Objective: This study investigates the effectiveness of open-ended psychotherapy in a large, naturalistic, and diverse patient cohort using rigorous and multifaceted assessments. Method: Patients (N = 370) in open-ended psychotherapy completed an extensive set of self-report measures and diagnostic interviews, including long-term follow-up in order to assess stability of outcomes. About half of the patients qualified for a personality disorder at the onset of treatment. Treatments were open-ended, and on average therapists provided substantially larger treatment doses than common in the literature. Results: A substantial majority recovered from their respective Axis I (58%) and/or Axis II (55%) disorders during treatment. Patients also experienced large positive changes in selfreport measures of overall psychiatric symptoms and moderate positive changes in selfreported interpersonal problems, while very few (< 3%) demonstrated negative development. The patients maintained their diagnostic and self-assessed changes at a two-and-a-half-year follow-up. In contrast, self-reported occupational functioning showed minimal improvement throughout the treatment and follow-up phase. Conclusion: A naturalistic patient cohort undergoing open-ended psychotherapy demonstrates substantial and stable improvements.

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Objective: This systematic review and meta-analysis summarize current knowledge on emotional change processes and mechanisms and their relationship with outcomes in psychotherapy. Method: We reviewed the main change processes and mechanisms in the literature and conducted meta-analyses of process/ mechanism-outcome associations whenever methodologically feasible. Results: A total of 121 studies, based on 92 unique samples, met criteria for inclusion. Of these, 85 studies could be subjected to metaanalysis. The emotional change processes and mechanisms most robustly related to improvement were fear habituation across sessions in exposure-based treatment of anxiety disorders (r = .38), experiencing in psychotherapy for depression (r = .44), and emotion regulation in psychotherapies for patients with various anxiety disorders (r = .37). Common methodological problems were that studies often did not ascertain representative estimates of the processes under investigation, determine if changes in processes and mechanisms temporally preceded outcomes, disentangle effects at the within-and between-client levels, or assess contributions of therapists and clients to a given process. Conclusions: The present study has identified a number of emotional processes and mechanisms associated with outcome in psychotherapy, most notably fear habituation, emotion regulation, and experiencing. A common denominator between these appears to be the habitual reorganization of maladaptive emotional perception. We view this as a central pan-theoretical change mechanism, the essence of which appears to be increased differentiation between external triggers and one's own affective responses, which facilitates tolerance for affective arousals and leads to improved capacity for adaptive meaning-making in emotion-eliciting situations.What is the public health significance of this article? This review demonstrates that helping clients differentiate between emotion-eliciting stimuli and their associated affective responses is essential across theoretical approaches. Increased affective differentiation presumably leads to reorganization of perceptual processes, improves tolerance of emotional activation, and fosters openness to the informational value of emotions, thus leading to therapeutic improvement. Findings also indicate that psychotherapy models focusing on emotional processes would profit from more systematically differentiating between different emotions (e.g., anxiety, sadness, anger, contempt, disgust, shame, guilt, interest, joy, and tenderness) and more explicitly focusing on helping clients adaptively express such emotions.