Working With Emotions in Cognitive Behavioural Therapy for Depression: A Qualitative Study of Patients' Experiences of Emotional Engagement, Avoidance and Change

ABSTRACT Background Depression is characterised by emotional blunting, avoidance and difficulties in emotional awareness, yet cognitive behavioural therapy (CBT) typically targets thoughts and behaviour more than direct emotional work. Integrating emotion‐focused elements within CBT may enhance change processes, but little is known about how depressed patients experience such in‐session interventions. Aims This study explored how primary care patients with depression experienced a behavioural activation (BA) protocol enhanced with emotion‐focused components conceptualised as targeted exposure to avoided emotions. Methods Semi‐structured interviews were conducted with eight primary care patients after completing treatment. Data were analysed inductively using reflexive thematic analysis. Results Three overarching themes captured patients' experiences: moving towards embracing my feelings (gaining understanding, recognising needs, accepting what I feel), dealing with resistance (getting stuck in ambivalence) and feeling secure due to supportive features (firm, empathic guidance; individualised pacing and structured format). Participants described confronting avoided emotions as meaningful yet demanding and emphasised the importance of therapist support and safety. Conclusions Emotion‐focused interventions may strengthen BA by promoting emotional understanding and acceptance, consistent with theories of emotional processing and emotion‐focused change. Future research should explore mechanisms and patient–therapist factors supporting emotional engagement in CBT for depression. Findings highlight how structured emotional engagement within CBT may enhance therapeutic change and inform clinical practice in routine care.