Negative emotion expression and emotion regulation in regulation focused psychotherapy for children (rfp-c) with externalizing and comorbid internalizing/externalizing problems

Abstract

Emotion regulation refers to how children utilize various strategies to manage the intensity and duration of their emotions, as well as the way they process emotional experiences. Difficulties in emotion regulation have been linked to the development of externalizing problems in children leading to growing emphasis on therapeutic approaches that address these regulatory difficulties. Regulation Focused Psychotherapy for Children (RFP-C) is a time-limited psychodynamic treatment model developed for children aged 5 to 12 who exhibit externalizing problems. In RFP-C, externalizing behaviors are conceptualized as maladaptive defenses against unbearable emotions such as sadness, shame or guilt, resulting from impairments in implicit emotion regulation capacity. By systematically interpreting children’s defenses, the therapist aims to help the child increase emotional tolerance and find adaptive ways to express these unbearable feelings. While limited research has demonstrated the effectiveness of RFP-C in reducing externalizing symptoms and improving emotion regulation, there remains a lack of empirical studies investigating how affective processes evolve throughout therapy. The present study aimed to examine how children’s emotion regulation and negative emotion expression change over the course of RFP-C, using the Children’s Play Therapy Instrument. It was hypothesized that anger expression would decrease while sadness expression and emotion regulation would increase over the course of therapy. The study was conducted as part of a Randomized Controlled Trial (RCT) at Istanbul Bilgi University. The sample consisted of 34 school-aged children with externalizing and comorbid internalizing/externalizing problems. Three therapy sessions per child were coded for affect regulation and affect expression using the CPTI. Repeated measures ANOVAs revealed a significant increase in anger expression across sessions, while sadness expression and affect regulation remained stable. These findings suggest that increased anger expression may reflect a shift from defensive acting out to symbolic processing of aggression through play. The stability of sadness expression highlights the need for more sensitive tools to detect subtle emotional changes, while the absence of change in emotion regulation may reflect the non-linear nature of therapeutic progress and highlight the need for more frequent session-level assessments and fine-grained analytic methods to detect subtle changes over time.