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In recent years, increasing attention has been directed toward understanding the processes and mechanisms that underlie the effectiveness of psychotherapeutic interventions (Crits-Christoph et al., 2013; Elliott, 2010; Kazdin, 2009). Among these, emotional change processes and mechanisms have been highlighted as particularly promising (Gross, 2013; Whelton, 2004), given their central role in both adaptive psychological functioning and the development and maintenance of psychopathology (Aldao et al., 2010; Power & Dalgleish, 2015). The overarching aim of this research project was to advance a broader and more nuanced understanding of emotional change in psychotherapy by conducting an extensive review of the relevant literature and by examining the validity of a specific theoretical framework: Affect Integration.
The thesis consisted of three studies. In Paper I, we aimed to summarize the current state of knowledge on emotional change processes and mechanisms, and their associations with psychotherapy outcomes. To this end, we conducted a systematic review and meta analysis of the primary change processes and mechanisms identified in the literature. A total of 121 studies, representing 92 unique samples, met the inclusion criteria. The emotional change processes and mechanisms most robustly associated with positive outcomes were fear habituation across sessions in exposure-based treatments for anxiety disorders (r = .38), experiencing in psychotherapy for depression (r = .44), and emotion regulation in psychotherapies for various anxiety disorders (r = .37). Despite differences in emphasis and theoretical lineage, these processes appear to converge on a shared underlying function: the reorganization of maladaptive emotional perception.
In Paper II, we examined affect integration as a potential mechanism of change in the treatment of social anxiety disorder (SAD). Affect integration refers to the functional and fluent integration of affect with cognition and behavior (Solbakken et al., 2011) and is operationalized in terms of the individual’s capacity for awareness, tolerance, and both nonverbal and verbal expression of nine discrete emotions (Solbakken et al., 2017). Research has shown that individuals with SAD often struggle to accurately perceive and adaptively utilize their emotions (Rozen & Aderka, 2023). Accordingly, we hypothesized that improvements in affect integration would be associated with reductions in social anxiety symptoms and interpersonal difficulties. The sample consisted of 88 clients who provided self-reports on affect integration, social anxiety, and interpersonal functioning at five time points during treatment and follow-up. We disaggregated the within- and between-person components of these variables and examined the lagged effects of affect integration on subsequent symptoms. As hypothesized, time-specific increases in affect integration predicted reductions in both social anxiety symptoms and interpersonal problems.
In Paper III, we aimed to evaluate the utility of Affect Integration Theory (AIT; Monsen & Solbakken 2013; Solbakken et al., 2011) in describing core psychotherapeutic change processes through a theory-building case study. Both qualitative and quantitative methods were employed to examine a successful course of affect-consciousness focused therapy (ACT, Monsen & Monsen, 1999) with a client suffering from depression. The client’s nuclear script—representing a central affective conflict—was identified prior to treatment. Drawing on AIT, the Affect Representation and Intervention Focus (ARIF; Monsen & Solbakken, 2013) coding system was applied to track therapist and client change processes across sessions. Affect consciousness and depressive symptoms were assessed on a session by-session basis. The qualitative analysis involved an in-depth review of session transcripts and video recordings. The nuclear script indicated that several uncomfortable feelings tended to merge and were encoded as a generalized diffuse and mixed state of discomfort and anxiety. Three main therapeutic phases were identified: (1) increased differentiation and integration of affects (shame, sadness, contempt, and anxiety) embedded in the nuclear script; (2) enhanced capacity to express discrete emotions in relational contexts; and (3) development of more nuanced and realistic representations of self and others. A notable finding was that early integration of aversive affects (i.e., contempt and disgust) appeared to facilitate access to sadness and grief related to past injustices. Contempt and disgust initially emerged as taboo feelings, but were relatively early on better integrated, with a clear signaling function in the form of a strong distancing from some of his father’s ways of behaving. After these (for him) unacceptable feelings became more integrated, they were also less fused with other emotional states such as shame, fear, and sadness. Increased affect integration and differentiation involved a clearer conceptualization of his own feelings, a clearer sense of self and self boundaries, a greater capacity to grieve and accept loss, and a more undisturbed access to joy and other positive feelings. The initially paralyzing feelings of shame and self-criticism were, by the end of the therapy process, transformed into greater humility and openness. Cross lagged regression analyses further showed that improvements in affect consciousness systematically predicted subsequent reductions in depressive symptoms, while the converse was not true.
Collectively, the three studies contribute to a more nuanced understanding of emotional change in psychotherapy. Meta-analytic findings indicate that several emotional change processes—such as fear habituation, emotional experiencing, and emotion regulation—are robustly associated with therapeutic improvement. These processes appear to converge on a shared underlying function: the reorganization of maladaptive emotional perception. Affect integration emerged as a plausible mechanism of change in the treatment of social anxiety disorder, and findings from the theory-building case study highlighted its role in the treatment of depression.
