“So Much Comes Up”: Emotion Regulation in Psychotherapy Addressing Existential, Spiritual and Religious Themes

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I appreciate the opportunity to review this article, which explores the underexamined topic of how meaning, spirituality, and religiosity influence mental health. While the methodological and analytical components are well executed, I find that the theoretical section (Introduction) and, by extension, the Discussion, require more comprehensive analysis. In particular, a very in-depth analysis of the current literature on the concepts of meaning, spirituality and religiosity and their impact on the functioning of the individual is needed. A superficial treatment of meaning, spirituality, and religiosity yields insufficient in-depth conclusions from a well-conducted study.

In the Introduction, the final two sentences of the first paragraph highlight the significance of "religious struggles," a concept with substantial empirical support, yet only a single article is cited. Furthermore, I observe that the analyses and conclusions focus more on the role of "religious struggles" than on meaning, spirituality, or religiosity. Consequently, the absence of a thorough examination of "religious struggles" results in conclusions that lack sufficient clarity and depth.

The Introduction primarily addresses emotion regulation. However, while the conclusions discuss beliefs about emotions, the main text does not address this topic, which is conceptually distinct from emotion regulation.

References:

Ceylan, U. A. & Koc, M. S. (2026). The mediating role of beliefs about emotions in the relationship between invalidating childhood environment and borderline personality traits. DOI: 10.57127/kpd.26024438.1690878

Exline, J. J., Keller, Y., Moffitt, A. C., Wilt, J. A., & Pargament, K. I. (2025). Many reasons for religious doubt: Links with doubt struggles, mental health, and an open, humble, questing orientation. Psychology of Religion and Spirituality. Advance online publication. https://doi.org/10.1037/rel0000596

Ford, B., & Gross, J. (2018). Why beliefs about emotion matter: An emotion-regulation perspective. Current Directions in Psychological Science, 28(1), 1–8. https://doi.org/10.1177/0963721418806697.

Grupa, M., Zarzycka, B., Tomaka, K., & Di Malta, G. (2025). Relational depth, spiritual growth, and authenticity in spiritual direction: A dyadic perspective. Psychology of Religion and Spirituality, 17(3), 261–269. https://doi.org/10.1037/rel0000568

Hong, E. J. & Kangas, M. (2021). The Relationship between Beliefs about Emotions and Emotion Regulation: A Systematic Review. Behaviour Change 39(4):1-30. DOI: 10.1017/bec.2021.23

Kéri, S. Existential thinking and religious/spiritual struggles in patients with major depressive disorder receiving cognitive-behavioral therapy. Sci Rep 15, 42205 (2025). https://doi.org/10.1038/s41598-025-26014-z

Koc, M. S. & Uzun, R. B. (2024). Investigating the Link Between Dispositional Mindfulness, Beliefs About Emotions, Emotion Regulation and Psychological Health: A Model Testing Study. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 42(2), 475–494.

Krok D, Kocur D, Fopka-Kowalczyk M. (2025). Spiritual Care, Meaning in Life and Inner Harmony: The Parallel Mediation of Compassion for Others and Self-Compassion in Palliative Care Workers. J Soc Work End Life Palliat Care. 1-21.

Małycha, M., Krok, D. (2024). The mediating role of meaning in life in the relationship between spirituality and social well-being in homeless people. Polskie Forum Psychologiczne, 29(1), 5–20.

Mróz, J., Kaleta, K., Skrzypińska, K. (2023). Spiritual Intelligence as a Mediator Between Personality and Emotional and Decisional Forgiveness in Polish Adults, Religions, 14, 5, 1-14, Numer artykułu:574.

Radwańska, E., Szwamel, K., Lepsy, E., Żurek, A., Gurowiec, O., Krok, D., Żurek, G.  (2024). Relationship between the level of spirituality and quality of life or psychological well-being in elderly patients hospitalised for heart failure. Medical Studies, 40(2), 124–142.

Rybarski, R., Bartczuk, R. P., Śliwak, J., Zarzycka, B. (2023). Religiosity and death anxiety among cancer patients: the mediating role of religious comfort and struggle. International Journal of Occupational Medicine and Environmental Health, 36(4), 1-15

Skrzypińska, K. (2022). I Believe, So I Am – Reflections on the Psychology of Spirituality. Leiden: Brill Research Perspectives.

Vuillier, L., Joseph, J., Somerville, M., & Harrison, A. (2021). Believing emotions are uncontrollable is linked to eating disorder psychopathology via suppression and reappraisal. Journal of Eating Disorders, 9(43), 1–9. https://doi.org/10.1186/s40337-021-00395-8.

Webb, T. L., Miles, E., & Sheeran, P. (2012). Dealing with feeling: A meta-analysis of the effectiveness of strategies derived from the process model of emotion regulation. Psychological Bulletin, 138(4), 775–808. https://doi.org/10.1037/a0027600

Wilt, J. A., Exline, J. J., & Pargament, K. I. (2024). Coping with religious and spiritual struggles: Religious and secular techniques. Spirituality in Clinical Practice, 11(2), 143–159. https://doi.org/10.1037/scp0000289

Zarzycka, B., Tychmanowicz, A., Krok D. (2020). Religious Struggle and Psychological Well-Being: The Mediating Role of Religious Support and Meaning Making. Religions, 149, 1-14.

Comments for author File: Comments.pdf

Author Response

Reviewer 1

I appreciate the opportunity to review this article, which explores the underexamined topic of how meaning, spirituality, and religiosity influence mental health. While the methodological and analytical components are well executed, I find that the theoretical section (Introduction) and, by extension, the Discussion, require more comprehensive analysis. In particular, a very in-depth analysis of the current literature on the concepts of meaning, spirituality and religiosity and their impact on the functioning of the individual is needed. A superficial treatment of meaning, spirituality, and religiosity yields insufficient in-depth conclusions from a well-conducted study.

In the Introduction, the final two sentences of the first paragraph highlight the significance of "religious struggles," a concept with substantial empirical support, yet only a single article is cited. Furthermore, I observe that the analyses and conclusions focus more on the role of "religious struggles" than on meaning, spirituality, or religiosity. Consequently, the absence of a thorough examination of "religious struggles" results in conclusions that lack sufficient clarity and depth.

The Introduction primarily addresses emotion regulation. However, while the conclusions discuss beliefs about emotions, the main text does not address this topic, which is conceptually distinct from emotion regulation.

 

We have now strengthened the introduction following your suggestions, added insights about MSR and mental health, R/S struggles and beliefs about emotions. In addition we have adapted the discussion. Thanks for the suggested citations, we have included many of them now.

 

References:

Ceylan, U. A. & Koc, M. S. (2026). The mediating role of beliefs about emotions in the relationship between invalidating childhood environment and borderline personality traits. DOI: 10.57127/kpd.26024438.1690878

 

Exline, J. J., Keller, Y., Moffitt, A. C., Wilt, J. A., & Pargament, K. I. (2025). Many reasons for religious doubt: Links with doubt struggles, mental health, and an open, humble, questing orientation. Psychology of Religion and Spirituality. Advance online publication. https://doi.org/10.1037/rel0000596

 

Ford, B., & Gross, J. (2018). Why beliefs about emotion matter: An emotion-regulation perspective. Current Directions in Psychological Science, 28(1), 1–8. https://doi.org/10.1177/0963721418806697.

 

Grupa, M., Zarzycka, B., Tomaka, K., & Di Malta, G. (2025). Relational depth, spiritual growth, and authenticity in spiritual direction: A dyadic perspective. Psychology of Religion and Spirituality, 17(3), 261–269. https://doi.org/10.1037/rel0000568

 

Hong, E. J. & Kangas, M. (2021). The Relationship between Beliefs about Emotions and Emotion Regulation: A Systematic Review. Behaviour Change 39(4):1-30. DOI: 10.1017/bec.2021.23

 

Kéri, S. Existential thinking and religious/spiritual struggles in patients with major depressive disorder receiving cognitive-behavioral therapy. Sci Rep 15, 42205 (2025). https://doi.org/10.1038/s41598-025-26014-z

 

Koc, M. S. & Uzun, R. B. (2024). Investigating the Link Between Dispositional Mindfulness, Beliefs About Emotions, Emotion Regulation and Psychological Health: A Model Testing Study. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 42(2), 475–494.

 

Krok D, Kocur D, Fopka-Kowalczyk M. (2025). Spiritual Care, Meaning in Life and Inner Harmony: The Parallel Mediation of Compassion for Others and Self-Compassion in Palliative Care Workers. J Soc Work End Life Palliat Care. 1-21.

 

Małycha, M., Krok, D. (2024). The mediating role of meaning in life in the relationship between spirituality and social well-being in homeless people. Polskie Forum Psychologiczne, 29(1), 5–20.

 

Mróz, J., Kaleta, K., Skrzypińska, K. (2023). Spiritual Intelligence as a Mediator Between Personality and Emotional and Decisional Forgiveness in Polish Adults, Religions, 14, 5, 1-14, Numer artykułu:574.

 

Radwańska, E., Szwamel, K., Lepsy, E., Żurek, A., Gurowiec, O., Krok, D., Żurek, G.  (2024). Relationship between the level of spirituality and quality of life or psychological well-being in elderly patients hospitalised for heart failure. Medical Studies, 40(2), 124–142.

 

Rybarski, R., Bartczuk, R. P., Śliwak, J., Zarzycka, B. (2023). Religiosity and death anxiety among cancer patients: the mediating role of religious comfort and struggle. International Journal of Occupational Medicine and Environmental Health, 36(4), 1-15

 

Skrzypińska, K. (2022). I Believe, So I Am – Reflections on the Psychology of Spirituality. Leiden: Brill Research Perspectives.

 

Vuillier, L., Joseph, J., Somerville, M., & Harrison, A. (2021). Believing emotions are uncontrollable is linked to eating disorder psychopathology via suppression and reappraisal. Journal of Eating Disorders, 9(43), 1–9. https://doi.org/10.1186/s40337-021-00395-8.

 

Webb, T. L., Miles, E., & Sheeran, P. (2012). Dealing with feeling: A meta-analysis of the effectiveness of strategies derived from the process model of emotion regulation. Psychological Bulletin, 138(4), 775–808. https://doi.org/10.1037/a0027600

 

Wilt, J. A., Exline, J. J., & Pargament, K. I. (2024). Coping with religious and spiritual struggles: Religious and secular techniques. Spirituality in Clinical Practice, 11(2), 143–159. https://doi.org/10.1037/scp0000289

 

Zarzycka, B., Tychmanowicz, A., Krok D. (2020). Religious Struggle and Psychological Well-Being: The Mediating Role of Religious Support and Meaning Making. Religions, 149, 1-14.

 

Reviewer 2 Report

Comments and Suggestions for Authors

A qualitative research study of two data sources (n = 118) and (n = 19) to assess the use of existential, spiritual, and religious themes to regulate emotion in therapy.

 

The strengths are (1) the Abstract is a succinct summary of the manuscript, (2) the Introduction contextualizes the problem, defines relevant terms and provides three research questions, (3) the Materials and Methods are described sufficiently for study replication, (4) the themes in the Results are reflected by the quotations from participants, (5) the Discussion includes the clinical implications, limitations, and future directions, (6) the Conclusions follow from the Results.

 

The weaknesses are (1) the Title is not sufficiently descriptive, (2) there is no hypothesis, (3) most of the citations in the Introduction and Materials and Methods are outdated research, (4) the Materials and Methods lack a subsection on obtaining informed consent, (5) Tables 2 and 3 are confusing, (6) the initial section of the Discussion has several older citations lacking additional support from citations to research published since 2022, (7) there are no citations to the research identifying the limitations as limitations, (7) although there are Supplementary Materials listed as downloadable, they were not included in the information to review.

 

Line-by-line suggested edits

2–3 Please change the Title to something like “Emotion regulation in therapy regarding existential, spiritual, and religious themes” to make it more descriptive of the manuscript content.

42–87 The following line numbers have claims supported by outdated citations. For each citation, please add a citation to research published since 2022 to support it: 42, 44, 47, 48, 55, 65, 67, 71, 72, 74, 82, 86, and 87.

103 After this line, please add a hypothesis.

123 After this line, please include a subsection on the method of obtaining informed consent.

128–247 The following line numbers have outdated citations. Please support them with citations to research published since 2022. For those citing methods, please cite studies similar to this published since 2022 that use the same methodology.

521–252 “Age (mean, SD)” is listed as “41(14)”. A number is missing regarding the clients. Please delete “Christian, liberal” as there is no representation of this group in the participants. There is an asterisk after “Diagnoses (patients, self-reported). There is no explanation of its meaning.

255–256 “Codes used.” It is not a sufficient heading for Table 3. Please describe the columns. Additionally, “Regulation strategies (deductive) has three columns rather than two. Please recognize the third column with a heading.

539–665 The following line numbers contain older citations that lack the support of research published since 2022. For each, please add a supporting citation of such research: 539, 548, 550, 558, 576, 593, 599, 600, 605–606, 606–607, 613, and 665.

641–665 For each identified limitation, please cite the research that recognizes the limitation as such.

666 After the heading, please return to the research hypothesis and describe the extent to which the Results corroborate it.

679–680 Please include the supporting information for review.

Author Response

Reviewer 2

A qualitative research study of two data sources (n = 118) and (n = 19) to assess the use of existential, spiritual, and religious themes to regulate emotion in therapy.

 

The strengths are (1) the Abstract is a succinct summary of the manuscript, (2) the Introduction contextualizes the problem, defines relevant terms and provides three research questions, (3) the Materials and Methods are described sufficiently for study replication, (4) the themes in the Results are reflected by the quotations from participants, (5) the Discussion includes the clinical implications, limitations, and future directions, (6) the Conclusions follow from the Results.

 

The weaknesses are (1) the Title is not sufficiently descriptive, (2) there is no hypothesis, (3) most of the citations in the Introduction and Materials and Methods are outdated research, (4) the Materials and Methods lack a subsection on obtaining informed consent, (5) Tables 2 and 3 are confusing, (6) the initial section of the Discussion has several older citations lacking additional support from citations to research published since 2022, (7) there are no citations to the research identifying the limitations as limitations, (7) although there are Supplementary Materials listed as downloadable, they were not included in the information to review.

 

Thank you for your clear and detailed feedback. You can find our point-by-point responses below.

 

Line-by-line suggested edits

2–3 Please change the Title to something like “Emotion regulation in therapy regarding existential, spiritual, and religious themes” to make it more descriptive of the manuscript content.

We have changed the title into:  “So much comes up”: Emotion regulation in psychotherapy addressing existential, spiritual and religious themes and hope this is inline with your expectations.

 

42–87 The following line numbers have claims supported by outdated citations. For each citation, please add a citation to research published since 2022 to support it: 42, 44, 47, 48, 55, 65, 67, 71, 72, 74, 82, 86, and 87.

We have added more recent citations now.

 

103 After this line, please add a hypothesis.

We have now added our hypotheses.

 

123 After this line, please include a subsection on the method of obtaining informed consent.

Apologies for forgetting to inform the reader about this. We have added the information.

 

128–247 The following line numbers have outdated citations. Please support them with citations to research published since 2022. For those citing methods, please cite studies similar to this published since 2022 that use the same methodology.

We have updated the citations. The only small reservation we have is the term ‘outdated’, as qualified research can - hopefully - last for a long time, longer than four years; but we assume the reviewer meant ‘also include contemporary or recent research’, which is a valuable suggestion.

 

521–252 “Age (mean, SD)” is listed as “41(14)”. A number is missing regarding the clients. Please delete “Christian, liberal” as there is no representation of this group in the participants. There is an asterisk after “Diagnoses (patients, self-reported). There is no explanation of its meaning.

We have followed your suggestions, for which we thank you. We have tried to clarify the table.

 

255–256 “Codes used.” It is not a sufficient heading for Table 3. Please describe the columns. Additionally, “Regulation strategies (deductive) has three columns rather than two. Please recognize the third column with a heading.

Thank you for this correct remark, we have clarified the table.

 

539–665 The following line numbers contain older citations that lack the support of research published since 2022. For each, please add a supporting citation of such research: 539, 548, 550, 558, 576, 593, 599, 600, 605–606, 606–607, 613, and 665.

We have now added more recent citations.

 

641–665 For each identified limitation, please cite the research that recognizes the limitation as such.

We have added research addressing these themes.

 

666 After the heading, please return to the research hypothesis and describe the extent to which the Results corroborate it.

We have now partly rewritten the conclusions and integrated our hypothesis in it.

 

679–680 Please include the supporting information for review.

We would like to clarify that there are no supplementary files for this manuscript. The line in the template stating ‘Figure S1: title; Table S1: title; Video S1: title’ is automatically generated by the MDPI submission template and does not reflect any actual supplementary materials. It was included in error and can be disregarded.

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors Abstract: The acronym SPIRIT-CBT should be explained as Spiritual Psychotherapy for Inpatient, Residential & Intensive Treatment
Hypothesis B should be revised and clarified, as it is unclear in its current form (it concerns three unrelated topics)
The discussion requires significant revision: it largely overlaps with the analyses, whereas it should focus solely on drawing conclusions in the context of the hypotheses and the results of other studies.
- ...the results of the analyses fully (partially) confirmed the hypothesis A ..., because they revealed that ...this is consistent with the research results...This suggests that SPIRIT-CBT...
- paragraph 1. (It says "One could think of three layers," but the text mentions two levels.)

Author Response

Thank you for the feedback. We have addressed these points by clarifying the SPIRIT-CBT acronym, revising Hypothesis B, and revising the discussion to focus on conclusions in relation to the hypotheses and other research, while removing the reference to the layers.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the changes to the manuscript. All have improved it. A few remain.

 

Many of the added citations are publications from the previous five years. Thank you for their addition. However, there are several instances where the intention of presenting older research is to represent the current view. If there has been no subsequent research published on a particular topic since the older publication, please state this in the text. The claim that the older research represents the present situation is unsupportable. The current situation is unknown due to a lack of research.

 

Line-by-line suggested edits.

Please make the following changes:

49–753 The following line numbers have older citations that lack the addition of research published since 2022: 49, 64, 70,  96, 100, 104, 120, 597, 603, 629, 639, 654, 676, 685, 686, 730, 734, 739, and 753. In some cases, no more current research is available. Please state this in the text if this is the case. For methodologies published before 2022, the point of adding current citations is to demonstrate that the method remains relevant in the field by citing research that uses the same methodology. If there is no other research using the method, justify its use.

Author Response

Thank you for the detailed suggestions. We have reviewed the citations and added newer studies. For older methodologies, we have clarified their continued relevance by referencing recent work that employs the same approaches or justified their use when no newer studies are available.

Round 3

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the manuscript changes, which have improved the text.

 

There remain some outdated citations that lack support of research published since 2022, for which such research exists. Please add this support. 

 

Line-by-line suggested edits

50–699 The following citations, by their line number, are outdated. Following each citation is a relevant Google Scholar search that may be useful in finding relevant research for a citation published since 2022.

50 (Pargament 1997, 2013) https://scholar.google.ca/scholar?as_ylo=2022&q=Religion+has+been+conceptualized+as+the+institutional+and+culturally+determined+expression+of+spirituality,+while+spirituality+can+be+defined+as+the+individual+search+for+the+sacred&hl=en&as_sdt=0,5

53 (Victor & Treschuk, 2020) https://scholar.google.ca/scholar?as_ylo=2022&q=comprehensive+definitions+of+religion+and+spirituality,+both+empirical+and+review-based+research+indicate+that+these+constructs+are+conceptualized+in+diverse+ways+and+lack+a+shared+definition&hl=en&as_sdt=0,5

60 (Krok, 2015) https://scholar.google.ca/scholar?as_ylo=2022&q=meaning+in+life+is+highly+intertwined+with+the+fields+of+religion+and+spirituality&hl=en&as_sdt=0,5

123–124 (Kivity et al., 2021) https://scholar.google.ca/scholar?as_ylo=2022&q=CBT+decreases+expressive+suppression+and+increases+cognitive+reappraisal,+which+in+turn+predict+reductions+in+social+anxiety&hl=en&as_sdt=0,5

229 (Elo & Kyngäs, 2008) https://scholar.google.ca/scholar?as_ylo=2022&q=thematic+content+analysis&hl=en&as_sdt=0,5

699 (Van der Kolk, 2014) https://scholar.google.ca/scholar?hl=en&as_sdt=0%2C5&as_ylo=2022&q=body-based+trauma-informed+perspectives&btnG=

 

 

Author Response

We sincerely thank the reviewer for the time and suggestions to improve the clarity and contemporary relevance of the manuscript. Below you can find or point-by-point answers to the suggestions.

There remain some outdated citations that lack support of research published since 2022, for which such research exists. Please add this support. 

Line-by-line suggested edits

50–699 The following citations, by their line number, are outdated. Following each citation is a relevant Google Scholar search that may be useful in finding relevant research for a citation published since 2022.

50 (Pargament 1997, 2013) https://scholar.google.ca/scholar?as_ylo=2022&q=Religion+has+been+conceptualized+as+the+institutional+and+culturally+determined+expression+of+spirituality,+while+spirituality+can+be+defined+as+the+individual+search+for+the+sacred&hl=en&as_sdt=0,5

Thank you for this suggestion. We have incorporated a more recent reference to Pargament in the relevant sentence, alongside one of the suggested recent articles in the subsequent sentence. This revision clarifies that Pargament’s definition remains influential in contemporary research, while also acknowledging the diversity of conceptualizations of religion and spirituality in the current literature.

53 (Victor & Treschuk, 2020) https://scholar.google.ca/scholar?as_ylo=2022&q=comprehensive+definitions+of+religion+and+spirituality,+both+empirical+and+review-based+research+indicate+that+these+constructs+are+conceptualized+in+diverse+ways+and+lack+a+shared+definition&hl=en&as_sdt=0,5

We have added a more recent article now as explained above.

60 (Krok, 2015) https://scholar.google.ca/scholar?as_ylo=2022&q=meaning+in+life+is+highly+intertwined+with+the+fields+of+religion+and+spirituality&hl=en&as_sdt=0,5

Indeed we found recent work discussing the same issue and have added the citation.

123–124 (Kivity et al., 2021) https://scholar.google.ca/scholar?as_ylo=2022&q=CBT+decreases+expressive+suppression+and+increases+cognitive+reappraisal,+which+in+turn+predict+reductions+in+social+anxiety&hl=en&as_sdt=0,5

We cited Knowles & Tolin earlier in this paragraph, and have added this quotation to the current sentence now.

229 (Elo & Kyngäs, 2008) https://scholar.google.ca/scholar?as_ylo=2022&q=thematic+content+analysis&hl=en&as_sdt=0,5

Thank you, we have now added Braun & Clarke to the same sentence to support the use of thematic analysis in health research, highlighting both its continued relevance and the need for transparent, rigorous application.

699 (Van der Kolk, 2014) https://scholar.google.ca/scholar?hl=en&as_sdt=0%2C5&as_ylo=2022&q=body-based+trauma-informed+perspectives&btnG=

Thank you for your suggestions, we have added a more recent quotation focusing on the effects of group therapy.

We hope the revised manuscript will meet your expectations.