Journal of Contextual Behavioral Science (JCBS)
Volume 40, April 2026
Authors
Tim Lindeberg, Emi Patmisari, & Helen McLaren
Key Findings
Realist synthesis reveals how therapeutic change occurs in anxiety therapy. • Sixteen patterns link therapy, context, mechanisms, and outcome. • Mechanisms of change form two-way and three-way process patterns. • Differentiates transdiagnostic and context-based mechanisms across modalities. • Proposes the Therapeutic Growth Model for clinical formulation and planning.
Abstract
Psychological interventions for anxiety are widely supported as effective, yet the lived processes of therapeutic change remain contextually underexplored. This systematic review synthesised qualitative studies examining clients’ accounts of therapy for anxiety. A comprehensive search across six databases (CINAHL, MEDLINE, PsycINFO, PubMed, Scopus, and Web of Science) returned 3529 records. Following screening and full-text assessment, 27 studies were included in the synthesis. A realist-informed thematic approach was used to examine how specific processes enabled or constrained change across therapeutic contexts. Four categories of therapeutic mechanisms were identified: cognitive, emotional, behavioural, and relational. These were integrated into a model of Therapeutic Growth. Within this model, four dyadic processes captured recurrent ways in which participants described engaging with therapy over time (Reflective Action, Courageous Participation, Nurtured Expression, and Co-Constructed Meaning). Additionally, four triadic domains reflected more complex patterns in which multiple mechanisms interacted across relational and contextual conditions. Therapeutic growth was experienced as gradual and context-dependent, emerging through experiences of insight, emotional safety, behavioural engagement, and relational connection. This review offers a process-oriented account of how therapy for anxiety may support change. The Therapeutic Growth model may assist practitioners in identifying which cognitive, emotional, behavioural, or relational processes are most salient for a given client and how these processes might be supported flexibly over time.