in such a way that both affective science and clinical psychology are enhanced.

This commentary focuses on common themes addressed in the articles in this Special Issue, including the importance of (a) context in understanding and changing both emotions and emotion regulation strategies, (b) targeting positive emotions in treatment, (c) flexibility in the use of emotion regulation strategies, and (d) the application of a developmental lifespan perspective regarding emotion regulation. We conclude with the implications and promise of treatment-oriented research on emotion-focused approaches, including our own unified approach (Allen, McHugh, & Barlow, in press; Barlow, Allen, & Choate, 2004; Ehrenreich & Barlow, 2007; Ehrenreich, Buzzella, & Barlow, 2007).

CONTEXT AND ASSESSMENT OF EMOTIONS AND EMOTION REGULATION

As discussed in this Special Issue, there is a growing acknowledgment of both the important role emotions play in the development of psychopathology, as well as an increasing awareness of the importance of addressing emotions and emotional processes in clinical interventions. When considering ways to assess emotion in emotion-focused interventions, it is important to be conceptually clear about the underlying emotion-related construct the intervention purports to address, thereby clarifying proposed targets of change, defining the constructs and processes that are to be the focus of assessment, and delineating the standards by which the intervention might be evaluated. To ensure that we accurately and efficiently assess emotion in clinical interventions, we need to determine (a) what exactly it is we are proposing to assess (i.e., emotional awareness, expression, regulation, etc.), (b) the function of the assessment in relation to the desired clinical outcome, and (c) the context in which the emotion occurs.

What Should Be Assessed?

Zeman, Klimes-Dougan, Cassano, and Adrian (2007) point out that as a first step it is necessary to consider what it is about emotions we are proposing to assess. Are we concerned with emotion in its structural content (what an emotion is), or are we concerned with its functional role (what an emotion does)? In emotion-focused interventions, the well-being of clients is considered to be intimately tied with the functional role emotions play in their lives. As such, it is important to both understand what emotions are as well as the role of emotions in everyday experiences and interactions with the internal and external world. Therefore, both the structure and the function of emotion are important areas of assessment. Emphasizing the structure of emotions early on in interventions allows an entry point by which to begin educating clients about emotions, why we have them, and what makes up an emotional experience. In this way, assessment of the structure of an emotion may allow clients to become more aware of their emotional experiences. Assessing the functional role of emotions is critical for understanding how emotions are used to navigate and regulate interactions with the external and internal environment. Within this domain, it may be important to assess the ways in which the client responds to his or her emotional experiences, the client’s relationship to his or her own emotional experiences and the emotions of others, and how the client regulates his or her emotions according to situational demands. Assessing both what an emotion is and what an emotion does, therefore, may be important areas of interest in clinical interventions targeting emotions. The question then becomes how to effectively measure progress in these domains over the course of an intervention, and what the most effective modes of measurement might be.

How Should It Be Assessed?

To assess the effectiveness of an emotion-focused intervention, we must be able to measure real changes in emotional processing over time. Yet, as several of the authors in this issue have pointed out, this can pose methodological challenges. In choosing appropriate modes of assessment in clinical interventions, it is important to keep the ultimate aims of assessment in mind. For instance, if the goal is to determine whether global levels of emotional experience have changed, then perhaps trait-focused self-report measures might be most appropriate. However, if the goal of the assessment is to track dynamic changes in emotional responding during the course of an exposure, then perhaps physiological or experience-sampling methodology would be more appropriate. Further research is needed to develop and validate measures that can reliably capture moment-to-moment changes in the target domains of functioning, and adequately capture the dynamic, context-driven use of emotion management or regulation strategies.

What Is the Context of the Emotion?

Context is a critical variable that must be considered carefully in the assessment of emotions and emotion regulation strategies in clinical interventions. The experience and function of emotions are inextricably linked with the context in which they occur, and therefore context cannot be ignored. Context includes not only situational/environmental factors, but also internal, developmental, social-interpersonal, and cultural factors. Consideration of these variables is critical for a complete understanding of the client’s emotional processes.

For example, it is important to have an understanding of the internal context in which emotions occur for the client. The relationship of the client to his or her own internal experiences may be thought of as the first crucial variable affecting the role of emotions in the client’s life, and therefore may be a particularly important target of change. How does the client relate to his or her own emotional experiences? Does the client view emotions as good, safe, positive, or helpful, or does the client view emotions as bad, threatening, or interfering? The stance taken by the client toward his or her emotions is of particular interest in emotion-focused interventions, as this stance may have far-reaching experiential, behavioral, and interpersonal consequences (Campbell-Sills & Barlow, 2006; Gross & John, 2003; Roemer et al., 2005).

As suggested by Zeman et al., (2007) and by Suveg, Southam-Gerow, Goodman, and Kendall (2007), placing the emotional life of the client in the context of the client’s developmental age is also an important consideration, particularly the extent to which the client is able to be self-aware and reflective of his or her own emotional state, to recognize emotions in others, to detect and focus on key aspects of the emotional environment, to access in memory and draw inferences based on past emotional experiences, and to possess the linguistic and verbal capacity to label and express emotional experiences. Social-interpersonal relationships are another important contextual variable, particularly for assessment of children and adolescents. For example, the degree to which emotional displays of the client are accepted and tolerated within important social-interpersonal relationships, or the way in which emotions are being modeled for the client within the home environment, can have direct consequences on the emotional functioning of the client.

An awareness of the ongoing situational context in which emotions are unfolding is also an important factor to assess in relation to adaptive emotional functioning. Emotional experiences do not occur in a vacuum, and are intimately tied with the context in which they occur. Therefore, assessing situational contextual variables is an important part of reflecting upon emotional experiences and considering situationally appropriate responses. Learning to take in information about the entire situational context in which an emotion arises (including ways in which emotions may be triggered by distal events, the way in which misattributions about a situation can influence emotional responding, and the consequences of subsequent emotional responses) is an important step toward the ultimate goal of promoting flexible, situationally appropriate application of emotional responses, such that the client begins to recognize when it is appropriate to express emotions, and when it might be more appropriate to modulate or suppress emotional responses.

Culture is yet another contextual variable to consider in emotion assessment, as there is some variability in cultural norms of emotion expression and experience. As such, cultural differences must be kept in mind when making assumptions about the adaptive versus maladaptive nature of the client’s emotional responses and emotion management strategies. For example, in Japanese culture, one may value the avoidance of negative outcomes in social interactions and the maintenance of social harmony, and stoicism is valued over the expression of negative emotions (Mesquita & Karasawa, 2002). Therefore, stressing emotional expression may be sending a message that is incongruent with the client’s cultural values. The ways in which emotional experiences are communicated and reported by clients may also vary across cultures. For example, some English words used as labels for emotions do not have counterparts in other languages. Similarly, there may be limitations in the ability to directly translate emotional words in English into similar words in other languages that capture the same experiential meaning in both languages. There may be differences in the way in which physiological responses to emotional experiences are reported. For example, the experience of el calor, or “the heat,” is a symptom reported by Salvadoran refugees who have been victims of trauma, but is not reported by people in other cultures (i.e., Jenkins & Valiente, 1994). Being mindful of the culturally specific ways in which clients may view emotions and report on emotional experiences is critical to assessing emotions in clinical interventions.

Understanding the importance of context in learning new, adaptive ways of relating to emotional experiences is a critical variable in the ultimate success of emotion-focused interventions. The therapist must bear in mind that what is experienced in the context of the session may not generalize into real-world contexts, and as such efforts must be made to make connections for the client between the adaptive skills learned in session and the application of these skills in his or her everyday emotional life. By assessing the context in which emotional experiences arise in the real world, the therapist can draw on some of these cues and bring them into session when demonstrating new, adaptive skills. As suggested by Mennin and Farach (2007), accessing the internal context in session through emotional engagement may be particularly important and useful for making new skills salient and accessible for the client in emotionally evocative situations outside of session.

ROLE OF POSITIVE EMOTIONS

A common theme among the articles in this Special Issue is the importance of increased attention to and focus on positive emotions in assessment and psychological therapy. Research has identified trait levels of negative and positive affect as underlying a wide range of emotional disorders. Studies into the latent structure of emotional disorders have identified negative affect as a common diathesis among a range of mood and anxiety disorders. Moreover, depression and social phobia have been found to be marked by diminished trait levels of positive affect. This finding has been replicated in a number of studies, using a variety of different methods, including longitudinal latent variable methodology (Brown, 2007), experience-sampling methodology (Kashdan & Steger, 2006), and laboratory-based paradigms (Larson, Nitschke, & Davidson, 2007). Given the overlap between a disorder such as depression and a range of potentially co-occurring emotional disorders (e.g., Cole, Peeke, Martin, Truglio, & Seroczynski, 1998; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003), it may be relevant to consider positive affect as another avenue of emotion-focused intervention across emotional disorders.

Functional accounts of emotions have long noted the informative role that emotions serve and the close connection between emotion and behavior (Frijda, 1986; Lazarus, 1991). Negative emotions function by narrowing attention and mobilizing the body for response. Specific negative emotions are tied to specific action tendencies (fear–escape, anger–attack, etc.), which are presumed to be evolutionarily adaptive. Functional theories tend to focus on providing theoretical accounts of negative emotions, but Fredrickson (1998, 2001) has extended the concept of action tendencies to positive emotions with her broaden-and-build theory, which posits that positive emotions broaden people’s thought-action repertoires and build their enduring personal resources.

As research into the nature of positive emotions increases, new and exciting opportunities for expanding and strengthening (or improving) existing treatment approaches are introduced. For instance, Fredrickson’s (2001) broaden-and-build theory suggests ways in which we can bolster extant treatments. One of the most exciting opportunities suggested by the broaden-and-build theory is the ability of positive emotions to “undo” or ameliorate the lingering effects of negative emotions. That is, by broadening the responses available to the individual in the moment, positive emotions might serve as an incompatible response to the attention-narrowing, physiologically arousing effects of negative emotions. The so-called undoing hypothesis has received support from a handful of studies, suggesting that positive emotions have the ability to alter or reduce the physiological aftereffects of negative emotions (see Fredrickson, 2001; Hughes & Kendall, in press).

This suggests the intriguing possibility that positive emotions, if cultivated in treatment, might serve as opposite action tendencies or incompatible responses for lingering negative emotions. Changing these emotion-driven behaviors comprises one of the three major components of our unified treatment approaches to emotional disorders (Allen et al., in press; Ehrenreich et al., 2007). Treatment approaches based on emotion science, that specifically target emotion regulation, would benefit from focusing on building positive emotions in addition to alleviating negative emotions. Strategic building of positive emotions appears to have beneficial effects on both the course and duration of negative emotions. Additional research is needed to further explicate the nature of the ameliorative effects of positive emotions, including whether such effects are seen for the subjective experience of emotions.

Studies are needed to examine the utility and limits of building positive emotions. For instance, it remains an open question whether the building of positive emotions is a strategy that can be employed deliberately and consciously to alter the experience of negative emotions, or whether such a strategy only has salubrious effects when primed or initiated externally (e.g., a fortuitous event or experimentally induced via film clips). It is likely the case that the function of this strategy will be key in determining whether such a response is adaptive or not. For instance, if the building of positive emotion is employed for the purpose of suppressing or avoiding the experience of a negative emotion, the beneficial effect might be lost. On the other hand, a beneficial effect might be accomplished if the function of building positive emotion is to transform the emotional experience by tolerating or accepting the negative emotion and refocusing attention as a way of circumventing the sustained processing of negative emotion that is so common among the emotional disorders. Further investigations into the relationship between positive and negative emotions are needed.

Incorporating positive emotions into an emotion-focused treatment approach might also bolster outcome by building an individual’s long-term coping resources. According to Fredrickson, positive emotions broaden attention in the short term, while the long-term effect might be to increase available coping resources by facilitating flexible and creative thinking. This suggests that incorporating positive emotions into treatment might help maintain long-term gains and perhaps buffer against relapse by strengthening an individual’s enduring coping resources and resiliency.

IMPORTANCE OF FLEXIBILITY IN EMOTION REGULATION

One important implication discussed in this Special Issue is the importance of promoting flexible use of emotion regulation strategies. Historically, psychological treatments have focused on the amelioration of negative emotions. Emotion science and theory have begun to recognize the importance of a more flexible approach to regulation of one’s emotions. Successfully navigating the ebb and flow of emotional life requires the dynamic use of multiple regulatory strategies. As mentioned previously, the building of positive emotions is one important aspect of emotion regulation that psychological treatments would benefit from incorporating. Additional emotion regulation skills, such as appropriately reducing positive emotions and increasing experience of some negative emotions, are important additional targets for emotion-focused treatment approaches. As discussed earlier, the appropriateness of employing a particular strategy depends largely upon the context in which it is to be enlisted and further research is needed to explicate the appropriateness of particular emotion regulation strategies. This point highlights an important gap in our current knowledge base. Currently, it is largely unknown whether certain regulation strategies that might be less beneficial overall (e.g., suppression) can be beneficial under certain circumstances. The research that has been done has focused on either chronic use (or trait levels) of particular regulation strategies or on their immediate effects in a highly controlled laboratory environment. What have remained largely unstudied are the day-to-day effects of using such strategies within the context of the daily stressors and minor annoyances that necessarily arise. Research using more ecologically valid methods is needed to explicate the limits and bounds of the deleterious and beneficial effects of particular emotion regulation strategies. For instance, investigations employing experience-sampling methodologies would allow the examination of fluctuations in an individual’s daily use of a particular regulation strategy (i.e., suppression) over and above her or his trait levels of the strategy.

LIFESPAN DEVELOPMENTAL PERSPECTIVE

Consideration of developmental variables in the study of emotion and emotion regulation, along with the developmentally sensitive application of such concepts to treatment, is critical. Although the majority of research pertaining to emotion regulation has taken place with normal populations, literature has begun to conceptually implicate emotion regulation skills as a risk factor for most forms of childhood psychopathology (Bradley, 2000; Cicchetti, Ackerman, & Izard, 1995; Keenan, 2000; Vasey & Dadds, 2001). For instance, Bradley’s (2000) model of emotion regulation hypothesizes that a child has a temperamental or learned vulnerability to experience-increased levels of arousal in emotionally salient situations. When under stressful conditions, this vulnerability interferes with efforts to modulate emotional reactivity efficiently and successfully. This results in maladaptive efforts to cope and creates a risk factor for psychopathology. Given this, an understanding of which emotion regulation strategies individuals are most capable of learning and applying at various developmental levels may be an essential task for successful intervention.

In addition to the acquisition and utilization of emotion regulation skills available to the individual, one’s developmental trajectory can also alter regulatory targets or preferences. For instance, Carstensen et al. investigated how perceptions of time remaining can alter the targets of emotion regulation. Socio-emotional selectivity theory (Carstensen, 2006; Carstensen, Isaacowitz, & Charles, 1999) posits that perceived time constraints influence the relative priority placed on different regulatory goals, predicting a curvilinear trajectory for emotion-related goals over the lifespan. Drawing a broad distinction between regulatory goals focused on learning and exploration (knowledge-related goals) and those focused on the affective states of oneself and others (emotion-related goals), Carstensen et al. have found that processing priority is given to emotion-related goals earlier and later in life, while knowledge-related goals are prioritized in adolescence and early adulthood (Carstensen, 2006; Carstensen et al., 1999).

This distinction suggests that developmentally sensitive treatment approaches would benefit from recognizing how lifespan development interacts with not only capacities for emotion regulation, but also the targets of such processes. Thus, for adolescents and young adults, emotion-focused treatments might benefit from emphasizing the role of emotion regulation in the service of pursuing knowledge-related goals, or how regulatory targets other than emotion-related goals might be reconciled, incorporated, and pursued. However, for younger children and older adults, emotion-focused treatments might benefit from emphasizing emotion regulation in the service of emotion-related goals and interpersonal relationships. Although further research is needed, such work underscores the importance of incorporating a lifespan-developmental perspective into emotion science and the potential benefits such an approach provides for treatment development, including tailoring broadly focused treatment approaches (i.e., Allen et al., in press; Barlow et al., 2004; Ehrenreich & Barlow, 2007; Ehrenreich et al., 2007) to individual patients.

TREATMENT EFFICACY AND DISSEMINATION

One of the obstacles facing the widespread adoption and utilization of extant empirically based treatments is the difficulty associated with effective dissemination. Current disorder-specific approaches require the practicing clinician to receive extensive training in a number of different protocols. In a limited resource environment, such an approach may be doomed to fail. Designing a treatment that targets the diatheses and underlying processes found to be common across emotional disorders could help to improve dissemination and provide a more effective way of bridging the gap between science and practice. The benefit to training clinicians in a single-unified protocol as opposed to multiple trainings for numerous disorder-specific protocols is obvious. A unified protocol would reduce demand on limited clinician resources (time, money, etc.) and perhaps obviate one of the key barriers to widespread dissemination.

In addition to the added benefit for dissemination, a treatment targeting the commonalities among emotional disorders may help to improve treatment efficacy and effectiveness. An emotion-focused treatment may be applicable to a wider range of diagnostic and symptom presentations. The broader emotion-focus might facilitate the translation or generalization of the treatment from the research clinic to routine clinical practice (treatment effectiveness) by more closely matching to comorbid symptom presentations. Moreover, by targeting the common diatheses and processes underlying comorbid presentations, a unified emotion-focused approach might obtain an equivalent or a greater degree of efficacy for a range of comorbid conditions in less time (a single course of treatment versus multiple courses).

As noted by Suveg et al. (2007), one example of a treatment approach that targets such common diatheses and processes is the Unified Protocol for the Treatment of Emotional Disorders (Ehrenreich et al., 2007). Research into both the adult (Allen et al., in press) and adolescent (Ehrenreich & Barlow, 2007) variants of this protocol underway. These protocols are aimed at changing individuals’ relationships to their own emotional experiences, helping them to employ more adaptive emotion regulation strategies during times of emotional arousal. In particular, maladaptive regulation strategies aimed at reducing one’s experience with uncomfortable emotional experiences are targeted, and eliminated, to allow for the development and strengthening of adaptive responses to such stimuli. Both protocols rely heavily on experiential exercises to explain the concepts presented and emphasize the context of an individual’s own emotional experiences via the selection of tailored “emotion exposure” exercises throughout. A further emphasis on the incorporation of both positive and negative emotion exposures is now included in both versions of this protocol. The adult protocol is aimed at the individual client, while the adolescent-focused intervention incorporates both the client and a caregiver across the treatment. In order to meet the developmental demands of adolescence, the therapeutic language is as straightforward as possible and parent and adolescent workbooks provide relevant vignettes and developmentally sensitive explications of treatment concepts across a broad array of emotions. Initial outcomes following the open trials for both the adult and adolescent protocols hold excellent promise for the kinds of hoped-for treatment efficacy, dissemination, and clinician training benefits that a broadly emotion-focused treatment may confer. By incorporating emerging research in emotion science and that discussed in this Special Issue, it is believed that this unified approach to the treatment of emotional disorders will have far-reaching effects on the expression and experience of a wide range of emotional disorders.