PPRNet Clinical summary: Emotion Regulation is a Mechanism of Change Across Psychotherapies

Emotion regulation refers to the process by which individuals influence the emotions they experience and how they express emotions. Emotional reactivity, instability, and avoidance are critical components of many mental health problems, including depression, anxiety, and personality disorders. Two features of emotion regulation include cognitive reappraisal (modifying the meaning attributed to a situation and internal experience) and expressive suppression (inhibiting emotional expression). Cognitive reappraisal involves downregulating negative affect, whereas expressive suppression diminishes the experience of positive emotions. Previous research has shown that psychotherapies lead to improved emotion regulation strategies, including increased cognitive reappraisal and decreased expressive suppression. And that these improvements in emotion regulation are associated with better patient distress outcomes. However, it remains unclear whether improved emotion regulation leads to better outcomes or whether reduced symptoms lead to better emotion regulation. It is also unclear whether emotion regulation strategies are specific to CBT interventions or are common to all therapies. In this large study of community-based therapists and patients, Lo Coco and colleagues examined 1116 adults with depression treated by 947 licensed psychotherapists who worked from a CBT or from another therapeutic orientation (psychodynamic, systemic, or other). Patients completed measures of emotion regulation (cognitive reappraisal and expressive suppression) and symptom distress at pre-treatment, after session 12, and at 6 months follow-up. The researchers found that increases in cognitive reappraisal and concurrent decreases in emotion suppression were associated with subsequent decreases in distress. But the opposite was not found: changes in distress were not associated with subsequent changes in emotion regulation. This suggested that changes in emotion regulation preceded, and therefore may have caused, improved symptoms, rather than the other way around. There were no differences in effectiveness between CBT and other orientations, and the association between better emotion regulation and outcomes also was not different between therapeutic orientations.

The findings from this large community-based study indicate that changes in cognitive reappraisal and emotion suppression lead to better outcomes. Changes in emotion regulation are non-specific mechanisms of change. That is, they occur in different types of therapies. Therapists of all stripes would do well to take a balanced approach to emotion regulation that encourages patients to develop conscious reappraisal of emotional cues, alternative explanations for the cause and impact of their emotions, and moderated emotion expression. Such an approach can enhance patients’ capacity to influence their emotional experiences and expression to achieve the best outcomes.

Lo Coco, G., Kivlighan, D.M., Benzi, I.M.A., Zarbo, C., La Tona, A., Smeriglio, R., … & Parolin, L. (2026). Cognitive reappraisal and expressive suppression dynamics predict changes in distress across psychotherapy: Findings from the PsyCARE study. Psychotherapy Research, https://doi.org/10.1080/10503307.2026.2632043