Canadian Psychology 2008, Vol. 49, No.

1, 49 59

Copyright 2008 by the Canadian Psychological Association 0708-5591/08/$12.00 DOI: 10.1037/0708-5591.49.1.49

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

Emotion and Cognition in Psychotherapy: The Transforming Power of Affect

LESLIE GREENBERG

York University

Abstract Theory and research on emotion in both psychology and psychotherapy are reviewed to demonstrate the importance of emotion in human functioning and psychotherapeutic change. A proposal is made for the importance of integrating empirically supported emotion-focused change processes into psychotherapeutic work. Five principles of change in the emotion domain emotion awareness; expression; regulation; reflection on emotion; and the more novel principle of emotion transformation, by which emotion is changed by emotionare offered as processes of change that are rapidly gathering empirical support. The result of emotion coming of age will be the expansion of theories of dysfunction and of treatment to include emotion-focused coping and emotional processes of change. Keywords: emotion, emotion-focused therapy, awareness, regulation transformation

widely held by several schools of psychotherapy (Bowlby, 1980; Kohut, 1977; Rogers, 1951; Perls, 1969) but has been difficult to prove. However over the past decade, newer therapeutic approaches that treat affect as a primary target of intervention, within the context of an empathic relationship, have been developed, tested, and shown to be effective in the treatment of affective disorders, personality disorders, and trauma (Goldman et al., in press; Svartberg, Stiles, & Seltzer, 2004).

Emotions as an Adaptive Resource

Until recently, the prevalent commonsense view of emotion, endorsed by many, was that emotions were disruptive to functioning, were due to misinterpretation and were to be controlled, tempered, bypassed, or avoided (Beck, 1976). Control of emotion, however, is not always wise or adaptive, and overregulation of emotion, or its avoidance, does not ensure health or happiness. A large volume of research has now been collected on the debilitating physiological effects of not expressing deeply felt emotions (Traue & Pennebaker, 1993). It appears that inhibiting the expression of emotion can lead to impaired immune system function and poorer health on a variety of indices. In addition, there is increasing evidence on the importance of emotion knowledge and emotional intelligence in enhancing social competence and healthy development (Mayer & Salovey, 1997). Emotions are a fundamentally adaptive resource because they involve a meaning system that informs people of the significance of events to their well-being, and they organise people for rapid adaptive action (Frijda, 1986; Izard, 1991; Oatley & Jenkins, 1992; Tomkins, 1963). From birth onward, emotion also is a primary signalling system that communicates intentions and regulates interaction (Sroufe, 1996). Emotion thus regulates self and other and gives life much of its meaning. With the advent of a view of emotion as an adaptive resource, the understanding of its relationship with cognition and its role in human functioning and psychotherapy has changed. This new look has begun to set a new agenda for psychological researchto determine the conditions under which emotions play a determining role in human experience and how this occurs.

This article reviews both the evolving understanding of the role of emotion in human functioning and the evidence for the important role of emotion in psychotherapy, and a set of empirically grounded principles of emotional change is proposed. Given that emotion now is seen as information, as signalling the significance of the situation to a persons well being, and given that affect regulation is seen as a key human motivation, it has become clear that emotion needs to be focused on, accepted and worked with directly in therapy to promote emotional change. (Foa, Riggs, Massie, & Yarczower, 1995; Fosha, 2000; Greenberg, 2002; Goldman, Greenberg, & Angus, in press; Linehan et al., 2002; Samoilov & Goldfried, 2000). The idea that accessing and exploring painful emotions, within the context of a secure therapeutic relationship, leads to therapeutic change has been

Neurological Evidence on Affective Primacy

Correspondence concerning this article should be addressed to Leslie Greenberg, Department of Psychology, York University, 228 Behavioural Science Building, 4700 Keele Street, Toronto, Ontario M3J 1P3 Canada. E-mail: lgrnberg@yorku.ca 49

Research emerging from the arena of affective neuroscience supports the conceptualisation of emotion and cognition as separate but interacting mental functions mediated by separate but

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interacting brain systems. LeDouxs (1996) research on the emotional brain has demonstrated that it is possible for our brains to register the emotional meaning of a stimulus before that stimulus has been fully processed by the perceptual system. He suggests that there are two different paths for producing emotion. What he terms the low road is when the amygdala senses danger and broadcasts an emergency distress signal to brain and body, and the slower high road is when the same information is carried through the thalamus to the neocortex. Because the shorter amygdala pathway transmits signals more than twice as fast as the neocortex route, the thinking brain often cannot intervene in time to stop emotional responses. Thus, the automatic emotional response has already occurred before one can stop it, be it jumping back from a snake, snapping at an inconsiderate spouse, or yelling at a disobedient child. The neocortex, however, also has been found to have fibers leading back to the amygdala and provides a path for cognitive feedback to the emotional systems. This is the path by which deliberate conscious cognitive processes can be used to help regulate emotion. LeDoux noted, however, that the initial precognitive, perceptual, emotional processing of the low road, fundamentally, is highly adaptive because it allows people to respond quickly to important events before complex and time-consuming processing has taken place. Functional brain imaging studies have provided evidence consistent with LeDouxs view that the amygdala can perform its role in the processing of emotional stimuli nonconsciously. Using functional MRI, Whalen et al. (1998) demonstrated amygdala activation in response to emotional stimuli (facial expressions), even when conscious awareness of the stimuli is experimentally prevented. In addition, autonomic physiological and motoric aspects of emotion have been shown to occur in response to an emotional stimulus that is not hman & consciously recognised or is outside of attentional focus (O Soares, 1994). It should be noted that, in these studies, that lack of awareness of the emotionally salient stimulus does not necessarily prevent the person from being aware of emotional experience in response to the nonconsciously processed stimulus. More recently Tucker et al. (2003) have shown that an evaluative decision begins by recruiting motivational and semantic influences within limbic networks, and these influences appear to shape the development of decisions in various neocortical areas of the brain. Affect, by being so densely interconnected with other brain areas, has a significant influence on decision making. Ultimately, cognition and emotion are inextricably linked so that cognition often works in the service of affective goals, whereas emotion often is a response to cognition. Emotions thus set a basic mode of processing in motion, orienting consciousness to differentially analyse situations for loss, danger, intrusion, violation, novelty, or pleasure. Emotion, in essence, sets problems for reason to solve (Greenberg, 2002; Greenberg & Pascual Leone, 2001). Emotion moves us and reason guides us. An important consequence of this method of functioning is that people can respond emotionally without thought, as a situation is perceived to fit the category it activates. Damasio (1994), in his study of the neurology of emotion, explained that the tacit experiential level of functioning involves the development of systematic connections between categories of objects and situations and primary emotions. As certain images are stored in memory, they are marked with somatic information. As these imagesan argument with a boss, for example, or a moment of tenderness with a spouseare stored, the feelings

experienced in those moments also are stored. These emotions are then restored when the image is recalled. This produces an emotional experience without an actual train of thought. Memories are thus marked to set off the emotional responses that were set off by the original event. The next time something is recalled, the person will feel the same way unless the emotion-schematic memory and associations linked to it are revised. This can be facilitated therapeutically by re-experiencing the emotion-laden memory, thereby making it amenable to new input.

Psychological Processes in Emotion Generation

Association, appraisal, and degree of goal attainment have all been proposed as important psychological processes in understanding how emotion is generated. Association is the most fundamental process of which Bowers (1981) original associative network theory of emotion is a good example. Although he emphasised semantic associations, the principle of association applies to other types of associations, such as external stimuli previously associated with emotional arousal, posture, and facial expression (Berkowitz, 1999). Association helps explains some of the noncognitive and automatic aspects of emotional experience. People thus may become angry or sad by means of associative processes without knowing how situational stimuli are affecting them. However, not all emotions are produced associatively. Appraisal theory proposes that some form of cognitive evaluation is fundamental. Here, emotions are elicited and differentiated on the basis of a persons subjective evaluation or appraisal of the personal significance of a situation. In this view, anger, for example, is generated only with appraisals of blame; or sadness, only with appraisals of loss. Appraisals have, however, been found only to account for about 40% of emotions (Averill, 1983; Frijda, Kuipers, & ter Schure, 1989), suggesting that there is more to emotion generation than appraisal alone. A third type of theory emphasises desires to maintain or attain a certain desired state or goal. Here, for example, goal frustration can lead to anger without any attribution of wrongdoing or appraisal of blame. Rather, the anger is motivated by a desire to change undesirable situations, reinstate goals, or protect boundaries. This process involves a different form of evaluationa match or mismatch with a desired endstate. Emotions thus, at times, appear to involve some form of appraisal, but these may be out of awareness. Emotion, however, often is thoughtless and may be purely associative. Determining under what conditions emotion is and is not governed by cognitive processes remains a central task for psychological research in the coming decades. More encompassing multilevel theories of emotion that attempt to integrate a variety of different emotion generation processes have arisen to deal with this complexity. Leventhal (1984) was the first to suggest that sensorimotor, schematic, and conceptual levels were all involved in generating emotions, and Greenberg and Safran (1987) adapted this model to psychotherapy. Teasdale and Barnard (1996) more recently suggested a nine-level model starting out at a sensory level moving through a conscious propositional level one level lower than a final tacit implicational level of processing at the top of the hierarchy. Greenberg and Pascual Leone (1995, 2001) proposed a dynamic model of emotion construction by synthesis rather than a hierarchical model to explain how change occurs. In this type of model, the dynamic, dialectical

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synthesis of different components is the focus, rather than the hierarchical structuring of levels. The type of functioning suggested by these models, in which separate but interacting mental functions are mediated by separate but interacting brain systems, appears to be crucial in understanding a variety of areas of human functioning; for example, the operation of two types of memory (one, factual; the other, emotional), as well as two kinds of learning (one, a more conceptual, logical form of learning; the other, a more perceptual and emotionally, associative one; Pascual-Leone, 1987, 1991). These models help explain the difference between two ways of knowing: one, more conceptual; and the other, more experiential. The importance of accessing and working with the more tacit, procedural means of generating affective experience rather than more conscious declarative 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 are seen as consciously making sense of an independent source of affective experience that has to be organised by consciousness to construct meaning. Meaning results from the dialectical synthesis of emotion and reason. Without emotion, there is no motivation to action, but without conscious organisation, there is no coherence. The depth, range, and complexity of emotion cannot develop beyond its instinctual origins without conscious articulation. The process of experiencing an emotion thus involves construction (Neimeyer & Mahoney, 1995). Emotional expression is itself clearly an elaborate cognitive-processing task, in which data are integrated from many sources in the brain (often in milliseconds), and this occurs, in the main, outside awareness. The conscious narrative flow of evaluations, interpretations, and explanations of experiencethe reported story of the emotion often only comes afterward. The narrative account is significant as a record in memory of experience but often is only peripherally related to the process of generating ongoing emotion. Human beings thus are seen as actively constructing their sense of reality, acting as dynamic self-organising systems that synthesise many types and levels of information to create their experience (Greenberg & van Balen, 1998; Mahoney, 1991).

are converging on the view that there are emotional qualia, but how people make sense of their experience is as crucial as what they experience, and both are important in intervention. In addition to agreeing on emotion-laden core structures as the target of change, the approaches appear to agree on a number of other specific points of practice. All approaches recognise that awareness of emotion and acceptance of and attention to it in therapy are important to access the information in emotion. All agree that desynchronies or incongruence between cognition and emotion and physiology occur and need to be overcome. Another point of agreement is that emotion often needs to be aroused to access the core structures generating it and that the experience generated by these need to be further processed in therapy to promote change. The final point of agreement is that in therapy it is important to promote emotional experience, as well as emotion regulation. Thus, we have a picture in which emotion in therapy needs to be attended to, aroused, accepted, and processed, as well as regulated and changed when necessary. Crucial therapeutic questions then become: When should emotions be regulated, and when should they be facilitated or phrased differently? When should people be changed by their emotions (i.e., accept or be guided by them), and when should they change them?

Emotion in Psychotherapy
In discussing emotion in psychotherapy, it is important to recognise that not all emotions serve the same function both in and out of therapy and that therapists need to intervene differentially with different types of emotional processes. Therapists do not simply help clients regulate all emotions or become aware of or express all feelings. Rather, they distinguish clinically among different types of emotions to guide their interventions. Problems of overregulation are discriminated from problems of underregulation, and emotions that are a sign of distress are distinguished from emotions that are a sign of working through distress. Therapists intervene differentially with clients depending on their assessment of the in-session emotional state, helping them to accept and integrate certain emotions; to acknowledge some and bypass others; to regulate disruptive emotions; to express those that will enhance relationships; to contain and soothe painful emotions; and to explore and transform maladaptive emotions. This approach to differential intervention with emotions is based on the premise that some types of emotional expression are more productive than others, in and outside of therapy, and that emotional arousal of productive emotions relates to outcome in psychotherapy (Greenberg, Auszra, & Herrmann, 2007; Pos, Greenberg, Goldman, & Korman, 2003). In this view, primary emotions are the persons most fundamental, immediate reaction to a situation, whereas secondary emotions are a persons emotional reactions to their own emotional responses to a stimulus, rather than to the situation itself (Greenberg, 2002; Greenberg & Safran, 1987). For example, anger may be a reaction to a feeling of fear of abandonment, which itself may be adaptive or maladaptive depending on the function it serves in the situation. Primary emotions, the persons first, gutlevel, emotional response to the situation, need to be accessed for their adaptive information and capacity to organise action. Maladaptive emotions, on the other hand, are learned responses that are no longer adaptive and need to be regulated and transformed.

Convergence in Psychotherapeutic Views

All therapeutic approaches now appear to be converging on a shared view of emotion as a rapid-action, adaptive, control system that orients people to the relevance that events in their environment have to their well-being. All agree that emotion produces tendencies to act in specific ways in response to those events, sets a basic mode of information processing in motion, and plays an independent role in functioning and can affect cognition. There is also consensus that emotion and cognition are automatically and intimately connected in higher order meaning making, that people are constantly explaining their experience to themselves, and that how they make sense of their experience influences their experience. In addition, a striking point of agreement across approaches appears to be the shared view that, at automatic or unconscious levels, emotional and cognitive structures are highly integrated and that these affective cognitive, or cognitiveaffective, structures are the important targets of treatment. Another striking point of agreement is the importance of the meaning construction process. All views

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Secondary emotions may be defenses against feelings such as shame at ones sadness, hopelessness when angry, or reactions to negative thoughts. Secondary emotions need to be explored to access their more primary cognitive or emotional generators. Finally, instrumental emotions are those emotions that are used consciously or unconsciously to achieve an aim, such as crying crocodile tears. Primary emotions need to be accessed for their adaptive information and capacity to organise action, whereas maladaptive emotions need to be regulated and transformed. Secondary maladaptive emotions need to be reduced by exploring them to access their more primary cognitive or emotional generators. With this more differentiated perspective, we see that not only do we want to help clients down-regulate unproductive dysregulated secondary and primary maladaptive emotions, but at different times we may want to help them access productive primary emotions.

decrements in ruminative thoughts after a distressing stimulus (Salovey, Mayer, Golman, Turvey, & Palfai, 1995). Awareness of emotion also involves overcoming the avoidance of emotional experience. Leahy (2002) noted that there are two fundamental coping pathways for dealing with emotion: One pathway involves attending to and labelling emotions in a manner that accepts and normalises them, and the other pathway pathologises some emotional experiences leading to attempts to distort or avoid them, initiating guilt, frantic efforts at control, obsessive rumination, and so forth. To overcome emotion avoidance, clients must first be helped to approach emotion by attending to their emotional experience.

Emotional Arousal and Expression

Emotional expression mobilises the affect system, changes physiology and neurochemistry, overcomes inhibition, and changes interpersonal interaction. Emotional expression has recently been shown to be a unique therapeutic aspect of emotional processing that predicts adjustment to breast cancer (Stanton et al., 2000) and resolving interpersonal problems (Greenberg & Malcolm, 2002). Results from a variety of studies also support that emotional engagement with trauma memories in early sessions (Paivio, Hall, Holowaty, Jellis, & Tran, 2001; Paivio & Nieuwenhuis, 2001) during the first exposure and habituation (reduced distress) 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 of and exposure to previously avoided feelings as a mechanism of change, such as in exposure treatments for anxiety in youth and adults (Kendall & Hedtke, 2006). There, however, can be no universal rule about the effectiveness of arousing emotion or evoking emotional expression. Emotional arousal and expression, although helpful, are not always useful in therapy or in life. Recently, for example, Greenberg et al. (2007) found that the degree of productivity of processing of aroused emotions, rather than arousal alone, distinguished good from poor outcome cases in which productivity was defined in terms of degree of regulation, agency, and processing of the emotion. Arousal appears to be necessary but is not necessarily sufficient for certain types of therapeutic progress.

Principles of Working With Emotion

Outcome and process research findings point toward emotional processes as centrally important to good therapy, but what is good processing remains to be elucidated (Greenberg & Pascual Leone, 2006). Emotional insight, catharsis, awareness, and exposure have all been put forward as explanations of the role of emotion in change, but there is still not a comprehensive, empirically based understanding of how emotion and its processing lead to change. The following five principles provide an empirically based understanding of emotional change processes in clinical change: (a) increasing awareness of emotion, (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 the promotion of emotional awareness. The goal is for clients to become aware of their emotions and, more specifically, their primary adaptive emotions. Becoming aware of and symbolizing core emotional experience in words provides access both to the adaptive information and action tendency in the emotion. Labelling emotions often is a first step in problem definition. It is important to note that emotional awareness is not thinking about feeling, it involves feeling the feeling in awareness. Only when emotion is felt does its articulation in language become an important component of its awareness. The therapist thus needs to help clients approach, tolerate, and accept their emotions. Acceptance of emotional experience as opposed to its avoidance is the first step in emotion work. Emotion awareness has been grounded in a measure of levels of emotional awareness developed by Lane and associates (Lane & Schwartz, 1992). Five levels of emotional awareness can be measured. In ascending order, these are physical sensations, action tendencies, single emotions, blends of emotion, and blends of blends of emotional experience (the capacity to appreciate complexity in the experiences of self and other). Levels of emotional awareness correlate significantly with self-restraint and impulse control, indicating that greater emotional awareness is associated with greater selfreported impulse control. Individual differences in emotion awareness have also been found to predict recovery of positive mood and

Emotion Regulation
The provision of a safe, validating, supportive, and empathic environment is the first level of intervention that helps soothe and regulate automatically generated underregulated distress (Bohart & Greenberg, 1997). Linehan et al. (2002) found evidence for the effectiveness of emotional validation and soothing as part of the treatment for borderline personality disorder. Empathy from another person seems to be important in learning to self-soothe and restore emotional equilibrium and help strengthen the self (Greenberg et al., 2007). Important issues in any treatment are what emotions are to be regulated and how these emotions are to be regulated. Clients with underregulated affect have been shown to benefit both from validation and from the learning of emotion regulation and distress tolerance skills (Linehan, 1993). Undercontrolled secondary emotions and maladaptive emotions are what need to be regulated.

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Regulation of underregulated emotion involves getting some distance from despair and hopelessness and/or developing selfsoothing capacities to calm and comfort core anxieties and humiliation. Emotion self-regulation skills that involve such things as identifying and labelling emotions, allowing and tolerating emotions, establishing a working distance, increasing positive emotions, reducing vulnerability to negative emotions, self-soothing, breathing, and distraction also have been found to help with tolerance of high distress (Linehan, 1993). Forms of meditative practice and self-acceptance often are most helpful in achieving a working distance from overwhelming core emotions (Teasdale et al., 2000). These can be learned deliberately and with practice. Emotion, in addition, can be down-regulated by developing tolerance and soothing at a variety of different levels of processing. Physiological soothing involves activation of the parasympathetic nervous system to regulate heart rate, breathing, and other sympathetic functions that speed up under stress. In clinical work, a number of theorists, therapists, and researchers, however, believe that emotion regulation is not easily achieved through the cognitive system alone (Campos, Frankel, & Camras, 2004; Fosha, 2000; Hunt, 1998; Linehan, 1993; Schore, 2003). Problems in vulnerable personalities arise most often from deficits in the more implicit forms of regulation of emotion and its intensity. Although deliberate behavioural and cognitive forms of regulationmore left hemispheric processare useful for people who feel out of control, over time, the building of implicit or automatic emotion regulation capacities is important for enduring change, especially for personality-disordered clients. Implicit forms of regulation often cannot be trained or learned as a volitional skill. People with underregulated affect have been shown to benefit both from interpersonal validation and from the learning of emotion regulation and distress tolerance skills (Greenberg & Watson, 1998; Linehan, 1993; Linehan et al., 2002). Here, regulation is seen as an aspect of emotion generation. Clinical work that views dysfunction as resulting from faulty learning and skill deficit also sees emotion regulation as following emotion generation and has focused on teaching skills and changing the cognitive system to regulate emotion (Beck, 1976). In views of emotion regulation in which regulation is seen as coterminous with generation, rather than emotion control, the facilitation of adaptive emotions is seen as necessary, and clinical work focuses on clarifying which emotions one allows into awareness. Here, emotion regulation is viewed as having the desired emotions at adaptive levels at the right time, and therapy is based on the acceptance or facilitation of particular emotions. An issue of major clinical significance, then, is generating theory and research to help understand the extent to which automatic emotion processes can be changed through (a) deliberate regulation processes and (b) more implicit regulation processes based on new emotional and/or relational experiences.

apy (Frank, 1974). In addition to the value of emotional awareness as a source of information, symbolizing emotion in awareness promotes reflection on experience to create new meaning, and this helps clients develop new narratives to explain their experience (Greenberg & Angus, 2004; Greenberg & Pascual-Leone, 1997; Guidano, 1995; Pennebaker, 1990). What we make of our emotional experience makes us who we are. Understanding an emotional experience always involves putting it into narrative form. As witnessed in therapy, as well as in literature, all emotions occur in the context of significant stories, and all stories involve significant emotions (Greenberg & Angus, 2004). Therapy thus involves change in both emotional experience and change in the narratives in which they are embedded. This principle applies to all types of emotion: secondary, primary, adaptive, or maladaptive. For example, understanding that one is prone to get angry at ones partner because one feels abandoned, and understanding that this relates to ones past history of abandonment, is very therapeutic. Alternately being able to symbolise and explain traumatic emotional memories in words helps promote their assimilation into ones ongoing self-narrative (Van der Kolk, 1995). This form of putting emotion into words allows previously unsymbolised experience in emotion memory to be assimilated into conscious, conceptual understandings of self and world, where it can be organised into a coherent story. Pennebaker and colleagues have shown the positive effects of writing about emotional experience on autonomic nervous system activity, immune functioning, and physical and emotional health (e.g., Pennebaker, 1995). Through language, individuals are able to organise, structure, and ultimately assimilate both their emotional experiences and the events that may have provoked the emotions. In addition, once emotions are put into words, people are able to reflect on what they are feeling, create new meanings, evaluate their own emotional experience, and share their experience with others (Pennebaker, 1995; Rime , Finkenauer, Luminet, Zech, & Philippot, 1998). There also is a vast empirical literature on the influence of attributions and cognition on emotion in general, and on depression in particular (Clarke & Blake, 1997), that attests to the importance of reflecting on emotion to create meaning.

Emotion Transformation
The final, most novel, and probably most fundamental principle of emotional change involves the transformation of one emotion by another. This applies most specifically to transforming primary maladaptive emotions by contact with more adaptive emotions. Although the more traditional ways of transforming emotion either through exposure, experience, expression, and completion or through reflection on them do occur, another process appears to be more important. This is a process of changing emotion with emotion (Greenberg, 2002). This novel principle suggests that a maladaptive emotional state can be transformed best by undoing it with another more adaptive emotion. In time, the co-activation of the more adaptive emotion along with or in response to the maladaptive emotion helps transform the maladaptive emotion. Rather than reason with emotion, one can transform one emotion with another. Whereas thinking usually changes thoughts, feeling usually changes emotions. Spinoza (1967) was the first to note that emotion is needed to change emotion. He proposed that An emotion cannot be re-

Reflection on Emotion
The role in psychotherapy of the human capacity for conscious awareness of the processes and contents of their own mind, and for reason and insight to shed light on unconscious motivations, has been substantial, from the beginnings of psychoanalysis right up to the present day. In addition, many therapists have written on the importance of changing peoples assumptive frameworks in ther-

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strained nor removed unless by an opposed and stronger emotion (1967, p.195). Reason clearly is seldom sufficient to change automatic emergency-based emotional responses. Rather than reason with emotion, one needs to transform one emotion by accessing another emotion. In an interesting line of investigation, positive emotions have been found to undo lingering negative emotions (Frederickson, 2001). The basic observation is that key components of positive emotions are incompatible with negative emotions. Frederickson (2001) suggested that, by broadening a persons momentary thought action repertoire, a positive emotion may loosen the hold that a negative emotion has on a persons mind. The experience of joy and contentment were found to produce faster cardiovascular recovery from negative emotions than a neutral experience. Frederickson, Mancuso, Branigan, and Tugade (2000) found that resilient individuals cope by recruiting positive emotions to regulate negative emotional experiences. They found that these individuals manifested a physiological bounce back that helped them to return to cardiovascular baseline more quickly. Thus, it appears that bad feelings can be transformed by happy feelings, not in a simple manner, such as by trying to look on the bright side, but through the evocation of meaningfully embodied alternate experience to undo the negative feeling. For example, in grief, laughter has been found to be a predictor of recovery. Being able to remember the happy times and to experience joy helps as an antidote to sadness (Bonanno & Keltner, 1997). Warmth and affection are similarly often an antidote to anxiety. In depression, a protest-filled, submissive sense of worthlessness can be transformed therapeutically by guiding people to the desire that drives their protesta desire to be free of their cages and to access their feelings of joy and excitement for life. According to Isen (1999), it has been hypothesised that at least some of the positive effect of happy feelings depends on the neurotransmitters effect, in the experiencing of joy, on specific parts of the brain that influence purposive thinking. Mild positive affect has been found to facilitate problem solving. These studies together indicate that emotion can be used to change emotion. However it is not only that unpleasant feelings are transformed by pleasant ones. Davidson (2000) suggested that the right hemispheric withdrawal-related negative affect system can be transformed by activation of the approach system in the left prefrontal cortex. In addition, both clinical and research observations show that many different emotions can change distressing emotions. For example, in a study of self-criticism, Whelton and Greenberg (2004) found that people who were less vulnerable to depression were able to recruit emotional resources such as self-assertive anger to combat depressogenic contempt and shame. Empowering anger in therapy changes depressive hopelessness and shame, as well as the anxiety and fear in anxiety disorders. Sadness, love, and forgiveness have also been observed to change anger (Malcolm, Warwar, & Greenberg, 2004). It is important to note that the process of changing emotion with emotion 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, another feeling is used to transform or undo it. Although exposure to emotion, at times, may be helpful to overcome affect phobia in many situations in therapy, change also occurs because one emotion is transformed by another 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. This involves more than simply feeling or facing the feeling, leading it to diminish. Rather, emotional change occurs by the activation of an incompatible, more adaptive experience that replaces or transforms the old response. Clinical observation and research suggests that emotional transformation occurs by a process of dialectical synthesis of opposing schemes. When opposing schemes are co-activated, they synthesise compatible elements from the co-activated schemes to form new higher level schemes, just as in development when schemes for standing and falling, in a toddler, are dynamically synthesised into a higher level scheme for walking (Greenberg & PascualLeone, 1995; Pascual-Leone, 1991). Schemes of different emotional states similarly are synthesised to form new integrations. Thus, in therapy, maladaptive fear, once aroused, can be transformed into security by the more boundary-establishing emotions of adaptive anger or disgust or by evoking the softer feelings of compassion or forgiveness. Similarly, maladaptive anger can be undone by adaptive sadness. Maladaptive shame can be transformed by accessing both anger at violation and self-comforting feelings and by accessing pride and self-worth. Thus, the tendency to shrink into the ground in shame is transformed by the thrustingforward tendency in newly accessed anger at violation. Withdrawal emotions from one side of the brain are replaced with approach 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 between emotional experiences that are adaptive or maladaptive and emotions that are primary or secondary. Primary emotions need to be accessed in awareness for their adaptive information and capacity to organise action. In contrast, maladaptive emotions need to be accessed to be transformed, which occurs by exposing them to new experience, thereby creating new meaning. Secondary emotions need to be bypassed to get to more primary emotions. Emotion-focused therapy (EFT) suggests that it is important to be aware of and reflect on primary emotions and to regulate and transform maladaptive emotions. A two-step therapeutic process is recommended when the core emotion avoided is adaptive. First, the symptomatic secondary emotions (e.g., feeling upset, despairing, and hopeless) are evoked in therapy, then the core primary adaptive emotion that is being interrupted (e.g., sadness of grief or empowering anger are accessed and validated). A three-step sequence, however, is required to transform maladaptive core emotion. In this sequence, first the secondary emotion is evoked, and then core maladaptive emotions being avoided (e.g., shame, fear, or anger) are accessed. These are then transformed by accessing adaptive emotions such as anger, sadness, and compassion. When adaptive emotions finally are evoked, they are incorporated into new views of self and used to transform personal narratives.

The Therapeutic Relationship

In addition to the principles of emotional change, the therapeutic relationship is the crucible of emotional processing. The link between 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 prerequisite to productive emotional processing. In studies across several types of psychotherapy, the role of emotional arousal has been found to be mediated by the working alliance (Beutler, Clarkin, & Bongar, 2000), so that high arousal predicted good session outcome, but only when there was a strong alliance (Iwakabe, Rogan, & Stalikas, 2000). If the client feels overwhelmed and emotion is dysregulated, the relationship is soothing, validating, and regulating (Greenberg, 2002; Linehan, 1993). On the other hand, if the clients level of arousal is unproductively low (e.g., avoidance, worry intellectualization), the relationship can be empathically evocative, focusing, and supportive, thereby heightening emotional activity (Gendlin, 1996; Greenberg, 2002; Perls, Hefferline, & Goodman, 1951).

Evidence-Based Treatment
In addition to the aforementioned theoretical and empirical developments, a number of approaches focused on working directly with emotion have been demonstrated to be effective in randomised clinical trials (Elliott, Greenberg, & Lietaer, 2004; Greenberg & Pascual-Leone, 2006; Whelton, 2004), providing empirical support for the importance of focusing on painful emotion in therapy. EFTs have shown to be effective in both individual and couples therapy in a number of randomised clinical trials (Elliott et al., 2004; Johnson, Hunsley, Greenberg, & Schlindler, 1999). A manualised form of EFT of depression, process experiential (PE) therapy (in which specific emotion activation methods are used within the context of an empathic relationship), has been found to be highly effective in treating depression in three separate studies (Goldman et al., in press; Greenberg & Watson, 1998; Watson, Gordon, Stermac, Kalogerakos, & Steckley, 2003). The EFT treatment added the use of specific tasks to the client-centered (CC) therapyin particular, systematic evocative unfolding, focusing, two chair, and empty chair dialogue. In the York II Depression Study, Goldman et al. (in press) replicated the York I study by comparing the effects of CC and PE therapy on 38 clients with major depressive disorder; they obtained a comparative effect size of .71 in favour of PE therapy. They then combined the York I and II samples to increase power of detecting differences between treatment groups, particularly at follow-up. Statistically significant differences among treatments were found on all indices of change for the combined sample, with differences maintained at 6- and 18-month follow-ups. This provides evidence that the addition of PE emotion-focused interventions to the foundation of a CC relationship improves outcome. In a later study, Watson et al. (2003) carried out a randomised clinical trial comparing PE therapy and cognitive behavioural therapy (CBT) in the treatment of major depression. Sixty-six clients participated in 16 sessions of weekly psychotherapy. There were no significant differences in outcome on depression between groups. Both treatments were effective in improving clients level of depression, self-esteem, general symptom distress, and dysfunctional attitudes. However, clients in PE therapy were significantly more self-assertive and less overly accommodating at the end of treatment than clients in CBT. At the end of treatment, clients in both groups developed significantly more emotional reflection for

solving distressing problems. In these studies, EFT for depression was found to be equally or more effective on some measures than both a purely relational empathic treatment and a cognitive behavioural treatment. EFT for adult survivors of childhood abuse (EFT-AS), which uses empathy plus empty-chair work and involves arousal and processing of painful emotions, has been found to be effective in treating abuse (Paivio & Nieuwenhuis, 2001). Emotionally focused couples therapy (Greenberg & Johnson, 1988) that involves partners revealing their underlying attachment and identity-related vulnerable feelings to each other has been found to be effective in treating couples distress (Johnson, Hunsley, Greenberg, & Schindler, 1999). Short-term dynamic therapy (STDP) that works on overcoming defenses and treats affect phobia by exposure to dreaded emotion has garnered empirical support in the treatment of cluster C personality disorders when compared with CBT, pure cognitive therapy, and brief supportive psychotherapy (Svartberg et al. 2004; Winston et al., 1994). A convincing amount of outcome research also supports the efficacy of STDP in the treatment of complicated Axis I disorders (Winston et al., 1994; Winston et al., 1991). In addition, CBTs based on exposure to imaginal stimuli have a long history of demonstrated effectiveness for trauma and other anxiety-related disorders (Borkovec, Alcaine, & Behar, 2004; Shapiro, 1999). Outcome research supports the efficacy of exposurebased therapies with diverse traumatised populations, including survivors of child abuse (e.g., Foa, Rothbuam, & Furr, 2003; Paivio & Nieuwenhuis, 2001; Shapiro, 1999). More recently, an avoidance theory of generalized anxiety disorder, in which worry is understood as a cognitive response that orients individuals to a threat while insulating them from the immediacy of their emotional experience, has gained support (Borkovec et al., 2004).

The Process of Change

In addition to clinical trials, empirical research on the independent role of emotion in therapeutic change is growing. Process research has consistently demonstrated a relationship between in-session emotional activation and outcome. Jones and Pulos (1993) found that the strategies of evocation of affect and the bringing of troublesome feelings into awareness were correlated positively with outcome in both dynamic treatment and CBT in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. A more recent study (Coombs, Coleman, & Jones, 2002) examining therapists stance on interpersonal therapy and CBT for depression showed the importance of focusing on emotion, regardless of orientation. This study found that collaborative emotional exploration, which occurred significantly more frequently in interpersonal therapy, was found to relate positively to outcome in both forms of therapy, whereas educative/directive process, utilised more frequently in CBT, had no relationship to outcome. Helping people overcome their avoidance of emotion, focusing collaboratively on emotions, and exploring them in therapy appears to be important in therapeutic change, regardless of therapeutic orientation. The importance of facilitating in-session emotional experience to promote change has become increasingly recognised (Greenberg, 2002; Samoilov & Goldfried, 2000). Reviews of past process outcome studies testing these claims show a strong rela-

56

GREENBERG

tionship between in-session emotional experiencing, as measured by the Experiencing Scale (Klein, Mathieu, Kiesler, & Gendlin, 1969) and therapeutic gain in dynamic, cognitive, and experiential therapies (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Goldman, Greenberg, & Pos, 2005; Orlinsky & Howard, 1986; Silberschatz, Fretter, & Curtis, 1986). These findings suggest that processing ones bodily felt experience and deepening this in therapy may well be a core ingredient of change in psychotherapy, regardless of approach. The recipe for emotional processing from the perspective of behaviour therapy is arousal plus habituation to the distressing stimulus and exposure to new information: In short, it is the experience of old distress in the presence of new information accrued experientially in the moment. From an experiential therapy perspective, however, approach, arousal, acceptance, and tolerance of emotional experience are necessary but not sufficient for change. In addition, optimum emotional processing involves the integration of cognition and affect (Greenberg, 2002; Greenberg & Pascual-Leone, 1995). Once contact with emotional experience is achieved, clients must also cognitively orient to that experience as information, explore, reflect on, and make sense of it; they also must access other internal emotional resources to help transform the maladaptive state. Supporting the first aspect of this hypothesis, process outcome research on EFT for depression has shown that both higher emotional arousal at midtreatment, coupled with reflection on the aroused emotion (Warwar & Greenberg, 1999), and deeper emotional processing late in therapy (Pos et al., 2003) predicted good treatment outcomes. High emotional arousal plus high reflection on aroused emotion distinguished good and poor outcome cases, indicating the importance of combining arousal and meaning construction (Missirlian, Toukmanian, Warwar, & Greenberg, 2005; Warwar, 2003). EFT thus appears to work by enhancing the type of emotional processing that involves helping people experience and accept their emotions and make sense of them. A clients individual capacity for emotional processing early in therapy also predicted outcome, but the increase in degree of emotional processing from early to mid-, or early to late, phases of treatment was found to be a better predictor of outcome than early level of processing or than the early alliance (Pos et al., 2003). Early capacity for emotional processing thus does not guarantee good outcome, nor does entering therapy without this capacity guarantee poor outcome. Although likely an advantage, early emotional-processing skill appears not to be as critical as the ability to acquire and/or increase depth of emotional processing throughout therapy. Therapists interventions that focused more deeply on clients experience were also shown to deepen clients experience and to predict outcome (Adams & Greenberg, 1996). Studies of the behavioural treatment of anxiety disorders has long demonstrated that clients who profited most from systematic desensitization (Borkovec & Stiles, 1979; Lang, Melamed, & Hart, 1970) and flooding (Watson & Marks, 1971) exhibited higher levels of physiological arousal during exposure. More recently, methods that increase arousal have also been found to be effective in treating panic (Clarke, 1996; Mineka & Thomas, 1999). These and other findings suggest that the arousal of the fear-activated phobic memory structures is important for change. Research on couples therapy also supports the role of emotional awareness and expression in a satisfying relationships and change

in therapy. Emotionally focused couples therapy (Greenberg & Johnson, 1988) that helps partners access and express underlying attachment-oriented emotions, has been found to be effective in increasing marital satisfaction (Johnson & Greenberg, 1985; Johnson et al., 1999). In addition, couples who showed higher levels of emotional experiencing in therapy, which accompanied the softening in the blaming-partners stance, were found to interact more affiliatively and ended therapy more satisfied than couples who showed lower experiencing (Greenberg, Ford, Alden, & Johnson, 1993; Johnson & Greenberg, 1985; Makinen & Johnson, 2006). A similar effect of the expression of underlying emotion was found in resolving family conflict (Diamond & Liddle, 1996). The evidence from psychotherapy research indicates that certain types of therapeutically facilitated emotional awareness and arousal, when expressed in supportive relational contexts and in conjunction with some sort of conscious cognitive processing of the emotional experience, is important for therapeutic change with regard to certain classes of people and problems. Emotion also has been shown to be both adaptive and maladaptive. In therapy, emotions sometimes need to be accessed and used as guides and at other times regulated and modified. The role of the cognitive processing 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 are all important in therapeutic work. Privileging one system for therapeutic attention over the others leads to a narrowing of perspective. Understanding the conditions under which it is optimal to intervene therapeutically with a specific system is crucial. In this article, a number of principles for working with emotion have been suggested to promote the inclusion of emotion-focused work into an ultimate empirically based, integrative, emotionfocused cognitive behavioural therapy for the new millennium.

Re sume
Le document traite des the ories et des recherche relatives aux e motions, releve es dans les domaines de la psychologie et de la psychothe rapie, en vue de montrer limportance de ces e tats affectifs dans le fonctionnement humain et le changement psychothe rapeutique. Linte gration de processus de changement axe s sur les e motions, soutenus empiriquement, dans lexercice psychothe rapeutique est fortement sugge re e. On propose cinq principes de changement dans le domaine des e motions : la reconnaissance, lexpression, la re gulation et la re flexion sur les e motions ainsi que le principe novateur de la transformation de ces dernie ` res, selon lequel une e motion peut changer une e motion. Il sagit de processus de changement qui se me ritent un soutien empirique grandissant. Le tude des e motions en pleine e volution se traduira par les the ories de la dysfonction et du traitement connexe, qui incluront la re ponse de lindividu face aux e motions et les processus e motionnels du changement.

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Received September 19, 2007 Accepted September 21, 2007